E:\2021\NERS AGUSTUS\2--jurnal 153Arsa, Charunnisa, The Correlation of Self-Regulation Theory Constructs and ... The Correlation of Self-Regulation Theory Constructs and the Incidence of Intradialytic Complications during Hemodialysis 2Midwifery Department, STIKes Patria Husada Blitar, Indonesia JURNAL NERS DAN KEBIDANAN (JOURNAL OF NERS AND MIDWIFERY) http://jnk.phb.ac.id/index.php/jnk JNK Keywords: self-regulation, intradialytic compli- cations, hemodialysis. Article Information Abstract Hemodialysis is currently applied as a routine treatment that is widely used by patients with chronic kidney failure, though complications still occur during dialysis. Self-regulation is a kind of theoretical model that represents the effect of perceived disease on behavior and health-related consequences. There is a process of problem representation, coping and appraisal or as- sessment of coping success involved in self-regulation. This study aimed to determine the correlation between self-regulation theory constructs and the incidence of intradialytic complications during hemodialysis. This was a descriptive analytic study with cross-sectional design. Consecutive sam- pling resulted in 42 respondents. Logistic regression results obtained dis- ease representation variable with timeline (p=0.122; OR=0.412) and control (p=0.068; OR=0.582) sub-variables; as well as coping variable with Problem- focused (p=0.219; OR=0.912) and emotion-focused (p=0.036; OR=0.3) sub- variables. Intradialytic complications are complex conditions that involve many factors, but the patient’s psychological adaptation process also de- serves to be considered in developing self-regulation among hemodialysis patients. It is necessary to consider the provision of health education based on the constructs of this self-regulation theory, especially on variables/ factors that have a correlation with the incidence of intradialytic complica- tions in order to improve self-management among hemodialysis patients to get a better life. © 2021 Journal of Ners and Midwifery 153 Correspondence Address: STIKes Patria Husada Blitar – East Java, Indonesia P-ISSN : 2355-052X Email: sandialfa.wiga@gmail.com E-ISSN : 2548-3811 DOI: 10.26699/jnk.v8i2.ART.p153–160 This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/) Sandi Alfa Wiga Arsa1, Miftah Chairunnisa2 1Nursing Department, STIKes Patria Husada Blitar, Indonesia History Article: Received, 05/07/2021 Accepted, 04/08/2021 Published, 15/08/2021 https://crossmark.crossref.org/dialog/?doi=10.26699/jnk.v8i2.ART.p153-160&domain=pdf&date_stamp=2021-08-15 https://doi.org/10.26699/jnk.v8i2.ART.p153-160 154 Jurnal Ners dan Kebidanan, Volume 8, Issue 2, August 2021, page 153–160 INTRODUCTION Hemodialysis is currently applied as a routine treatment that is widely used by patients with chronic kidney failure. However, side effects are frequently encountered during dialysis, which may be due to technical problems, and patient comor- bidities. Intradialysis complications can be expe- rienced by patients during hemodialysis in the forms of hypotension, muscle cramps, nausea, vomiting, headache, chest pain, fever and chills, hyperten- sion, disequilibrium syndrome, arrhythmia, hemoly- sis, air embolism and shortness of breath during hemodialysis. Heart disease is the most common cause of death for people with dialysis (American Kidney Fund, 2019). Intradialytic complications are often associated with high IDWG (Interdialytic weight gain) and poor prognosis (Gul et al., 2016). The results of therapy will not be optimal without the awareness of the patient to maintain his life, and this can also lead to therapy failure or complications that are detrimen- tal and fatal (Endah & Supadmi, 2016). Based on the results of observations in September 2020 in the Hemodialysis Unit of Mardi Maluyo Regional General Hospital, Blitar, it was found that about 60% patients did not comply with the advice given re- garding fluid restriction, so that in the further he- modialysis therapy, patients still often came with certain complaints such as shortness of breath, weight gain exceeding 5% of the patient’s dry weight and uremic symptoms (nausea, vomiting, anorexia), which resulted in commonly experienced complications, namely hypotension and hyper- tension. The main principles in managing chronic diseases such as CKD are patient involvement and acceptance of responsibility for controlling compli- cations with self-care behaviors. Self regulation stems from the individual’s ef- forts to maintain the status quo and return to a ‘nor- mal’ state of health. Emotional reactions can ap- pear at any stage. Cultural or social differences, for example regarding perception of symptoms or expectations of disease, can lead to different rep- resentations and different coping structures. Self- regulation actively emphasizes the individual ability and how the individual can operate and reflect on his actions. The concept of self regulation theory can iden- tify the patient’s ability to self-regulate through his ability to recognize the disease (illness cognition) wherein the patient is able to develop constructive coping. This constructive coping will maximize the patient’s potential for self-regulation. A study con- ducted by Chironda et al., (2019) identified infor- mation about models and theories of care for the management of patients with CKD (Chronic Kid- ney Disease) which could improve patient compli- ance. The advantage of the Common Sense Model (Self Regulation) theory is sourced from the theory of individuals who act to prevent, treat, cure or adapt to acute or chronic diseases experienced and a good self-regulation process will help individuals to man- age the disease and this further improve compli- ance. Self-regulation strategies among hemodialysis patients need to be observed so that appropriate interventions can be planned and eventually, inter- dialysis complications do not occur since increas- ing self-control was revealed to decrease morbid- ity and mortality rates among this vulnerable popu- lation (Kauric-Klein et al., 2017). Problem solving process is referred to analysis on the constructs of self-regulation theory. Solving health problems is basically no different from solving other problems. There is a process of problem representation, cop- ing and appraisal or assessment of coping success in self-regulation (Ogden, 2007). Based on the de- scription above, the researchers intended to observe the correlation between self-regulation theory con- structs and the incidence of intradialytic complica- tions during hemodialysis. METHODS This was a descriptive analytic study with a cross-sectional design. The samples were collected using consecutive sampling technique which re- sulted in 42 respondents. The independent variable in this study was the constructs of self-regulation theory with the instrument of disease representa- tion factor variable developed by the researchers by adapting the illness perception questionnaire (Weinman, 2000). Furthermore, coping variable was measured using a questionnaire developed by re- searchers by adapting the Ways of Coping devel- oped by Lazarus and Folkman (Vitaliano et al., 2016). The Appraisal variable was measured using a questionnaire developed by the researcher by adapting the Primary Appraisal Secondary Appraisal Questionnaire (PASA) (Gaab, 2009) which was then modified according to the study objective. The de- pendent variable was intradialytic complications measured using an observation sheet for complica- 155Arsa, Charunnisa, The Correlation of Self-Regulation Theory Constructs and ... tions during the hemodialysis process. Bivariate analysis used chi-square statistical test which aims to test the difference in proportions. If the bivariate test obtained a p value of < 0.25, then the variable could be included in the multivariate model. Multi- variate analysis used logistic regression analysis since there was a categorical dependent variable. Important variables included in the multivariate model were those with a p value of < 0.05. Vari- ables that had an effect on the dependent variable were defined based on each p-value. RESULTS No Variable N % 1 Age 17-25 1 2.38 26-35 3 7.14 36-45 9 21.43 46-55 18 42.86 56-65 9 21.43 > 66 2 4.76 2 Gender Male 17 40.48 Female 25 59.52 3 BP Pre HD Hypotension 2 4.76 Normal 22 52.38 Hypertension 18 42.86 4 BP Post HD Hypotension 3 7.14 Normal 21 50.00 Hypertension 18 42.86 5 Education on HD never 8 19.05 1 time 10 23.81 3 times 9 21.43 >3 times 15 35.71 Table 1. Demographic Data of Respondents Table 1 presents the number of respondents who underwent hemodialysis at the Hemodialysis Unit of Mardi Waluyo Regional General Hospital, Blitar City. The majority of them were aged be- tween 46-55 years or as many as 18 respondents (42.86%). The majority were female or as many as 25 respondents (59.52%). Furthermore, 15 re- spondents (35.71%) ever received information on hemodialysis more than 3 times. Before hemodi- alysis, the majority of respondents had normal blood pressure or as many as 22 respondents (52.38%) and after hemodialysis as many as 21 respondents (50%) had normal blood pressure. Table 2 presents the intradialytic complications experienced by the respondents. The most com- mon complications experienced by patients were muscle cramps and headaches, as many a 39 re- spondents (92.86%) respectively. Table 3 presents the results of bivariate selec- tion. Not all variables showed a p value of <0.25 as a requirement to be included in the multivariate test. The variables that were included in the logistic re- gression analysis were those which had a p value of <0.25 in the bivariate analysis. Logistic regres- sion results obtained disease representation vari- able with timeline (p=0.122) and control (p=0.068) sub-variables; as well as coping variable with Prob- lem-focused (p=0. 219) and emotion-focused (p=0.036) sub-variables. Table 4 presents the test results of several vari- ables, namely Timeline (p=0.211), Control (p=0.472), problem-focused coping (p=0.908), emotion-fo- cused coping (0.143), which indicated that individu- ally, the four variables had no significant effect on intradialytic complications, however simultaneously, these four variables had an effect on intradialytic complications with a p value = 0.044. Thus, it can be concluded that the equation obtained was g(x) = (constant(1.375)) + (timeline(-0.887)) + (control(- 0.0541)) + (problem-focused (-0.092)) + (emotion- focused (-1.203)) Value of Independent Variable was 1 for se- vere intradialytic complications and 0 for mild dia- lytic complications. The Table above shows a Nagelkerke R square value of 0.222 which meant that the contribution of the four variables, namely timeline, control, prob- lem-focused coping, and emotion-focused coping Complication N % Hypertension 15 35.71 Muscle cramp 39 92.86 Nausea 31 73.81 Headache 39 92.86 Chest pain 3 7.14 Itchy 30 71.43 Hypotension 23 54.76 Table 2. Intradialytic complications 156 Jurnal Ners dan Kebidanan, Volume 8, Issue 2, August 2021, page 153–160 No Variable Sub-Variable Category Mild   Severe   p value N % n % 1 Disease Representation Identity Mild 21 53.8 18 46.2 0.503 Severe 1 33.3 2 66.7 Cause Couldn’t recognize 19 54.3 16 45.7 0.582 Could recognize 3 42.9 4 571 Timeline Negative 13 65 7 35 0.122*) Positive 9 40.9 13 59.1 Consekuensi Negative 13 50 13 50 0.694 Positive 9 56.3 7 43.8 Control Negative 14 66.7 7 33.3 0.068*) Positive 8 38.1 13 61.9 2 Appraisal First Appraisal Negative 22 53.7 19 46.3 1 Positive 0 0 1 100 Second Appraisal Negative 11 61.1 7 38.9 0.329 Positive 11 45.8 13 54.2 3 Coping Problem-focused Negative 14 61.9 8 38.1 0.219*) Positive 9 42.9 12 57.1 Emotion-focused Negative 17 65.4 9 34.6 0.036*) Positive 5 31.3 11 68.8 *) p value of < 0.25 Table 3. Bivariate selection of variables in self-regulation theory with the level of complications experienced by patients during hemodialysis at Mardi Waluyo general hospital, Blitar (n=42). Coeff S.E. Wald df Value p OR CI 95% Min Max Disease Representation Timeline -0.887 0.709 1.562 1 0.211 0.412 0.103 1.655 Control -0.541 0.753 0.517 1 0.472 0.582 0.133 2.545 Coping Problem-focused -0.092 0.795 0.013 1 0.908 0.912 0.192 4.338 Emotion-focused -1.203 0.822 2.144 1 0.143 0.300 0.060 1.503 Constant 1.375 0.682 4.058 1 0.044 3.954 Table 4. Variables correlated with intradialytic complications at Mardi Waluyo general hospital, Blitar (n=42) Cox & Snell R Square Nagelkerke R Square 0.116 0.222 Table 5. Negelkerke R square value Chi-square Df Sig. 5.791 7 0.564 Table 6. The Result of the Hosmer and Lemeshow Chi- square test was able to explain the accuracy of 22% and the other 11% was explained by other factors. The Table above presents the result of the Hosmer and Lemeshow Chi-square test with a p value of significance of 0.564 (>0.05), then H0 was accepted and the model had sufficiently explained the data (goodness of fit). The Table above shows that the prediction ac- curacy in this study was 69%. 157Arsa, Charunnisa, The Correlation of Self-Regulation Theory Constructs and ... DISCUSSION This study showed that 45% of patients aged 46-55 years experienced severe complications dur- ing the hemodialysis process. The perceived intradialytic complications were muscle cramps (92.86%), headache (92.86%), nausea (73.81%), itching (71.43%), and hypotension (54.76%). 57% of all patients had undergone hemodialysis for more than 3 years. Hypotension was found as the most common acute complication (20-50%) of HD fol- lowed by muscle cramps (20%), nausea and vom- iting (5-15%), dialysis imbalance (10-20%), head- ache (5%), chest pain (2-5%), itching (5%), fever and chills (<1%), arrhythmias, hypoglycemia, bleed- ing, blood membrane interactions such as first use syndrome and acute hemolysis (Singh et al., 2015). The findings indicate that intradialytic complications may occur among new patients or old patients. In this study, the constructs of self-regulation theory found that 4 subvariables from 2 variables had a relationship with the level of intradialytic com- plications, namely the timeline and control in the disease representation variable, and problem-fo- cused coping and emotion-focused coping in the coping variable. Self regulation stems from the individual’s efforts to maintain the status quo and return to a ‘normal’ state of health. Emotional re- actions can appear at any stage. Cultural or social differences, for example regarding perception of symptoms or expectations of disease, can lead to different representations and different coping struc- tures. Self-regulation actively emphasizes the indi- vidual ability and how the individual can operate and reflect on his actions (Cameron, 2012). This shows that self-regulation theory provides a frame- work for understanding the factors that can influ- ence how a person perceives the threat of disease and how client beliefs influence client decisions in self-regulating health outcomes. However, not all frameworks/constructs in the theory are related to this study which is only specialized in intradialytic complications. It has been described in table 5 that the contribution of the four variables, namely timeline, control, problem-focused coping, and emotion-fo- cused coping was able to explain the accuracy of 22% and the other 11% was explained by other factors. Furthermore, it ha been also revealed that the prediction accuracy in this study was 69%. The order of the sub-variables from strongest to weak- est cor rela tion was problem-focused coping (OR=0. 912), Control (OR=0.582), Timeline (OR=0. 412), a nd Emotion-focused coping (OR=0.300). The variables that were found to have a correlation with intradialytic complications are described below. The Correlation of disease representation (timeline and control) and intradialytic com- plications Disease representation in this study is defined as the perception of a health threatening disease based on sensations and symptoms. Perception is built on information received from three sources. The first source of information is generally obtained from previous social conversations or cultural knowledge and the effects of the disease. The sec- ond source of information is generated from sig- nificant people or authority figures such as nurses and doctors. The third sources of information are obtained from the individual’s previous experience with the disease as well as their current experience with the disease (Parfeni et al., 2013). Timeline was one of the subvariables in the constructs of self- regulation theory that was proven to have a rela- tionship with the level of intradialytic complications. It has been described in general self-regulation theory that health threats perceived due to chronic condition is associated with poorer psychological well-being, poorer social and role functioning and vitality, and greater psychological distress. Although Observed Predicted Intradialytic Complication Percentage Correct Mild Severe Intradialytic Complication Mild 15 7 68.2 Severe 6 14 70 Overall Percentage 69 Table 7. Accuracy Prediction of the Study 158 Jurnal Ners dan Kebidanan, Volume 8, Issue 2, August 2021, page 153–160 chronic condition timeline beliefs are usually asso- ciated with poorer outcomes, sometimes the oppo- site is true. This paradox highlights the complexi- ties of self-management and the importance of de- termining the phenomenological representation of disease in the individual. For example, viewing a long-term condition as acute might lead to delays in treatment (McAndrew et al., 2018). Beliefs about the time to development and duration of a disease, the point in time for using a treatment regimen, the time required for cure or control, and the time from disease onset to death when no treatment is initi- ated are significant factors. So, it cannot be denied that delays or denial of people with a chronic dis- ease such as hemodialysis patients can cause a worse condition, which is reflected in the level of intradialytic complications in the current study. Al- though intradialytic complications are clinical con- ditions related to the patient’s physical condition, in this study it was shown that the patient’s psycho- logical condition could be a factor in the incidence of intradialytic complications. In this study, control is defined as the client’s perception of the ability to control the condition as part of the hemodialysis problem, indicating a rela- tionship with the level of intradialytic complications. Feeling greater control over health threats usually leads to more active self-management, resulting in better outcomes. Likewise, feeling greater control over one’s mental health leads to seeking psycho- therapy attitude and/or engagement in preventive care to stop mental health problems before they get worse. Control belief also has an effect on the type of self-management approach chosen. This is especially important when cultural beliefs about how to control health threats do not match those of men- tal health providers (McAndrew et al., 2018). Based on general data, 35.71% of patients had received education on disease and hemodialysis, this is one thing that can develop the patient’s ability to control the conditions experienced during routine hemodi- alysis therapy. This is in line with the opinion that action plans are effective in providing action strat- egies, but are not the same as helping them acquire the skills to plan themselves, or to build manage- ment routines automatically (Leventhal et al., 2016). The control mechanism in the self regulation theory is related to anticipation and perception of respon- siveness to self-medication and expert intervention (nurses and doctors), which further creates a form of control that is appropriate for the conditions ex- perienced. Intradialytic complications such as nau- sea, vomiting, cramps, hypotension, headaches are less likely to occur if the control mechanism in self- regulation is running well, although many other fac- tors outside of these factors can also influence the occurrence of intradialytic complications. The Correlation of coping (emotion-focused and problem-focused) and intradialytic compli- cations In this study, sub-variables of emotion-focused and problem-focused involved in the coping vari- able had a relationship with intradialytic complica- tions. These complications stressed patients out, requiring them to cope. Coping mechanisms are broadly categorized into problem-focused and emo- tion-focused. Most HD patients tend to use emo- tion-oriented coping strategy to deal with stress. Emotion-focused strategies have been associated with poor therapeutic outcomes and poor health- related quality of life). (Ndanu, 2020). Coping pro- cedures are cognitive and behavioral actions that are taken (or not taken) to improve health and to prevent, treat (cure or control), and rehabilitate from disease which then forms self-regulation in which the system or mental set of mechanisms describe the self to solve health-medical problems, seek to improve self-health, and overcome the threat of dis- ease, and redefine the problems being faced. Muscle cramps, headache were some of the most common intradialytic complications experienced by patients involved in this study. Intradialytic events have been reported to have physiological and psy- chological effects on patients. The majority of HD sessions were discontinued due to complications since certain intra-dialytic complications stressed the patients (Ndanu, 2020). The finding in Johnson’s study (2017) regarding emotional-focused coping strategy used by the majority of hemodialysis pa- tients revealed that stress during hemodialysis was significantly affected by coping strategies. Although individuals undergoing outpatient he- modialysis are susceptible to many psychosocial stressors, many of which are potentially manage- able and individuals should be encouraged to cope with manageable stressors. Efforts by the health care team to understand the coping strategies ap- plied by patients undergoing hemodialysis are needed. Coping strategies are dynamic and change as people/environments change. Patients develop dynamic and interactive cognitive and emotional representations of their experiences to understand 159Arsa, Charunnisa, The Correlation of Self-Regulation Theory Constructs and ... their illness. They also develop specific represen- tations of each coping procedure or treatment op- tion. Guided by their representations, patients de- velop short- and long-term action plans and use specific coping procedures to manage symptoms and regulate negative emotions (Karekla et al., 2019). CONCLUSION The self-regulation model is the most widely used theory to explain and predict adaptation to dis- ease as well as patient behavior and self-manage- ment choices. In this study, only 2 variable con- structs of self-regulation had a correlation with intradialytic complications. Although intradialytic complications are complex conditions that involve many factors, the patient’s psychological adapta- tion process also deserves to be considered to es- tablish self-regulation among hemodialysis patients. 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