copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 e-issn: 2406-8799 p-issn: 2087-7811 nurse media journal of nursing volume 13 number 1, april 2023 accredited by ministry of research and technology/national research and innovation agency, republic of indonesia (decree no. 148/m/kpt/2020) editorial office department of nursing faculty of medicine, universitas diponegoro jl. prof. soedarto, sh., tembalang, semarang, indonesia, 50275 email: media_ners@live.undip.ac.id website: https://medianers.undip.ac.id copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 ii 1. editor-in-chief meira erawati department of nursing, faculty of medicine, universitas diponegoro, indonesia 2. editorial board ▪ andrew cashin southern cross university, australia ▪ rozzano c. locsin department of nursing, tokushima university, japan ▪ yati afiyanti faculty of nursing, universitas indonesia, indonesia ▪ sri warsini school of nursing, universitas gadjah mada, indonesia ▪ jennieffer a barr school of nursing and midwifery, central queensland university, australia ▪ maarten m kaaijk school of nursing, hanze university of applied sciences, netherlands ▪ ferry efendi faculty of nursing, universitas airlangga, indonesia ▪ mardiyono mardiyono department of nursing, poltekkes kemenkes semarang, indonesia ▪ faustino jerome gulle babate beta nu delta nursing society, philippines ▪ tantut susanto school of nursing, universitas jember, indonesia ▪ cyruz p. tuppal st. paul university philippines system, philippines ▪ suhartini ismail department of nursing, faculty of medicine, universitas diponegoro, indonesia 3. associate editors ▪ sri padma sari department of nursing, faculty of medicine, universitas diponegoro, indonesia ▪ nana rochana department of nursing, faculty of medicine, universitas diponegoro, indonesia ▪ meidiana dwidiyanti department of nursing, faculty of medicine, universitas diponegoro, indonesia ▪ fatikhu yatuni asmara department of nursing, faculty of medicine, universitas diponegoro, indonesia 4. managing/technical editors ▪ asih nurakhir department of nursing, faculty of medicine, universitas diponegoro, indonesia ▪ pradipta ary pamungkas faculty of medicine, universitas diponegoro, indonesia ▪ septi harni wahyuningtyas department of nursing, faculty of medicine, universitas diponegoro, indonesia editorial team copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 iii the nurse media journal of nursing (nmjn) is an international nursing journal which publishes scientific works of nurses, academics and practitioners. nmjn welcomes and invites original and relevant research articles in nursing as well as reviews (systematic and meta-analysis) and case reports. this journal encompasses original research articles, reviews (systematic and meta-analysis), and case studies, including: ▪ adult nursing ▪ emergency nursing ▪ gerontological nursing ▪ community nursing ▪ mental health nursing ▪ pediatric nursing ▪ maternity nursing ▪ nursing leadership and management ▪ complementary and alternative medicine (cam) in nursing ▪ education in nursing the nurse media journal of nursing (nmjn) is published three time a year, every april, august and december. for the year 2023, 3 issues (volume 12, number 1 (april), number 2 (august), and number 3 (december)) are scheduled for publication. the journal is published by the department of nursing, faculty of medicine, universitas diponegoro and available at https://medianers.undip.ac.id. scopus id : 21101019708 citescore in scopus : 0.4 (2021), 1.0 (2022) sjr in scimago : q3 google scholar h-index / i10-index : 21/62 total articles published in google scholar : 248 total citations in google scholar (total) : 2007 aims and scope publication information journal citations copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 iv the nurse media journal of nursing has been covered (indexed and abstracted) by the following indexing services: ▪ scopus (https://www.scopus.com/sourceid/21101019708) ▪ science and technology index (sinta score = s1) (https://www.sinta.ristekbrin.go.id/journals/detail?id=914) ▪ directory of open access journal (doaj). 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v editorial team ................................................................................................................ ii aims and scope, publication information, journal citation ......................................... iii indexing and abstracting .............................................................................................. iv table of contents ........................................................................................................... v-vi 1. filipino nursing students’ health promoting behaviors during pandemic (ma. prestige leudouel j. diana, francesca g cercado, pearl zerrha chiu, pamela andrea de justo, april rhose de silva, ryan michael f. oducado) ....... 1-11 2. women’s knowledge of sexually transmitted diseases in telafer city, iraq (mohmmed qassim baktash, abdul-aziz ahmed aziz) ......................................... 12-21 3. correlating demographics and well-being among rural college students in the philippines (resti tito villarino, maureen lorence villarino, maria concepcion temblor, prosper bernard, michel plaisent) ..................................... 22-30 4. resilience-related breast cancer: a concept analysis (fitria endah janitra, nur aini, anggi lukman wicaksana) ................................................................... 31-55 5. parents’ experiences of caring for children with congenital rubella syndrome (crs) in remote and rural areas of indonesia (petrus kanisius siga tage, herliana monika azi djogo, erna febriyanti, yulia martiningsih karmila letor, maria yoanita bina, maria yasintha goa goa, angela muryanti gatum) .................................................................................................................... 56-67 6. effects of patient and family-centered care on quality of care in pediatric patients: a systematic review (tuti seniwati, dessie wanda, nani nurhaeni) .. 68-84 7. postpartum depression and its contributing factors among mothers during the covid-19 pandemic in north jakarta, indonesia (venna yaasmiin aadillah, irma nurbaeti) ...................................................................................... 85-94 8. the prevalence of nurses’ emotional exhaustion during covid-19 pandemic: a systematic review and meta-analysis (rana alaseeri, omar ghazi baker, maram banakhar) ................................................................................................. 95-108 9. self-management and relating factors among chronic kidney disease patients on hemodialysis: an indonesian study (fitri mailani, emil huriani, rahmi muthia, rahmiwati rahmiwati)............................................................................ 109-120 10. perception of covid-19 vaccination based on health belief model and the acceptance of covid-19 booster vaccination (risma arlyani dewi, jon hafan sutawardana, ana nistiandani) ................................................................ 121-131 11. health care providers’ perceptions of the ministry of health’s organisational readiness for change (jamilah m almuqati, mysara alfaki, ahmed alkarani) .. 132-140 author guidelines ......................................................................................................... app.1-9 copyright transfer agreement ...................................................................................... app.10 copyright transfer agreement form ............................................................................. app.11 publication ethics and malpractice statement .............................................................. app.12-14 reviewer acknowledgment ............................................................................................ app 15 submission information ................................................................................................ app.16 subscription information............................................................................................... app.17 table of contents copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 vi [ this page is intentionally left blank ] copyright © 2022, nmjn, p-issn 2087-7811, e-issn 2406-8799 copyright © 2022, nmjn, p-issn 2087-7811, e-issn 2406-8799 e-issn: 2406-8799 p-issn: 2087-7811 nurse media journal of nursing volume 12 number 3, december 2022 accredited by ministry of research and technology/national research and innovation agency, republic of indonesia (decree no. 148/m/kpt/2020) editorial office department of nursing faculty of medicine, universitas diponegoro jl. prof. soedarto, sh., tembalang, semarang, indonesia, 50275 email: media_ners@live.undip.ac.id website: https://medianers.undip.ac.id copyright © 2022, nmjn, p-issn 2087-7811, e-issn 2406-8799 ii 1. editor-in-chief meira erawati department of nursing, faculty of medicine, universitas diponegoro, indonesia 2. editorial board ▪ andrew cashin southern cross university, australia ▪ rozzano c. locsin department of nursing, tokushima university, japan ▪ yati afiyanti faculty of nursing, universitas indonesia, indonesia ▪ sri warsini school of nursing, universitas gadjah mada, indonesia ▪ jennieffer a barr school of nursing and midwifery, central queensland university, australia ▪ maarten m kaaijk school of nursing, hanze university of applied sciences, netherlands ▪ ferry efendi faculty of nursing, universitas airlangga, indonesia ▪ mardiyono mardiyono department of nursing, poltekkes kemenkes semarang, indonesia ▪ faustino jerome gulle babate beta nu delta nursing society, philippines ▪ tantut susanto school of nursing, universitas jember, indonesia ▪ cyruz p. tuppal st. paul university philippines system, philippines ▪ suhartini ismail department of nursing, faculty of medicine, universitas diponegoro, indonesia 3. associate editors ▪ sri padma sari department of nursing, faculty of medicine, universitas diponegoro, indonesia ▪ nana rochana department of nursing, faculty of medicine, universitas diponegoro, indonesia ▪ meidiana dwidiyanti department of nursing, faculty of medicine, universitas diponegoro, indonesia ▪ fatikhu yatuni asmara department of nursing, faculty of medicine, universitas diponegoro, indonesia 4. managing/technical editors ▪ asih nurakhir department of nursing, faculty of medicine, universitas diponegoro, indonesia ▪ pradipta ary pamungkas faculty of medicine, universitas diponegoro, indonesia ▪ septi harni wahyuningtyas department of nursing, faculty of medicine, universitas diponegoro, indonesia editorial team copyright © 2022, nmjn, p-issn 2087-7811, e-issn 2406-8799 iii the nurse media journal of nursing (nmjn) is an international nursing journal which publishes scientific works of nurses, academics and practitioners. nmjn welcomes and invites original and relevant research articles in nursing as well as reviews (systematic and meta-analysis) and case reports. this journal encompasses original research articles, reviews (systematic and meta-analysis), and case studies, including: ▪ adult nursing ▪ emergency nursing ▪ gerontological nursing ▪ community nursing ▪ mental health nursing ▪ pediatric nursing ▪ maternity nursing ▪ nursing leadership and management ▪ complementary and alternative medicine (cam) in nursing ▪ education in nursing the nurse media journal of nursing (nmjn) is published three time a year, every april, august and december. for the year 2022, 3 issues (volume 12, number 1 (april), number 2 (august), and number 3 (december)) are scheduled for publication. the journal is published by the department of nursing, faculty of medicine, universitas diponegoro and available at https://medianers.undip.ac.id. scopus id : 21101019708 citescore in scopus : 0.4 (2021), 1.0 (2022) sjr in scimago : q4 google scholar h-index / i10-index : 20/54 total articles published in google scholar : 231 total citations in google scholar (total) : 1830 aims and scope publication information journal citations copyright © 2022, nmjn, p-issn 2087-7811, e-issn 2406-8799 iv the nurse media journal of nursing has been covered (indexed and abstracted) by the following indexing services: ▪ scopus (https://www.scopus.com/sourceid/21101019708) ▪ science and technology index (sinta score = s1) (https://www.sinta.ristekbrin.go.id/journals/detail?id=914) ▪ directory of open access journal (doaj). (https://doaj.org/toc/2406-8799?) ▪ google scholar; (https://scholar.google.co.id/citations?user=gs6negkaaaaj&hl=en) ▪ portal garuda/indonesian publication index (ipi); (http://id.portalgaruda.org/?ref=browse&mod=viewjournal&journal=1284) ▪ indonesian scientific journal database (isjd) (http://isjd.pdii.lipi.go.id/index.php/direktorijurnal.html) ▪ asean citation index (https://www.asean-cites.org/index.php?r=contents%2findex&id=9) ▪ ebsco (https://atoz.ebsco.com) ▪ garba rujukan digital (garuda) (http://garuda.ristekdikti.go.id/journal/view/1284) ▪ sherpa/romeo (http://sherpa.ac.uk/romeo/search.php?issn=2087-7811) ▪ worldcat (https://www.worldcat.org/search?q=so%3a%22nurse+media%22&qt=res ults_page) ▪ microsoft academic (https://academic.microsoft.com/journal/2764736586) ▪ crossref (https://search.crossref.org/?q=2406-8799) ▪ base (https://www.base-search.net) indexing and abstracting https://www.scopus.com/sourceid/21101019708 copyright © 2022, nmjn, p-issn 2087-7811, e-issn 2406-8799 v editorial team ................................................................................................................ ii aims and scope, publication information, journal citation ......................................... iii indexing and abstracting .............................................................................................. iv table of contents ........................................................................................................... v-vi 1. assessment of entrepreneurial leadership among undergraduate nursing students: the case from thailand (chawapon sarnkhaowkhom, siriporn santre, payao phonsuk, nathatsanan wongtawee, siriwimol piansamer, ajjita laohapisitpanich, wiyada suriyalerd, natthakarn supapote, thunyathon kaewmuean, napakaed hosangon, siriphorn mathaworn, parichat phikunthong) ........................................................................................... 288-299 2. “a life without a supervisor is like a seed that never grows”: students’ experiences of undergraduate nursing research supervision (olufemi oyebanji oyediran, olamide hope olafare, ifeoluwapo oluwafunke kolawole, emmanuel olufemi ayandiran, iyanuoluwa, oreofe ojo, boluwaji reuben fajemilehin) ............................................................................... 300-315 3. the effect of mindfulness-based stress reduction on restless legs syndrome in hemodialysis patients: a randomized clinical trial (zahra delshad, mohammad aghajani) ............................................................... 316-324 4. measures of nursing environment multidimensionality and patient centricity using importance-performance map analysis (andy andy, salsabilla maula zalfa el-hamzah, ferdi antonio) .............................................. 325-339 5. triggers of workplace violence in emergency departments: a qualitative study (ibrahim ayasreh, ferial hayajneh, rana al awamleh, mohammed albashtawy, abdullah al-khawaldeh) ............................................ 340-352 6. individual characteristics, adherence, and barriers to medication adherence of hypertensive patients at the indonesia timor leste border (pius almindu leki berek, bambang budi siswanto, dewi irawati, wisnu jatmiko) ...................................................................................................... 353-366 7. perceived stress, sexual and marital satisfaction among married healthcare workers in nigeria (matthew idowu olatubi, olamide olayinka, olufemi oyebanji oyediran, grace oluwaranti ademuyiwa, taiwo omotayo dosunmu) ................................................................................... 367-379 8. the effect of pelvic rocking exercise with a birth ball and sp6 acupressure on duration of the first and second stage of labor (karningsih karningsih, dwi purwanti, fauziah yulfitria, gita nirmala sari, een nuraenah) .............................................................................................. 380-389 9. non-comorbid respiratory factor and work of breathing in pediatric covid-19 patient: how is their synergistic correlation with the level of care? (defi efendi, maria dyah kurniasari, mega hasanul huda, raudha ilmi farid, yohanes andy rias, yogi prawira, nina dwi putri, ayuni rizka utami, titik ambar asmarini, pande lilik lestari, pricilia mais, abram babakal) ........................................................................................... 390-403 10. the associated factors of quality of life among stroke survivors: a study in indonesia (fitria handayani, reni sulung utami, chandra bagus ropyanto, niken safitri dyan kusumaningrum, yuni dwi hastuti) ....... 404-413 11. relationship between nurses’ attitudes and satisfaction with bedside shift reports and patient safety culture (samara jaber, mirna fawaz, ahmad rayan, nisser alhroub, mohammad suliman, mohammed albashtawy, rasmieh al-amer, abdullah alkhawaldeh) .................................... 414-422 table of contents copyright © 2022, nmjn, p-issn 2087-7811, e-issn 2406-8799 vi 12. the effect of music therapy on adult patients’ heart rate: a meta-analysis (kamila alammar, omar ghazi baker, areej alotaiba, amwar alkhunaizi) ................................................................................................ 423-436 13. targeting smoking triggers: a nurse-led intervention for tobacco smoking cessation (sadeq al-fayyadh, ali hussein alek al-ganmi, musaab majid abdulwahhab, shaymaa mohammed hussein, linda cook, abdulellah al-solais, mayada sabri) .......................................................... 437-451 14. anatomical points of cupping therapy for musculoskeletal pain: a systematic review (aris setyawan, isma nur hikmah, eka oktavianto, i made moh. yanuar saifudin) .............................................................................. 452-465 author guidelines ......................................................................................................... app.1-9 copyright transfer agreement ...................................................................................... app.10 copyright transfer agreement form ............................................................................. app.11 publication ethics and malpractice statement .............................................................. app.12-14 reviewer acknowledgment ............................................................................................ app 15 submission information ................................................................................................ app.16 subscription information............................................................................................... app.17 copyright © 2022, nmjn, p-issn 2087-7811, e-issn 2406-8799 vii [ this page is intentionally left blank ] copyright © 2015, nmjn, p-issn 2087-7811, e-issn 2406-8799 nurse media journal of nursing, 5 (2), 2015, 67 75 available online at http://ejournal.undip.ac.id/index.php/medianers recovery among people with mental illness (pmi) as perceived by the caregivers in islamic boarding school (ibs) in indonesia widodo sarjana1, alifiati fitrikasari2, sri padma sari3 abstract background: mental hospitals as places to rehabilitation people with mental illness (pmi) in indonesia are limited in numbers and do not meet with the number of pmi. the society may contribute in facilitating recovery and rehabilitation place for pmi including islamic boarding school. some islamic boarding schools provide rehabilitation for pmi to help with recovery process. recovery is an important aspect to assess the success of pmi rehabilitation. nevertheless, there has been no study on islamic boarding school’s caregivers’ perception on pmi recovery. purpose: this study aims to explore recovery perception of caregivers treating pmi in islamic boarding school and factors affecting recovery. methods: data are acquired from 19 caregivers from three islamic boarding schools providing rehabilitation for pmi with focus group discussion (fgd). the data analyzed using descriptive analysis. result: having a good communication is a recovery criterion that is mentioned the most by caregivers. there are three biggest factors affecting recovery based on the caregivers such as prayers or religion followed by social support from family and environment and also doing activities. conclusion: the results may depict the pmi recovery so that the health care providers can provide interventions that can support the recovery process in pmi. keywords: people with mental disorders, recovery, caregivers, islamic boarding school 1 psychiatric department, faculty of medicine, diponegoro university, indonesia. email: widodosarjana22@yahoo.com 2 psychiatric department, faculty of medicine, diponegoro university, indonesia. 3 school of nursing, faculty of medicine, diponegoro university, indonesia. 68 copyright © 2015, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 5 (2), 2015, background prevalence of mental disorders including severe disorders such as schizophrenia and emotional mental disorders are considered high in indonesia. based on national basic health research 2013, nation-world wide prevalence of emotional mental disorder is 6% while severe mental disorder is 1% (basic health research, 2013). in central java the number of mental disorders has increased from 2007 to 2011 from 0.49% to 7.18%. data in the regional mental hospital (rmh) dr. amino gondohutomo semarang mentioned that the number of inpatients is 3.914 persons with 99% suffering from schizophrenia and emotional mental disorders (lukitasari & hidayati, 2013). people with mental illnesss have some symptoms as a form of mental disorder such as psychosis (hallucination and delusion), speech disorder, loss of motivation and cognitive disorder. some of those symptoms may cause social and work dysfunctions, lack of interpersonal relationship, decline in personal care and mortality or morbidity (moller, 2009; townsend 2008). individuals suffering from this disorder also suffer from a second disease, from social environment reaction and stigma. the society often label “crazy people” making pmi feel ashamed to the society, have low self-esteem and the absence of hope. the impact of stigmatization will result in social isolation, lack of opportunity such as in job opportunity and social discrimination of pmi (horrison & gill, 2010). all of these may reduce the quality of life of pmi. some people with mental illnesss also suffer from “pasung” (physical restraint) because family or society feel disturbed with their presence. therapies for pmi can be devided into two therapies, pharmacological and nonpharmacological therapy. the pharmacological therapy such as antipsychotic agents is effective in alleviating symptoms in schizophrenia such as hallucination, delusion, speech and inappropriate affect (moller, 2009). while the nonpharmacological therapy or psychosocial therapy in schizophrenia are psychoeducation, cognitive behavior therapy (cbt), social skills training (sst), family therapy and assertive community treatment (act) (tandon, nasrallah, & keshavan, 2010). psychosocial therapy has some benefits such as relieving symptoms, preventing relaps, increasing social and selfcare functions and quality of life in people with schizophrenia. both modalities of therapy are aimed at helping the recovery of pmi. recovery is an important aspect to the success of the treatments of pmi. recovery is a unique process in each individual. recent studies stated that the definition of recovery is divided into clinical recovery and personal recovery. clinical recovery is a low level of psychopathology or decline in symptoms of mental disorders (bobes et al, 2009) and no rehospitalization (grossman et al., 2008). meanwhile, social recovery is defined as prescence of hope and meaningful purpose (hoper, 2007; lysaker et al., 2010), happiness (buckland, schepp, & crusoe, 2013), socialization and finding place in the society and being involved in a job (cavelti et al., 2012; roe, mashoach-eizenberg, & lysaker, 2011; silverstein & bellack, 2008). rehabilitation for pmi plays an important role in helping the recovery process. rehabilitation is an interventional program to prevent or reduce the severity of the mental disorders in need (perese & wu, 2010). the government has responsibilities in 69 copyright © 2015, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 5 (2), 2015, providing rehabilitation care in order to help pmi recovery based on regulation no. 36 year 2009 about health clause 145 (konas jiwa, 2013). however, psychiatric hospital (ph) as a rehabilitation place for pmi is limited in number and do not meet with the number of people with mental disorders which is increasing through the years. islamic boarding school (ibs) is a place to learn the religion of islam which is growing and expanding in indonesia because of enormous supports and hopes from the society. some ibs do not only function as a place for the students to learn but also contribute in facilitating recovery and rehabilitation place for people with mental illnesss. some studies showed that rehabilitation in ibs is beneficial in helping recovery along with religious activities done in ibs (sari & wijayanti, 2014). however, during the course there are some problems affecting the pmi rehabilitation in ibs such as the lack of care giver, therapies provided, the minimum budget and the lack of society and family support (dahliyani, 2012; naufal, 2014). recovery is a crucial aspect for people with mental disorders especially to offer positive impact on the quality of life. the caregivers are the person who responsible to the development and recovery for pmi in ibs replace the role of caregiver when the pmi lived with the family. nevertheless, study on pmi recovery according to ibs’ caregivers has not been done in indonesia. thus, the purpose of the study is to get overview of the definition of recovery and factors that may help the recovery process according to the caregivers treating pmi in ibs. objective the objective of this study is to explore recovery perception of caregivers treating pmi and factors affecting recovery perceived by the caregivers in islamic boarding school in indonesia. methods study design this study is a qualitative research with fenomenology method meaning that a study has the purpose of depicting and analyzing. with this method, the authors may understand about pmi recovery perception according to the caregivers and factors affecting recovery. sample and setting this study conducted at three boarding schools in demak, magelang and yogyakarta which provided rehabilitation among pmi. participants in this study are caregivers treating pmi in ibs. inclusion criteria for the participants are (1) caregivers who are responsible for treating pmi, (2) living in islamic boarding school and (3) are willing to participate in this study. ethical considerations this study had been approved by the ethic committee from faculty of medicine diponegoro university. the informed consent was obtained from all patients. informed consent is provided for the participants to gather information in the study, the right to participate and the confidentiality guaranteed by the researchers including anonymity. 70 copyright © 2015, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 5 (2), 2015, data collection and analysis data collection is used by the questionnaire about personal identity, and focus group discussion (fgd). the authors then use descriptive analyses to thoroughly review the significant results. result characteristics of the participants there are 19 caregivers from three islamic boarding schools. the description of participants’ characteristics can be seen in table 1. table 1. participants’ characteristic no. name (initial) age sex level of education length in boarding (month) length in caring (month) 1 m 18 f junior high school 24 18 2 aa 23 m senior high school 72 36 3 n 18 m senior high school 48 1 4 rcm 16 m junior high school 24 12 5 mnk 16 f junior high school 11 1 6 uc 16 f junior high school 36 1 7 mi 17 m senior high school 24 1 8 ra 23 m senior high school 60 1 9 sn 18 f senior high school 48 1 10 sf 17 f junior high school 36 6 11 nf 19 f senior high school 36 1 12 ak 28 m bachelor 48 36 13 yp 28 m senior high school 84 24 14 tar 22 m senior high school 96 3 15 iu 24 m senior high school 48 24 16 ma 27 m senior high school 60 8 17 ms 23 m senior high school 84 3 18 rr 23 f junior high school 30 4 19 ff 25 f junior high school 96 12 recovery according to the participants, there are some criteria when pmi is said to recover, as can be seen in the table 2. after living for some time with pmi, caregivers formulate a definition of recovery itself. some caregivers assume that patients are said to recover when they talk appropriately and act like normal people. 71 copyright © 2015, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 5 (2), 2015, table 2. criteria of recovery no criteria of recovery n % 1 good communication 15 78.9 2 normal attitude 10 52.6 3 good relationship 3 15.8 4 good behaviour 3 15.8 5 good orientation 3 15.8 6 having activity 3 15.8 7 socialisation 2 10.5 8 having no hallucination 2 10.5 9 having goal of life 2 10.5 10 nonadherence to medication 2 10.5 this is implied from the said of a participant as follows: “…to recover means being able to comprehend and answer appropriately when being spoken to… when one is not recovered, the answers might not be proper...” (yp) “…recovery… can be calm, used to have a weird behavior, smiles and sings on his own… now those are diminished...” (ff) factors affecting recovery some factors may affect patients’ recovery according to the caregivers, among others can be seen in table 3. table 3. factors contributing to recovery no factors n % 1 praying/ religion 11 57.9 2 support from family and community 10 52.6 3 having activity 10 52.6 4 belief for recovery 5 26.3 5 medication 5 26.3 there are some factors affecting the recovery according to caregivers such as therapy/ prayers, family and environmental support, doing activities, faith to recover and taking medications. these things are stated by an informant as follows: …religious activity, doing quran recital, prayer may accelerate recovery. (ak) …to recover, factors contributing to it are willingness, from medications to help, prayers given: communal prayers may make us closer and have more faith in allah. (rr) 72 copyright © 2015, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 5 (2), 2015, discussion recovery is a unique process in each individual. the definition of recovery in people with mental disorder (pmi) that is found in most studies is being able to communicate followed by behaving like normal person and cooperative. this definition is in line with previous studies referring that recovery is an outcome with low level of psychopathology and severity of the existing symptoms such as speaking and behaving well (bobes et al., 2009; silverstein & bellack, 2008). some expressed by caregivers also don’t meet other criteria i.e. the return of social function like working and absence of rehospitalization (grossman et al., 2008). this shows that the definition of pmi recovery chosen mostly by the islamic boarding school caregivers still focuses on the clinical recovery or the low level of psychopathology or lack of symptoms of mental disorder. only few caregivers mention that pmi recovery chose the presence of socialization and purpose in life that is a part of a personal recovery (cavelti et al., 2012; roe, mashoach-eizenberg, & lysaker, 2011).this study was supported by other studies about the concept of recovery as a process to achieve a meaningful life (hopper, 2007), happiness (buckland, schepp, & crusoe, 2013) or quality of social relationship, selfesteem, and hopes (lysaker et al., 2010). the study is also supported by ciudad, bobes and alvarez (2011) in his study that recovery in pmi at least meet three different criteria i.e. reduced symptoms, increased function and subjective response in each individual. the lack of symptoms can be obviously seen such as good communication, absence of hallucination or good orientation. increased function can be seen by socialization and activities while subjective response can be seen by knowing the purpose of life. factors affecting recovery according to participants of the study are therapies done by the islamic boarding school such as prayers, family and environmental support, doing activities, faith to recover and taking the medications. some caregivers in islamic boarding school believe that therapies and supplications given to pmi while living in islamic boarding school contribute hugely to recovery process of pmi. this agrees with other studies done in islamic boarding school that is dahliyani (2012) exploring methods and religious activities done in islamic boarding school to pmi. the result showed that religious activity done in islamic boarding school for pmi such as congregational prayers, quran recital, review about wisdom stories, communal supplications, remember of god’s messanger, studying and individual mentoring. the main therapy applied is, among others, supplications and proven effective on pmi recovery. besides, supplication is a part of spirituality which is beneficial for pmi recovery. this is in line with previous studies done by sari and wijayanti (2014) which attempted to explore spiritual experience of pmi and benefits while living in islamic boarding school. the results were: 1) spiritual definition of being close to allah and religious activities which become increasingly consistent, and 2) benefits of spirituality i.e. recovery from mental illness, symptoms management, behavioural change, emotional change and attention for the future. spirituality plays an important role for patients including helping recovery of pmi. 73 copyright © 2015, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 5 (2), 2015, some caregivers also choose family and environment support as an important influence to affect the pmi recovery while living in islamic boarding school. some caregivers complain about the lack of family support of pmi. the results are in line with other studies that the low rate of seclusion and the abundant social support may increase recovery and quality of life of pmi (roe, mashoach-eizenberg, & lysaker, 2011). the results of this study show that therapy, supplications etc play more important role compared to medications. this contradicts the previous studies in other countries stating that medication compliance and types of medications given are predictors for recovery (novick et al, 2009). some islamic boarding schools in indonesia providing rehabilitation for pmi do not utilize medications in the treatment of pmi similar to previous studies done in ibs but only using therapies and prayers which are considered beneficial for the pmi recovery process (dahliyani, 2012; nusrotuddiniyah, 2013). conclusion the study reflects recovery perception people with mental illness (pmi) according to caregivers treating pmi in islamic boarding school. most caregivers consider pmi recovery has some characteristics, with top three characteristics as follow: being able to communicate well followed by behaving like normal people and is cooperative. meanwhile factors affecting recovery according to ibs’ caregivers are prayers, family and environmental support, doing activities, faith to recover and taking medications. there are three themes acquired from this study that is spiritual definition, spiritual experience and its effect. the result of the study recommends that mental health care providers may discuss regarding education about mental illness to ibs’ caregivers considering there are ibs in indonesia that provide rehabilitations for pmi. besides, health care providers and/ or psychiatric hospital are expected to provide spiritual therapy and facilities for pmi’s spiritual improvement because supplications and spiritual condition may help with pmi recovery process. pmi recovery in this study is a perspective of pmi caregivers living in ibs. therefore, future studies may explore pmi recovery from the perspective of pmi, family or mental health care provider such as psychiatrists and mental nurses. as a result, all elements have the same perception on pmi recovery and proper measures to help with pmi recovery process. acknowledgments this paper is part of research funded by the faculty of medicine, diponegoro university indonesia under its programme grants for developments and applied research. 74 copyright © 2015, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 5 (2), 2015, references basic health research. 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(2008). psychiatric mental health nursing: concepts of care in evidence-based practice (5th ed.). philadelphia, pa: davis. http://www.psychosocial.com/index.htm http://www.psychosocial.com/index.htm copyright © 2016, nmjn, p-issn 2087-7811, e-issn 2406-8799 nurse media journal of nursing, 6 (1), 2016, 1 8 available online at http://ejournal.undip.ac.id/index.php/medianers strategies for successful transition into mainstream schools for young children with autism spectrum disorders: a case study mardiyanti1 1faculty of medicine and health sciences, islamic state university of syarif hidayatullah, indonesia corresponding author: mardiyanti@uinjkt.ac.id abstract background: meeting changes can be very problematic for children with autism spectrum disorders (asds) whereas other children may take it for granted. as a result, they may cry, get upset, scream, do hand flapping or even self-harming that shows their inability to cope with the changes and their preference of sameness and routine activities. to understand the issue of changes in children with autism, people should know the complexity of the disorders. purpose: this article will explain further about the strategies for successful transition into mainstream schools for young children with autism as illustrated in jack’s case study in the appendices. methods: a case study was conducted to one respondent. firstly, the article will explain asds and its atypical characteristics of 6-years old jack. then it will discuss strategies to help jack’s transition process, as well as strategies to support his learning process during schooling which finally comes up with conclusion to support jack and his family’s transition into mainstream primary education. results: strategies for successful transition into mainstream schools for young children with autism include using visual information and activity schedules, managing sensory overload, and building literacy skills. conclusion: attractive playing can be effective strategies to build skills for successful transition of young children with autism. keywords: autism spectrum disorders (asd), transition strategies, children 2 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (1), 2016, background meeting changes can be very problematic for children with autism spectrum disorders (asds) whereas other children may take it for granted (lawson, 2001; smith, donlan, & smith, 2012). even small changes in day-to-day life can be very overwhelming for them. for instance, changing the room decoration, clothes, route, unannounced visitors and changing activities from weekday activities to weekend activities and vice versa can create confusion and anxiety. as a result of changes they may cry, get upset, scream, do hand flapping or even self-harming that shows their inability to cope with changes and their preference of sameness and routine activities (lawson, 2001). to understand the issue of changes in children with autism, people need to know the complexity of the disorders (dodd, 2005). people with autism have core deficits in social communication (including speech, comprehension, tone of voice, use of body language, facial expression and gesture), social interaction (inability to understand other thought and feeling, does not understand what happen and why it is happening, inability to mix and engage with socially-accepted behaviors) and limited interest or showing stereotype behaviors (dodd, 2005). these deficits or difficulties may put the children and their families into more difficult situation if they have to meet with significant changes in their life, for example starting new schools. nevertheless typical development children may find it hard too to start a new school but they are less likely to show challenging behaviors as children with autism. every child with asds is unique and therefore the planning of the interventions need to be adjusted based on the needs of every individual and family (lindgren, 2011). if one child is successfully treated with one particular intervention, the others may not necessarily be addressed by the similar intervention (huang, 2006). families, teachers and the environment should focus on how children learn, rather than seeing that children experience learning difficulties. this reason underlies the overriding importance of the embodiment of coping strategies for children with autism who have been studied in the previous researches. however, real description of how the strategy is implemented in actual cases is rarely discussed. objective this case study aims to explain the strategies for successful transition into mainstream schools for young children with autism. methods this article use a case study of a-6 years old jack who has autism spectrum disorders (asds) to analyze the possible best strategies for successful transition into mainstream schools. the case is illustrated in appendices. discussion understanding autism autism spectrum disorders refers to lifelong neurodevelopment disorders with unknown etiology (robert & prior, 2006) characterized by persistent impairment in reciprocal social interaction and communication, and restricted and repetitive pattern of behaviors, interest and activities (diagnostic and statistical manual of mental 3 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (1), 2016, disorders, fifth edition [dsm-v]; american psychiatric association [apa], 2013). dsm-v now only uses the term asd to cover all the categories (autistic disorder [autism], asperger syndrome and pervasive development disorder not otherwise specified) which has been used previously under dsm-iv. there are three level of severity: level one is requiring support; level two is requiring substantial support, and level three is requiring very substantial support. in addition, the diagnosis may be followed by specifiers such as intellectual disability and co-morbid conditions such as adhd or anxiety disorder to understand fully the person condition (autism spectrum australia [aspect], 2012). people may refers autism as an invisible disability because apparently there is nothing different with other children until the way that someone communicates, socializes and learns to reveal the symptoms of asds (verdick & reeve, 2012). jack in this case study, is having problems with social interaction and communication as he only masters two to three words which is atypical child development for six-year old (hamaguchi, 2010). he is also reported for repeating the last words or ‘echolalia’ while communicates with others or when anxiety occurs. jack may also find it difficult to interact with other people as he does not like being put in a group. he also likes sameness and refuses changing activities in particular to activity’s moving from indoor to outdoor activities, gets obsess with his transport toys “thomas the tank and friends” and shows a lack of imaginative playing as typical development child usually does. he also shows stereotype or restricted behavior such as lining up his toys. another characteristic of autism to jack case study is that he usually covers his ears due to his difficulties in managing sensory integration. issue with transition inclusive education even though children with autism prefer sameness and refuse changes, they should be introduced to significant changes which are inevitable in everyday life. changes may bring the opportunity to a new and exciting experience, bring the benefit of stimulation and education to the children to increase their self-esteem and self-awareness as well as promote new relationships and independent performance (smith, donlan, & smith, 2012). jack in the case study, has already undertaken preschool setting and next term he will begin the school in a mainstream classroom which currently becomes popular choice for children with disabilities worldwide (keane, aldridge, costley, & clark, 2012). mainstream classroom embraces the philosophy of inclusion which means that children with disabilities including autism will be educated in the general classes with general curriculum similar to other children without disabilities (keane et al, 2012). studies have shown that this strategy will bring advantages and disadvantages for the children. the strategy promotes equal rights, and increases the interaction within their peers in a learning environment and thus promotes gaining appropriate social skills (crisman, 2008; reiter & vitani, 2007; tsaputra, n.d). on the other hand, the students will also be put in high risks of more distress and fearful situation due to the exposure of sensory overload such as noisy classroom, teasing and bullying, and inability to cope with school demands, peer expectation and new routine (humphrey & lewis, 2008). 4 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (1), 2016, transition techniques children with asd need to be provided with the necessary skills and training to succeed in a mainstream classroom (humphrey & lewis 2008; jordan 2004). it is likely that training on social and communication skills, educating social norms, rules and expectation before transition reduce anxiety and improve their ability to function effectively into a mainstream classroom (humphrey & lewis, 2008). humphrey (2008) also recommends the introduction of predictable routine and classroom order, developing peer understanding and modifying language for communication to assist their transition. however, to meet the most useful strategies for transition planning is likely depends on the child as each child with autism is different and one strategy which works to a child may not work to another. dunlop et al. (2009) argued that the things need to provide for transition are: ‘providing information about where they have to be, who might be there, what they will or should be doing, what behavior is expected, how much they have to do, how will they know that they are finished and what they will do next’ (p. 126). however, dunlop (2009) only explained ‘what’ things need to do but does not explain further about ‘how’ to do it. use visual information to introduce new routines helping children with autism using visual support are highly recommended as the child is best learns through visualization (dunlop et al, 2010; marks et al, 2003). visual supports such as pictures, cue cards, prompts, story boards, diagram and graphic schedules have been effectively useful for learning (marks et al, 2003). hume (2012) and smith et al (2012) also recommended visual support such as picture and photograph which can be collected from google image engine to introduce a new activity. smith et al. (2012) also recommends to introduce new routines step by step, breaking the information of new routines into small pieces and using signs, sketches or scripts to help the young child transition. smith et al (2012) strategies may help in describing the ‘how’ to do with transition. in term of ‘what’ and ‘how’ to support transition, those suggestions may be helpful for jack’s transition into mainstream education. firstly, use the school’s picture or photograph then information about why he should be there, when he should be there, who might be there and what he will do there. while doing these, it can be possible to use someone’s judgment to identify how much information should be given and breaking it down into several times. in addition, involving the preschool teacher to introduce the new school would be very helpful. later on, tell the child about visiting the new school. this may need to build up very slowly by first just passing through the school; then the next day visiting the school in a quiet day and stop at the school’s gate. later on try to come in into the school and finally meet new people there. try to involve preschool teachers and parents while visiting, or have a plan to meet jack sister and brother in the school. it is also recommended to introduce him with a buddy who will have the same class when he starts his new school. 5 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (1), 2016, using activity schedules to introduce changes between activities banda, grimmet & hart (2009) recommended the use of activity schedules using visual supports to anticipate transition between or within activities. the technique is almost similar with visual schedules from hume (2012) and visual information from smith et al (2012). the different is that activity schedules are provided in a sequential format to represent activities throughout the day, thus provide predictability of the new activities but may lead to adult’s dependency (banda et al, 2009). one example of activity schedule is picture communication symbols that consist of many pictures of activities which are arranged in order to illustrate between-activity schedule in a day. activity schedule may be used for jack to introduce a new routine while schooling, such as the list of activities that start from the beginning of class until finishing the class. managing sensory deficits during transition sensory overload is likely the most problem affected the child in everyday life including in the transition process (myles, 2000). knowing what senses he might affected by the new situation is the key to manage sensory overload. some strategies to manage sensory difficulties are: using earplug, cards, sunglasses, hat or distraction techniques to reduce fear and anxiety (myles, 2000; smith et al, 2012). it is also recommended for controlling the stimulus by modifying the environment such as segmenting space for specific activity, and minimizing auditory as well as visual distractions by using visual boundaries such as using tablecloths or rugs to cover instruments in the classroom (hume, 2012). grandin (1995) in his personal account found the sound of the toilet flushing in his school was very painful for him. in his case, modifying the school toilet for him may be helpful. learning strategies building literacy skills become a major issue as jack is ready for reading program. literacy skills may also become a key for jack to be able to communicate any message and socialize with everyone (grether & pelatti, 2010). when the child develops literacy skills, the development of speaking, reading and writing occurs concurrently (grether & pelatti, 2010). however, in term of communication, children with asd often have difficulties in the development of spoken language or gestures, lack of ability to initiate or maintain conversation, have repetitive and idiosyncratic use of language and lack of pretend play. gabriel (2002) suggests to build communicative gestures by encouraging eye contacts, reaching, grasping and giving the objects, touching or tapping objects, pushing object away, pointing, or any other controlled, purposeful and coordinated movements. gabriel (2002) also suggests to build social communication and social interaction from the child interest either based on behavioral learning theory or developmental theory, or even combination of them. pivotal response training (prt) strategies from the behavioral principle can be employed to increase the motivation of using communicative gestures such as pointing to request the desired toys. meanwhile, the picture exchange communication system (pecs) also teaches the child with autism how to communicative using objects or sharing pictures. researchers recommended pecs for nonverbal children with autism (kelley, 2011). engaging the child in back and forth turn-taking activities can increase a the child’s desire to use spoken language and thus build social interaction and social communication (gabriel, 2002). 6 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (1), 2016, building attractive play can also be a suitable strategy particularly for young children like jack (chandler, christie, newson, prevezer, & venus, 2009). children love play and playing gives the child opportunities for learning about the world in a fun way thus will develop cognitive concepts, socio-emotional skills as well as language skills (gabriel, 2002). chandler et al (2009) describe that attractive play involves imitation and commenting such as imitate the vocal sound from the child and commenting of what the child does while trying to attract his/her attention. attractive plays are aimed to develop the child interaction actively so that the child gets used to shared interest, looking, listening and taking turn. in addition, playing games can build social interaction where people can use pauses within the interaction sequence to obtain a child’s gestures (gabriel, 2002). another strategy for reading skills comes from grandin (1995). he suggested a visualized reading method from miller and miller as beneficial for some children with autism. the method introduces the word as it respective meaning. for example ‘the word ‘fall’ has the letters falling over and the word ‘run’ has the letters that looks like runners’ (grandin 1995, p. 38). those learning strategies can be maximized by involving family members as well as peer participation into the planning. conclusion meeting changes can create difficulties for children with autism and their family. building strategies for successful transition is a key to support the children and their family. transition strategies should describe the “what” and “how” in order to give clear picture about things that people should do before the changes, during the changes and after the changes. using visual information and activity schedules are recommended as the child with autism is a visual learner and likes sameness or routine. managing sensory overload is also important as children with autism mostly have problem with sensory processing. it is also suggested to build literacy skills as well as social communication and social interaction after jack’s transition into mainstream education. building those skills may be effective by addressing attractive playing as young children like jack loves playing. furthermore, it is also suggested that teachers, families and the environment surrounding need to apply a strategic approach to children with asd individually, especially when they enter a new school environment. references american psychiatric association. 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(2012). the survival guide for kids with autism spectrum disorders and their parents. minneapolis: free spirit publishing. 8 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (1), 2016, appendices case study jack (pseudonym) is a six year old child with autism and a mild level of intellectual disability. he currently attends a pre-school setting and at the beginning of the next term he will begin school in a mainstream school classroom. jack is developing speech and can communicate his needs in two to three word sentences. when feels anxious he may engage in echolalic speech, generally repeating the last word of the sentence spoken to him. he is fascinated with most forms of transport, especially ‘thomas the tank and friends’, and enjoys lining up toy trains, cars and trucks. he will play alongside other children quite happily and has been seen on occasions to ‘drive’ his cars into the play space where other children are building or playing imaginative games. jack will articulate a few words about his activity. jack enjoys looking at photographs of family members, his pet dog and the family cat, as well as books associated with transport. he is quite skilled at drawing, in particular, transport objects. recently he has shown interest in using the computer to carry out basic designs of transport. jack can become distressed with larger groups of children. he will put his fingers in his ears, make hissing sounds and push any children who may come too close to him. there can be similar reactions when jack is required to move from indoor to outdoor activities. this is an issue when considering his inclusion in a classroom setting. jack has similar strong emotional reactions when asked to change activities, especially when he is focused on his special interests. jack’s pre-school teachers consider that he is now ready to commence a reading program and are aware of the need to focus on comprehension. he is just beginning basic number concepts as well as writing numerals. he can write his name with some efforts as he appears unsure of where to start and finish the individual letters. jack’s pre-school teachers would like to develop strategies to assist the above academic areas before his transitions into the grade 1 class. jack lives with his mother, father, nine-year-old sister and eightyearold brother. his siblings attend the school into which jack will have transition. the parents are very keen for jack to be able to play simple games with his siblings as well as his school peers. jack’s parents are a little worried about the feelings of responsibility that their daughter appears to have for jack when both are at school. she expresses a need to protect him during lunch and recess times, in case other students may bully him. le page i gede putu d.s., nurse’ perception about responsibility of care 79 nurses’ perception about responsibility of care in decubitus ulcer management i gede putu darma suyasa sekolah tinggi ilmu kesehatan (stikes) bali abstract this study was conducted in order to increase the understanding of issues around decubitus ulcer care in the indonesian context. the study identified indonesian nurses’ perception regarding responsibility of care in the area of decubitus ulcer management. the choice of a qualitative research approach to elucidate the research questions provides the most appropriate way to fully appreciate and understand the uniqueness of the participants’ view. in this study, eight nurses were interviewed using semi-structured interviews. two themes arose from the study include nurses’ responsibility and family involvement. in maintaining the quality of care in the decubitus ulcer area, the participants in this study emphasised the significance of the caring responsibility of both nurses and family. appropriate education and adequate training for the family are essential in ensuring quality care when involving the family in giving any direct care to hospitalised patients. keywords:, family involvement , responsibility of care, decubitus ulcer introduction decubitus ulcers reduce patients’ quality of life significantly. moore (2004) observed that decubitus ulcers contribute to a reduction in comfort and the increase of morbidity. they also increase the length of hospitalisation which leads to other problems such as an increase in the financial burden for hospital and patients. in dealing with this situation, however, few are sufficiently aware that most decubitus ulcers can be prevented with vigilance and a heightened quality of care. pressure ulcer prevention and management is an integral part of nursing practice. the prevalence of decubitus ulcers in the health care setting becomes a quality indicator of nursing care (lyder, 2003; moore, 2001). furthermore, the prevention of decubitus ulcers has been considered as a nursing responsibility (gould et al., 2000). although this responsibility is not solely in the hand of nurses, they have a ‘unique opportunity’ because they have traditionally taken the lead in pressure ulcer prevention and management among other health care team members (moore, 2004, p. 30). i gede putu darma (email: putu_darma78@yahoo.com) sekolah tinggi ilmu kesehatan, prodi keperawatan, bali after being discussed in some research paper around the globe (gould et al., 2000; lockhart, 2002; lyder, 2003; moore, 2001; moore 2004), another study and discussion need to be conducted around nurses’ perception of responsibility of care in decubitus ulcer area. however, there is limited mailto:putu_darma78@yahoo.com i gede putu d.s., nurse’ perception about responsibility of care media ners, volume 1, nomor 2, oktober 2007, hlm 49 80 study indicating the issue especially in the indonesian context. therefore, it becomes important to address the issue through this study. the aim of this study was to identify the indonesian nurses’ perception of caring responsibility in decubitus ulcer management. to achieve these outcomes, a qualitative approach with a case study design was adopted. this study provided an insight about indonesian nurses’ perception about caring in decubitus care area. instrument and method qualitative studies make a significant contribution in developing and integrating nursing knowledge into practice (sandelowski, docherty & emden, 1997). they tend to be holistic, striving for understanding the human condition as a whole and it attempts to deal with the complexity and subjectivity of human nature through in-depth investigation into the human experiences (patton, 1990; polit & beck, 2004; roberts & taylor, 2002). a purposive sampling was used in this study to select suitable participants. purposive sampling is ‘hand-picking cases that will most benefit the study’ (polit & beck, 2004, p. 306). the aim of this sampling is to select the participants that have a great deal of information regarding the study (grbich, 1999). data was collected by in-depth interviews with eight nurses who are currently working in an indonesian hospital. the interview was conducted by using a semi-structured question that is initially consisted of ten open-ended questions. open-ended questions stimulate participants to give variety of responses. these types of questions also give opportunity for researcher to generate other questions which will be able to enrich the understanding of caring responsibility around decubitus ulcer care. the site and time allocation of data collection are important issues in any qualitative data collection. the site should be a quiet setting (polit & beck, 2004; roberts & taylor, 2002) and the time commitment should not be considered as a burden especially for participants. this provision ensures that in-depth and rich data is gathered from each participant’s point of view. in this study, the allocation of time and place of interview depended on negotiations between the researcher and each of the participants. data was manually transcribed and before being analysed, the interview transcripts were sent to the participants to check for accuracy. all participants agreed to let the researcher use the data contained in the transcripts. thematic analysis was conducted by coding and grouping the data according to the similarities and differences of the responses to questions. i gede putu d.s., nurse’ perception about responsibility of care media ners, volume 1, nomor 2, oktober 2007, hlm 49 81 result during interviews, each participant painted a different picture based on their particular perspectives. however, similarities and differences between them emerged. two themes arose throughout the study. these themes were nurses’ responsibility and family involvement. in maintaining the quality of care in the decubitus ulcer area, the participants in this study emphasised the significance of the responsibility of both nurses and family. here, the participants will be identified by their pseudonyms, siki, kalih, tiga, papat, lima, kanem, pitu, and kutus. in presenting the themes, some important quotes will be included together with participant’s pseudonym and the page number of the interview transcript to support the data. nurses’ responsibility decubitus ulcer care is a nursing domain. it is a caring responsibility of nurses. nurses are the primary health care team members in relation to decubitus ulcer management. the nurses in this study were aware of this and highlighted that it is nurses who give direct constant care to patients. one participant, kanem, stated that nurses are available for twenty four hours to provide care. another participant, kalih, also underlined this view by stating that nurses not only maintain continuous contact with patients, but they also have a significant chance to assess patients’ skin condition regularly especially when attending to personal hygiene. she made the point: …because nurses have more contact time with patients. nurses are the ones who give attention to patients starting from giving a wash. when giving a wash we can assess a patient’s condition…when the signs are starting to appear, we can prevent them [decubitus ulcers]. (kalih, p. 2) however, another participant, pitu, had a different view about the nurse’s role in the responsibility for care. he described that this is not solely a nursing responsibility but decubitus ulcer management is a collaborative process. in his view, other health care team members such as doctors, nutritionists, and physiotherapists also have a significant contribution to make in this area of practice. he stated: the ones who are principally responsible in the practice area are nurses and it is done in connection with physiotherapists and doctors… (pitu, p. 3) pitu’s statement clarified the place of nurses in relation to the responsibility for care in decubitus ulcer practice among others in the health care team. although nurses had a more obvious and more significant contribution, all participants believed that decubitus ulcer prevention and management require a multidisciplinary approach that included collaboration with other professionals. some participants also highlighted that this multidisciplinary approach included family involvement. i gede putu d.s., nurse’ perception about responsibility of care media ners, volume 1, nomor 2, oktober 2007, hlm 49 82 family involvement the place of the family in the management of decubitus ulcer care was also addressed by the participants. according to lima, although the contribution of nurses and other health care team members was significant in decubitus ulcer management, the role of the family was also substantial. she stated: i think all of the health care teams must be responsible in general…but with help from other parties such as doctors and more importantly from families...because support, motivation and cooperation from families or a patient’s guardian are very important. (lima, p. 4) to these participants, family involvement in nursing care was perceived as mutually beneficial. this relationship was perceived by the interviewed participants as being very significant indeed and involved a kind of family empowerment in the ward because the family was seen to be able to help nurses in providing simple nursing care. kanem alluded to the benefits of the family being knowledgeable about prevention strategies. she stated: …as nurses we can’t do that [decubitus ulcer care] alone…it is because patients are sometimes obese…besides we are educating families to prevent ulcers. therefore, families understand about preventing decubitus ulcers. (kanem, p. 5) it was considered important for families to have adequate prevention knowledge because the family appeared to be criticised by nurses in this study if decubitus ulcers occurred in patients. pitu described this situation as follows: …because of lack of knowledge about decubitus ulcers among families. therefore, patients are very susceptible to getting decubitus ulcers; besides with less knowledge comes less ability as well as less motivation from their families to prevent decubitus ulcers. (pitu, p. 4) because of the perceived need for family involvement in decubitus ulcer care, especially in its prevention, family involvement was identified by these nurses as a risk factor in pressure ulcer development. lima explained: the main factor [in decubitus ulcer development], i think, is family involvement, because if we compare, for example, two patients who have the same degree of risk of getting decubitus ulcers, but one family is very cooperative and willing to help [compared to another situation where there is no family involvement]. we would suggest the family help with positioning patients left or right, but not all patients would actually be given a hand. it [family involvement] influences the incidence; therefore one patient [with family involvement] does not develop an ulcer whereas another one [without family involvement] does. (lima, p. 5) participants in this study also emphasised the role of the family in terms of providing financial support. according to the nurses in this study, economic conditions impacted on maintaining the quality of i gede putu d.s., nurse’ perception about responsibility of care media ners, volume 1, nomor 2, oktober 2007, hlm 49 83 care. if financial difficulties existed, this impacted on the capacity of the patients or their families to afford hospitalisation. as a result, families tried to keep patients in home care as long as possible and then when patients were finally admitted to hospital they were often in a more advanced stage and some had already developed decubitus ulcers. lima stated: i think it is a financial problem… the problem in indonesia currently; people will not come to hospital if they are not in an obvious sick condition. if it is not thought to be a critical condition, families will not bring them to hospital…the problem is financial. [there is] less financial support. finally after they arrive in hospital, the patients are really in a critical condition. (lima, p. 4) furthermore, lima, who had previous experience in a higher ward class, made a strong point about how the economic conditions of patients were very significant factors in being able to prevent decubitus ulcers. patients or families with a higher income level could afford appropriate preventative equipments for decubitus ulcers. she said: it really depends on access to appropriate equipment, for example, the patient who is able to afford a water mattress. that helps to prevent pressure ulcers. (lima, p. 3) participants’ comments on the responsibility for care suggested that preventing and managing decubitus ulcers were not only that of nurses. there were contextual considerations in the indonesian setting. although patients were being hospitalised, families were heavily involved in the maintenance of adequate care for patients with decubitus ulcers including positioning patients, giving a wash, assisting with food and applying massage. discussion the nurses in this study identified several factors in the responsibility for care in decubitus ulcer management, namely: nurses themselves, other health care professionals, the patient’s family and the patient’s circumstances. these will be used as a basis for the ensuing discussion. caring responsibility of nurses and other health care professionals the findings under the theme of responsibility for care, demonstrated that nurses in this study were aware of the duty of care for nurses in decubitus ulcer care. these findings are in line with several previous studies which emphasise that decubitus ulcer care is a nursing domain (gould et al., 2000; lyder, 2003; moore, 2001). however, careful interpretation and understanding are essential in handling this issue because patients and their families are often overlooked in this issue, being often viewed as a result of ‘substandard nursing care’ (lockhart, 2002, p. 64). there are several factors, i gede putu d.s., nurse’ perception about responsibility of care media ners, volume 1, nomor 2, oktober 2007, hlm 49 84 known as pressure ulcer risk factors, which make a very significant contribution in the development of pressure ulcers. these factors include ageing, sensory perception, immobility, malnutrition, mental status, incontinence, moisture, friction, shear and smoking (baranoski & ayello 2004; lueckenotte, 2000). the findings in this study highlighted the ways in which the responsibility of care in decubitus ulcer management was not solely a nursing responsibility but it was also a collaborative process. other health care team members have a significant contribution to this area of practice. lueckenotte (2000) considers nurses as front-line providers and managers of care’ in decubitus ulcer practice (p. 680). nurses, in decubitus ulcer management, not only act independently when patients are identified as being at risk of the development of pressure ulcers, but also they collaborate with other health care team members in relation to providing adequate care for patients (chambers, 1997). patient’s family and patient’s circumstances while these findings are in accord with several previous studies which emphasise the role of nurses and other health care teams in decubitus ulcer management, there are significant variations between them. according to the participants, nurses and other health care professionals such as doctors and physiotherapists are not the only team responsible for duty of care in decubitus ulcer prevention and management. in asia, there is a general assumption that people rely on their families including their children and extended relatives, to provide substantial support (kreager, 2003). this support includes physical, psychological and financial support. in indonesia specifically, family issues in decision-making and also in caring for sick family members is very important (nursasi, 1999; sahar, courtney & edward, 2003). this situation may differ from the western perspective which has the concept of ‘individualistic’ rather than ‘collective’ care. western people tend to be more individualistic in managing their diseases (mclaughlin & braun, 1998). in indonesia, the concept of ‘collective’ means the society and the family as a whole unit and is not just about the individual. the findings of this study suggested that preventing and managing decubitus ulcers also required family involvement. in the indonesian context, even though patients were being hospitalised, families were heavily involved in the maintenance of adequate care for patients with decubitus ulcers. the family as a care giver in a home care setting has been widely discussed as an acceptable approach to nursing intervention (barusch, 1995; boise, congleton & shannon, 2005; o’brien et al., 1999; sahar, courtney & edwards, 2003). barusch (1995) names this as ‘mandated family responsibility’ (p. 316). however, there are limited studies addressing the issue of family involvement in hospitalised patients. the main role of family in chronic hospitalised wound care is to provide patients with psychological support (chambers, 1997). the findings of this study suggested i gede putu d.s., nurse’ perception about responsibility of care media ners, volume 1, nomor 2, oktober 2007, hlm 49 85 that the role of family in hospitalised patients was not only in maintaining psychological and financial support, but also in providing direct care such as changing patients’ position, sponging, massage and feeding patients the practicalities of daily living activities. duty of care issues arise in regard to who is responsible for ensuring the safety of patients and the safety of families when families are giving direct care to hospitalised patients. families possess less knowledge about mobilisation and patients’ nutrition (petrella et al., 2005). they are also often poorly educated and prepared (sahar, courtney & edwards, 2003) and they may also have emotional difficulties related to their family members being ill (eisenberger & zeleznik, 2003). therefore, their actions may produce harmful effects on patients and themselves. inappropriate procedures for changing patients’ positions and sponging may increase friction to patient’s skin. family also can endanger their own safety because of inadequate lifting and handling techniques (brown & mulley, 1997). according to a study by brown & mulley (1997), family members developed back injury as a result of repositioning their relatives. this is an important consideration for nurses when they involve family members in nursing care. nurses therefore have a role in educating patients’ relatives about safe handling techniques in mobilising patients and other ‘mandated family responsibilities’. the question of who is responsible in ensuring the safety of patients and the safety of families when families are giving direct care in hospitalised patients remains unresolved according to contemporary studies because of the limited number of studies that specifically address this issue. considering it is a hospital based care, the responsibility appears to rest with health care team members, especially nurses. therefore, appropriate education and adequate training for the family are essential in ensuring quality care when involving the family in giving any direct care to hospitalised patients. financial concerns are a crucial issue in managing decubitus ulcers in hospitalised patients. this study demonstrated the significance of family involvement in providing financial support. this is supported by a previous study which reveals that financial support from the family is an important issue in the indonesian context (nursasi, 1999). however, many indonesians face financial constraints particularly in times of economic crisis. the low economic status of the patients or their families reduces the level of affordability of hospitalisation and impacts adversely on the hospital system’s ability to provide adequate preventative equipment as well as treatment regimes. the ward classification system in indonesia demonstrates this situation clearly and providing a good example of how the classification of the health system in indonesia works. a family with medium or low economic income can only afford hospitalisation in the economic class. in this class, such as the ward where this research was conducted, the facilities are usually very limited. for example, in this class, the bed is not adjustable, and the mattress is not a pressure-redistributing type i gede putu d.s., nurse’ perception about responsibility of care media ners, volume 1, nomor 2, oktober 2007, hlm 49 86 mattress. in the higher ward class, the bed is adjustable and the mattress is better for pressure area management. however, there is no study reporting a higher incidence of decubitus ulcer in the economic class compared to higher class ward. the issue of whether the ward classification system and the economic level of patients or families affects the incidence and the treatment of decubitus ulcers needs further research and analysis beyond the scope of this study. in summary, nurses, other health care team members and families were viewed to be responsible for decubitus ulcer management. the role of nurses and other health care team members were clearly and widely acceptable. considering the critical role of family involvement identified by participants in this study, family involvement appeared to be viewed as one factor relevant to the development of pressure ulcers in hospitalised patients. although family involvement is substantial in this area of nursing practice in indonesia, further study and analyses are essential when involving family in giving direct care for hospitalised patients with pressure ulcers and especially with regard to consideration of the safety of patients and families. conclusion nurses, other health care team members and patients’ families were identified by this study as being responsible for decubitus ulcer management in hospitalised patients. the role of nurses and other health care team members were clearly and widely accepted in maintaining a heightened quality of care in the area of decubitus ulcer management. another interesting finding in this study was that nurses involved the family in providing direct care to patients in the hospital setting. based on the conclusion above, there are several recommendations. firstly, nurses are required to deliver high quality care for patients; and therefore, they should have an adequate knowledge in the area of decubitus ulcers as a basis of their practice, secondly, family education and training is essential in ensuring family and patients’ safety when involving the families and relatives in providing direct care for patients. these training needs should be incorporated directly and evaluated carefully in the patients’ care plan on a regular basis. reference baranoski, s & ayello, e.a. 2004. wound care essential: practice principles. philadelphia: lippincott willams & wilkins. barusch, a.s. 1995. programming for family care of elderly dependents: mandates, incentives and service rationing. social work, 40 (3), 315-21. i gede putu d.s., nurse’ perception about responsibility of care media ners, volume 1, nomor 2, oktober 2007, hlm 49 87 boise, l, congleton, l & shannon, k. 2005. empowering family caregivers: the powerful tools for caregiving program. educational gerontology, 31, 573-86. brown, a.r & mulley, g.p. 1997. injuries sustained by caregivers of disabled elderly people. age and ageing, 26, 21-23. chambers, n. 1997. the holistic management of pressure sores in terminal illness. journal of wound care, 6 (8), 359-60. eisenberger, a & zeleznik, j. 2003. pressure ulcer prevention and treatment in hospices: a qualitative analyses. journal of palliative care, 19 (1), 9-14. gould, d, james, t, tarpey, a, kelly, d, pattison, d, & fox, c. 2000. intervention studies to reduce the prevalence and incidence of pressure sores: a literature review. journal of clinical nursing, 9, 163-77. grbich, c. 1999. qualitative research in health: an introduction. australia: allen & unwin. kreager, p. 2003. understanding elderly vulnerability in indonesia. iias newsletter, 32, 12. lockhart, d.g. 2002. the legal implications of pressure ulcers in acute care. critical care nursing quarterly, 25 (1), 63-68. lueckenotte, a.g. 2000. gerontologic nursing (2 nd edn). usa: mosby. lyder, c. 2003. pressure ulcer prevention and management. american medical association, 289 (2), 223-4. moore, z. 2001. improving pressure ulcer prevention through education. nursing standard, 16 (6), 64-70. moore, z. 2004. pressure ulcer prevention: nurses’ knowledge, attitudes and behaviour. journal of wound care, 13 (8), 330-4. nursasi, a. 1999. case study: the contributing factors of patients’ adherence to tuberculosis treatment in jakarta, indonesia., [unpublished masters thesis]. adelaide: flinders university. o’brien, sp, gahtan, v, wind, s & kerstein, m.d. 1999. what is the paradigm: hospital or home health care for pressure ulcers? the american surgeon, 65 (4), 303-6. patton, m.q. 1990. qualitative evaluation and research methods (2 nd edn). california: sage publication. petrella, f, nebbioso, g, gallucci, a, corona, g, collin, a, fiocco, s, notarangelo, s & maio, g. 2005. the importance of family and domiciliary treatment of immobile patients with chronic wounds. ewma journal, 5 (1), 16-21. polit, d & beck, c. 2004. nursing research: principles and methods (7 th ed). philadelphia: j.b. lippincott company. i gede putu d.s., nurse’ perception about responsibility of care media ners, volume 1, nomor 2, oktober 2007, hlm 49 88 roberts, k & taylor, b. 2002. nursing research process: an australian perspective (2 nd edn). australia: national library of australia. sahar, j, courtney, m & edwards, h. 2003. improvement of family carers’ knowledge, skills and attitudes in caring for older people following the implementation of a family 'carers’ training program in the community in indonesia. international journal of nursing practice, 9, 246-54. sandelowski, m, docherty, s & emden, c. 1997. qualitative metasynthesis: issues and techniques. research in nursing & health, 20, 365-71. nurse media journal of nursing, 1, 2, juli 2011, 211-223 211 dietary behaviors among patients with type 2 diabetes mellitus in yogyakarta, indonesia yanuar primanda, s. kep., ns 1 , charuwan kritpracha, rn., ph.d. 2 , ploenpit thaniwattananon, rn., ph.d 3 purpose: to describe dietary behaviors and examine relationships between selected factors and dietary behaviors among type 2 diabetes mellitus (t2dm) patients in yogyakarta, indonesia. method: seventy t2dm patients from a hospital in yogyakarta who met the inclusion criteria were recruited. patient’s dietary behaviors were measured by the dietary behaviors questionnaire developed for this study with adequate reliability. the questionnaire comprised of four dimensions: recognizing the amount of calorie needs, selecting healthy diet, arranging a meal plan, and managing dietary behaviors challenges. higher scores indicate better dietary behaviors. result: more than half of the patients were women (54.3%) with an average age of 56.8 years and diabetes duration of 9.7 years. the results revealed a moderate level of the total score of dietary behaviors. considering each dimension, the results showed a moderate level of recognizing the amount of calorie needs, selecting healthy diet, and managing dietary behaviors challenges. the patients reported a high level of arranging meal plans. pearson’s correlation was used to examine the relationships between selected factors and dietary behaviors. there was a positive significant relationship between the knowledge regarding diabetic diet and the total dietary behaviors scores (r = .36, p< .01). there were positive significant relationships between the knowledge regarding diabetic diet and the dimensions of recognizing the amount of calorie needs (r = .27, p< .05), selecting healthy diet (r = .35, p< .01), and managing dietary behaviors challenges (r = .28, p< .05). in contrast, the findings indicated no significant relationship between knowledge regarding diabetic diet and arranging a meal plan dimension. furthermore, there was no significant relationship between the diabetes duration and dietary behaviors. conclusion: dietary behaviors among t2dm patients in yogyakarta were at a moderate level. knowledge regarding diabetic diet is essential. further study regarding intervention in increasing patients’ knowledge is needed to achieve better dietary behaviors. keywords: dietary behaviors, type 2 diabetes mellitus, knowledge, yogyakarta, indonesia 1 master student, master of nursing science (international program), faculty of nursing, prince of songkla university, thailand and nursing lecturer of nursing school, faculty of medicine and health science, muhammadiyah university of yogyakarta, indonesia (corresponding author: andromeda_prim@yahoo.com) 2 lecturer, department of medical nursing, faculty of nursing, prince of songkla university, thailand 3 assistant professor, department of medical nursing, faculty of nursing, prince of songkla university, thailand mailto:andromeda_prim@yahoo.com dietary behaviors among patients with type 2 diabetes mellitus nurse media journal of nursing, 1, 2, juli 2011, 211-223 212 background diabetes mellitus (dm) is a worldwide health problem. in indonesia, the prevalence of dm was about 8.4 million in 2000 and is projected to increase up to 21.3 million in 2030 (wild, roglic, green, sicree, & king, 2004). in jogja hospital, a secondary hospital in yogyakarta indonesia, dm is the first in the top ten diseases in the outpatient departments (opd). the prevalence of dm in this hospital was 8,138 patients in 2007 and increased to 9,816 patients in 2008 with most of them (88.98%) being diagnosed with type 2 diabetes mellitus (t2dm) (jogja hospital, 2008). in most cases of t2dm, lifestyle modification, including dietary behaviors, become the first choice of diabetes management (williams & pickup, 2004). following dietary behaviors recommendations are important to control blood glucose levels (pastors, warshaw, daly, franz, & kulkarni, 2003; swinburn, metcalf, & ley, 2001), improve health status, and prevent complications (wing et al., 2001). however, several studies in western countries revealed that diabetic patients often did not follow the dietary behaviors recommendations (lin, anderson, hagerty, & lee, 2008; nagelkerk, reick, & meengs, 2005; nelson, reiber, & boyko, 2002). several factors contributing to patients’ dietary behaviors were identified from the previous studies. knowledge was believed to be the significant factor that influences dietary behaviors (backman, haddad, lee, johnston, & hodgkin, 2002). savoca and miller (2001) stated that knowledge of a recommended diet for diabetic patients influence patients’ food selection and dietary behaviors. nevertheless, the relationship between knowledge and dietary behaviors was inconclusive (chan & molassiotis, 1999; persell et al., 2004) thereby, limiting the generalizability of the previous study result. in indonesia, several studies were conducted to measure dietary behaviors among non diabetic patients. the study from djuwita, purwantyastuti, and kamso (2003) found that the minangkabau ethic group, one of the biggest ethnic groups in indonesia, preferred to consume high fat foods which lead to dyslipidemia and risk for cardiovascular diseases. another study from atmarita (2005) found that indonesian people in rural areas consumed excessive cereals (carbohydrate) while people in urban areas consumed excessively processed foods. those dietary behaviors should be avoided by t2dm patients. however, considering that indonesia consists of numerous distinct ethnic, linguistic, and religious dietary behaviors among patients with type 2 diabetes mellitus nurse media journal of nursing, 1, 2, juli 2011, 211-223 213 groups across numerous islands, the results from the previous studies could not be generalized easily. the guidelines on the management of t2dm in indonesia were established by the indonesian endocrinologist society (perkeni) and emphasize education, dietary behaviors, and exercise. however, these guidelines were developed based on western culture. the influence of socio-cultural and religious backgrounds was hardly considered in the management of diabetes (kanbara et al., 2007). therefore, dietary behaviors and its contributing factors among t2dm patients in yogyakarta, indonesia need to be investigated to fill those gaps. objectives the objectives of this study were: (1) to describe dietary behaviors among t2dm patients in yogyakarta, indonesia, and (2) to examine relationships between selected factors and dietary behaviors among t2dm patients in yogyakarta, indonesia. methods setting this study was conducted at the medical opd of jogja hospital. this hospital is a secondary hospital in yogyakarta, indonesia. in this hospital, t2dm patients in ambulatory care attend a regular check-up at the medical opd once a month. sample seventy t2dm patients who met the inclusion criteria were recruited. the inclusion criteria included an age of more than 18 years old, current fasting blood glucose (fbg) ≥ 126 mg/dl, and the ability to communicate in indonesian language both verbally and written. the patients who consented to participate in the study were recruited. data collection instruments demographic data questionnaire (ddq). the ddq was used to collect patient’s demographic data. this questionnaire was completed by using a check on the forced choices and/or fill in the blanks in the format. several sources of data including medical records, direct interviews, and direct measurement were used to complete this questionnaire. data about patient’s age, gender, marital status, religion, educational level, experience of receiving dietary educational programs, occupation, total monthly income, dietary behaviors among patients with type 2 diabetes mellitus nurse media journal of nursing, 1, 2, juli 2011, 211-223 214 health insurance, comorbid disease, and the duration of having diabetes were collected from a direct interview with the patients. current medication and current fasting blood glucose (fbg) results were collected from patient’s medical records. fbg was classified into three categories based on ada and (2009) and mcadam-marx, bouchard, aagren, conner, and brixner’s work (2011) as follows: controlled glycemia (fbg ≤ 153 mg/dl), intermediate glycemia (fbg 154 -211 mg/dl), and poorly controlled glycemia (≥ 212 mg/dl). the patient’s body weight and height needed to determine the patients’ body mass index (bmi) were measured directly by weight and height measurement tools which were regularly calibrated by the hospital technician to ensure validation. the patient’s bmi was classified based on who expert consultation (2004) as follows: underweight (bmi <18.5), normal weight (bmi = 18.5 22.9), overweight (bmi = 23 24.9, and obesity (bmi ≥25). knowledge of diabetic diet questionnaire (kddq). the kddq was used to measure the patients’ current knowledge about dietary behaviors in patients with t2dm. it was a 13-yes/no set of questions. the results showed that the reliability of knowledge on diabetic dietary behaviors by using the kr-20 formula was .58. patients’ knowledge was categorized into three categories: low (score 0 4.32), moderate (score 4.33 – 8.65), and high (score 8.66 – 13). dietary behaviors questionnaire (dbq). the dbq, a self-reported dietary behaviors questionnaire, was developed by the researcher based on a review of dietary behaviors in patients with t2dm and several tools used to measure dietary behaviors in the indonesian population including the dietary behaviors questionnaire developed by nazir (2009) and the nutritional health promoting behaviors questionnaire (nhpb) developed by sukmarini (2007). the dbq comprised of four dimensions (33-item statements): recognizing the amount of calorie needs (4-item), selecting healthy food (16item), arranging a meal plan (6-item), and managing dietary behaviors challenges (7-item). the rating scale of the dbq was a 4-likert scale (“1” = never, “2” = sometimes, “3” = often, and “4” = routinely). the total scores of dbg ranged from 33 to 132. the higher score of smdbg indicated better dietary behaviors. three experts content validated the instruments. the reliability test by using cronbach’s alpha coefficient of the dbq was .73 which was considered as reliable for newly developed instruments (polit & beck, 2008). dietary behaviors among patients with type 2 diabetes mellitus nurse media journal of nursing, 1, 2, juli 2011, 211-223 215 the dietary behaviors were classified into three categories: low (score 33 – 65.99), moderate (score 66 – 98.99), and high (score 99 – 132). ethical consideration this study was conducted with the intention of protecting the human rights of all the patients. the researcher asked for approval from the institutional review board (irb) of the faculty of nursing, prince of songkla university, thailand. the patients were approached with all needed information before giving written or verbal consent. they had the right to refuse to participate without any penalty. the identity of all patients was coded anonymously and the data collected from patients were destroyed after completion of the data analysis. data analysis both descriptive statistics and inferential statistics were used in this study. descriptive statistics were used to describe the demographic and clinical characteristics, and patients’ dietary behaviors. assumption tests of pearson correlation coefficient were performed prior to data analysis. the findings showed that the patients’ knowledge was negatively skewed (-5.34). thus, the data transformation was done based on munro (2001). as a result, the distribution of the variable after the data transformation was normally distributed (skewness/se of skewness = .70). it allowed the researcher to use pearson correlation coefficient to measure the mean difference of patients’ knowledge on dietary behaviors between the control group and the experimental group. results demographic characteristics seventy t2dm patients completed the questionnaire. the average age was 56.80 years (sd = 7.08, min-max age 38-73 years). more than half of the patients were women (54.3%). the majority of the patients were married (91.4%). more 55.7% of the patients had experience in receiving previous dietary educational programs, either formal or informal from jogja hospital’s staff. the results showed that 92.9% of the patients had a high level of knowledge about the diabetic diet (m = 11.44, sd = 1.66, min-max score = 6 13). see details in table 1. dietary behaviors among patients with type 2 diabetes mellitus nurse media journal of nursing, 1, 2, juli 2011, 211-223 216 table 1 demographic characteristics of the patients (n = 70) characteristics n % age (m = 56.80, sd = 7.08, min-max age 38-73 years) middle age (34 – 59 years) 42 60.0 elderly (≥ 60 years) 28 40.0 gender female 38 54.3 male 32 45.7 marital status married 64 91.4 widow 6 8.6 religion muslim 60 85.7 other 10 14.3 monthly income < 1,000,000 idr 8 11.4 1,000,001 – 2,000,000 idr 24 34.3 > 2,000,001 idr 38 54.3 education level no schooling to primary school 18 25.7 high school 18 25.7 college/university 34 48.6 occupation housewife/retired 41 58.6 teacher/governmental staff/private employer 29 41.4 received previous educational program yes 39 55.7 no 31 44.3 knowledge about diabetic diet (m = 11.44, sd = 1.66, minmax score = 6 13) moderate 5 7.1 high 65 92.9 health insurance yes 65 92.9 no 5 7.1 clinical characteristics dietary behaviors among patients with type 2 diabetes mellitus nurse media journal of nursing, 1, 2, juli 2011, 211-223 217 considering the patients’ clinical characteristics, the results showed that the average duration of having diabetes was 9.70 years (sd = 8.08, min-max duration = 0.17 – 28 years). more than 41% of the patients had poorly glycemic control (fbg ≥ 212 mg/dl) with an average fbg of 215.43 mg/dl (sd = 93.08, min-max fbg = 127-597 mg/dl). more than half of the patients were obese (51.5%, m = 25.32, sd = 4.77, min-max bmi = 16.22 – 39.52). see details in table 2. table 2 clinical characteristics of the patients (n = 70) characteristics m (sd) n % duration of diabetes mellitus 9.70 (8.08) fasting blood glucose 215.43 (93.08) controlled 22 31.4 intermediate 19 27.1 poorly controlled 29 41.4 body mass index 25.32 (4.77) underweight 3 4.3 normal 19 27.1 overweight 12 17.1 obese 36 51.4 comorbid disease yes 38 54.3 no 32 45.7 common comorbid diseases hypertension 5 13.2 hypercholesterolemia 5 13.2 others 28 73.7 receiving oral hypoglycemic agents yes 68 97.1 no 2 2.9 prescribed oral hypoglycemic agents sulphonlyureas 4 5.9 biguanides 8 11.8 combination 56 82.4 patients’ dietary behaviors the results on total dietary behaviors showed that the patients with type 2 diabetes mellitus had a moderate level of dietary behaviors (m = 89.44, sd = 13.83, min-max score = 63 – 124). considering each dimension of dietary behaviors, results showed moderate levels of recognizing the amount of calorie needs, selecting a healthy diet, and managing dietary behaviors among patients with type 2 diabetes mellitus nurse media journal of nursing, 1, 2, juli 2011, 211-223 218 dietary behaviors challenges. the patients reported a high level in the arranging meal plan dimension (table 3). table 3 mean, standard deviations, and the levels of dietary behaviors (n = 70) no variables possible score min-max score mean sd level 1. recognizing the amount of calorie needs 4 16 4 16 10.26 3.18 moderate 2. selecting healthy diet 16 64 26 61 42.21 6.86 moderate no variables possible score min-max score mean sd level 3. arranging a meal plan 6 24 9 24 17.87 3.52 high 4. managing dietary behaviors challenges 7 28 12 27 18.90 3.51 moderate 5. total dietary behaviors 33-132 63 124 89.44 13.83 moderate the relationship between selected factors and dietary behaviors the results showed that there was a positive significant relationship between the knowledge regarding diabetic diet and total dietary behaviors scores (r = .36, p < .01). there were positive significant relationships between knowledge regarding diabetic diet and dimensions of recognizing the amount of calorie needs (r = .27, p < .05), selecting healthy diet (r = .35, p < .01), and managing dietary behaviors (r = .28, p < .05), except for the dimension of arranging a meal plan. the level of relationship was considered as low (munro, 2001). in addition, the findings indicated no significant relationship between the duration of having diabetes and dietary behaviors. table 4 correlation coefficient between selected factors and dietary behaviors (n = 70) no variables age duration of dm knowledge a 1. total dietary behaviors -.02 .07 .36** 2. recognizing the amount of calorie needs .11 .17 .27* 3. selecting healthy diet .05 .03 .35** 4. arranging a meal plan -.13 -.06 .23 5. managing dietary behaviors challenges .06 .14 .28* dietary behaviors among patients with type 2 diabetes mellitus nurse media journal of nursing, 1, 2, juli 2011, 211-223 219 note. * p < .05, ** p < .01, a knowledge data after log transformation. discussion generally, the results of the current study showed that the dietary behaviors of t2dm patients in yogyakarta, indonesia were at a moderate level. there are several factors that might contribute to this result. the first factor that might contribute to the moderate level of dietary behaviors is cultural background. the patients in this present study were patients living in yogyakarta culture in which most of the foods contain high sugar and calories which limit the availability of food choices. moreover, several social and family gatherings such as a wedding ceremony or a community meeting placed the patients in a challenging situation to control their dietary behaviors. not only that, several behaviors that are important for the patients to control their dietary behaviors such as ordering a half portion of food (when buy food) and refusing offered foods (which contain high sugar, calories, and fat) and asking for other healthier foods other than that already offered were considered as impolite. considering recognizing the amount of calorie needs, measuring food by using grams or ounces for each meal was not the common behaviors and considered as complicated measures by the patients. cultural background influences diabetic’s dietary behaviors (misra & lager, 2009). this finding of the current study is consistent with the study from sowattanangoon, kotchabhaikdi, and petrie (2009) among diabetics in thailand. they found that reducing the consumption of rice was difficult for patients to do because rice had been their staple food since they were very young. moreover, the study from lanting, joung, vogel, bootsma, lamberts, and mackenbach (2008) found that refusing offered food was considered as culturally impolite among turkish and moroccan patients and eating food different to the rest of the family was also considered as culturally impolite among dutch patients. the second factor that might contribute to the moderate level of dietary behaviors is total monthly income. the study found that the majority of patients (68.6%) had a monthly income of 1,000,000 3,000,000 idr (equal to 114 – 342 usd). based on a decree by the governor of yogyakarta 2009 this monthly income was considered more than the minimum income for people in yogyakarta since the minimum income was 745,694 idr (equal to usd 85). this adequate income is important to ensure that the dietary behaviors among patients with type 2 diabetes mellitus nurse media journal of nursing, 1, 2, juli 2011, 211-223 220 patients are able to afford healthy food rather than high calorie and high carbohydrate foods. a low income was considered as one barrier to manage dietary behaviors among patients with type 2 diabetes (albarran, et al., 2006; vijan et al., 2005). the third factor might relate to the experience in receiving either formal or informal education on dietary behaviors. the result showed that the majority of patients had experience in receiving dietary educational programs, either formally or informally from opd of jogja hospital’s staff. this experience is important for the patients to gain more knowledge in order to control their dietary behaviors. patients who were informed about their illness and its treatment were more likely to succeed in managing their illness (ellis et al 2004). the findings of the study revealed that there was no significant relationship between the duration of being diagnosed with t2dm and dietary behaviors, while there was positive significant relationship between knowledge regarding diabetic diet and dietary behaviors. concerning each of the dimensions of dietary behaviors, there were positive significant relationships between knowledge regarding diabetic diet and other dimensions of dietary behaviors except for the dimension of arranging a meal plan. knowledge was a salient factor related to dietary behaviors control (backman et al., 2002). moreover, patients’ knowledge on a recommended diet reflected their understanding of dietary guidelines which influenced their food selection and eating patterns (savoca & miller, 2001). the relationship between knowledge and dietary behaviors among t2dm patients in previous studies were inconsistence. the study from chan and molassiotis (1999) found that there was no relationship between knowledge and compliance on dietary behaviors. on the other hand, a study from persell et al. (2004) found that a high knowledge score was associated with following dietary recommendations and knowledgeable patients were more likely to perform self-management activities. in this present study, the patients’ knowledge on diabetic dietary behaviors was measured by knowledge instruments developed by the researcher. indeed, this instrument had low reliability (cronbach’s alpha coefficient .58). therefore, the knowledge score on this study should be interpreted with caution. conclusions dietary behaviors among patients with type 2 diabetes mellitus nurse media journal of nursing, 1, 2, juli 2011, 211-223 221 in conclusion, dietary behaviors among type 2 diabetic patients in yogyakarta, indonesia were at a moderate level. cultural background, monthly income, and experience in receiving dietary education programs might contribute to this moderate level of dietary behaviors. knowledge of a diabetic diet is essential and statistically significantly related to the patients’ dietary behaviors. recommendations nurses should consider patients’ knowledge about a diabetic diet when dietary behaviors are the target outcome to be improved. further study regarding intervention and increasing patients’ knowledge is needed to achieve better dietary behaviors. acknowledgements the researcher wants to acknowledge several contributors for their valuable role in this study as follows: (1) faculty of medicine and health sciences, muhammadiyah university of yogyakarta, indonesia for full support funding during the study at the faculty of nursing, prince of songkla university, thailand, (2) graduate school and faculty of nursing prince of songkla university, thailand, for partial funding during the study, (3) all of experts, assist. prof. dr. jaruwan manasurakarn (prince of songkla university, thailand), assist. prof. dr. valla tantayotai (walailak university, thailand), and mr. timor hariyadi, dcn (jogja hospital) for their valuable suggestions on instruments validation, and (4) all of respondents enrolled in this research. references ada. 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(2004). handbook of diabetes (3 rd ed.). oxford, uk: blackwell publishing. wing, r. r., goldstein, m. g., acton, k. j., birch, l. l., jakicic, j. m., sallis, j. f., et al. (2001). behavioral science research in diabetes: lifestyle changes related to obesity, eating behavior, and physical activity. diabetes care, 24, 117-123. copyright © 2016, nmjn, p-issn 2087-7811, e-issn 2406-8799 nurse media journal of nursing, 6 (2), 2016, 47 58 available online at http://ejournal.undip.ac.id/index.php/medianers extent of collaboration in building academic – service partnerships in nursing cyruz p. tuppal1, mark donald reñosa2, said nasser al harthy3 1adjunct faculty, st. paul university philippines system; senior clinical tutor, oman specialized nursing institute, ministry of health, oman; honorary tutor, cardiff university, united kingdom. 2 science research specialist, research institute for tropical medicine, philippines. 3senior faculty, oman specialized nursing institute, oman; honorary tutor cardiff university, uk corresponding author: cyruz p. tuppal (drcyruztuppal@gmail.com) abstract background: there is a growing concern in the nursing service industries to expand the roles of nurses. a well-developed and planned collaboration between the academic and services in nursing is required. purpose: this study investigated the extent of collaboration in building academic-service partnerships based on the perceptions of the students, faculty, staff nurses, and nursing administrators. methods: this study employed a descriptive research design to obtain a thorough picture about the extent of collaboration in building academic and service partnerships. the majority of the participants (n=500) were staff nurses (n=232, 46.4%) from 5 hospitals, students (n=160, 32%) and faculty (n=62, 12.4%) from 7 schools who were informed, consented and selected using a purposive sampling. a questionnaire was used to describe the extent of collaboration. descriptive statistics such as mean, standard deviation, frequency, and the percentage were used. results: students, faculty, nursing administrators and staff nurses assessed the overall extent of collaboration in building academic-service partnerships to a great extent in terms of nursing education redesign, research collaboration, faculty practice, academic and clinical progression, and workforce development. conclusion: despite the fact there was a great extent of collaboration in building academic-service partnerships in nursing, the proposed intervention or enhancement program can be an instrument to strengthen the current status of nursing amidst radical reforms in the healthcare delivery. keywords: academic-service partnerships; collaboration; nursing 48 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (2), 2016, background the nursing profession around the globe is facing mounting pressures. for instance, the nursing education sector is bombarded with faculty and clinical staff shortage, burdened curriculum, and inadequate precollegiate preparation of the students. on the other hand, there is a growing concern in the nursing service industries to expand the roles of nurses, a heightened need for evidence-based practice, the impact of professional regulations and legislations in the practice of nursing, generational differences, and radical reforms in healthcare delivery system (cuellar & zaiontz, 2013). concomitantly, a strong connectivity has been established between these issues and diminished patient care, inefficient nursing practice, failure or excessive lag time in incorporating or deleting clinical practices based on the current evidence (hanberg & brown, 2006). the partnerships between the academic and service institutions in nursing should be well developed to deal with the emerging problems related to the nursing practices, education and research. an integrative review by beal et al. (2012) described that partnerships between academic and service settings provide many benefits such as cost effectiveness, good patient outcomes, positive student learning, increased research productivity, and faculty satisfaction. thus, to address these issues, academic and service institutions in nursing strategically developed the concept of collaboration since the beginning of the 21st century. however, schmitt (2001) insisted that the evidence to support this assertion remains sparse. he added that a need for a new paradigm and new practice models of collaborative partnerships should be developed. furthermore, the type of traditional relationships, behaviors and partnerships of academic and service no longer match the needs of an emerging and reforming health care system. objective this descriptive research study investigated the extent of collaboration in building academic-service partnerships based on the perceptions of the students, faculty, staff nurses, and nursing administrators. methods this descriptive research was appropriate for describing, exploring, and explaining the extent of collaboration between the academic and service partnerships in nursing. prior to the study, an approval was received from the institution in which the study was taking place, and also from the participants. a purposive sampling was utilized. the institutional selection eligibility criteria were (1) universities or colleges affiliated to one base hospital; (2) an integrated approach to the delivery of the joint program, whereby both the college and the university faculty teach in all four years of the program; (3) an articulated approach, meaning clear lines of separate teaching responsibilities between the college and the university faculty, with separate and distinct years of program delivery between the partners; and (4) an extended period before a formal agreement was reached. the participants were selected based on the following criteria: (1) nursing administrators who were currently holding administrative positions including the dean, coordinators for faculty, instruction, research, and among others for nursing schools. for the service, 49 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (2), 2016, nursing administrators are those who are currently holding chief executive officer, nursing directors, nurse supervisor and nurse managers; (2) faculty and clinical staff including those who have at least three-year experience, directly responsible for classroom and clinical supervision, while clinical staffs are those working in the hospitals, should have at least three-year experience in the hospital, and experience in student clinical supervision; and (3) students are those who are currently enrolled, having regular academic status, and have undergone related clinical learning experiences at the time of the data collection. for the quantitative data particularly on the demographic variables of participants, the extent of collaboration in building academic-service partnerships, descriptive statistics were used including frequency, percentage, means and standard deviations. results the findings of this study revealed that the participants evaluated the extent of collaboration in building academic – service partnerships as being met to a great extent referring to the nursing education (m=3.92, sd=0.72), research collaboration (m=3.76, sd=0.61), workforce development (m=4.02, sd=0.67), academic and clinical progression (m=3.96, sd=0.57), and faculty practice (m=4.05, sd=0.67). furthermore, the results revealed that in nursing education, participants agreed that both academic and service institutions in nursing collaborated to have a deep understanding of the enduring concepts of the discipline, as anchors for the many details students must learn (m=4.17, sd=0.71). in research collaboration, participants agreed that both academic and service institutions introduce nursing research and its contributions to healthcare outcomes (m=3.94, sd=0.71). in terms of workforce development, participants understood that both academic and service institutions work on a cooperative mechanism between the employers and employees to the potential workers and create a continued commitment and loyalty to the institution (m=4.10, sd=0.82). in terms of academic and clinical progression, the collaboration was done through partnering with practice colleagues to design creative collaborative initiatives to assure that the graduates are prepared to practice and to progress in their nursing education (m=4.18, sd=0.68). lastly, there was an evidence that formal communication processes between the clinical faculty coordinators and clinical instructors/teachers were regularly conducted as agreed by the participants in building academic – service partnerships (m=4.14, sd=0.67). table 1. extent of collaboration in nursing education redesign nursing education redesign mean sd 1. nursing education embeds program in the full development of the clinical expertise. 3.99 0.63 2. there is a deep understanding of the enduring concepts of the discipline, as anchors for the many details students must learn. 4.17 0.71 3. a deep knowledge of the methods where teachers can facilitate important learning, as well as an appreciation for the educational research literature. 3.83 0.72 50 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (2), 2016, nursing education redesign mean sd 4. engage in intensive dialogue with peers, students, and nursing service colleagues about the reform in nursing education. 3.78 0.67 5. explore new modalities and new key performance about nursing education. 3.95 0.76 6. create an evidence base for nursing education that embraces innovation, identifies best practices, and serves towards a diverse nursing population that can transform nursing practice. 3.83 0.87 7. re-examine clinical education in order to design new methods preparing students in today's health care environment challenges. 3.80 0.83 overall mean 3.92 0.72 table 2. extent of collaboration in research collaboration research collaboration mean sd 1. introduce nursing research and its contributions to healthcare outcomes. 3.94 0.71 2. have an opportunity to participate in research activity with a nurse as the lead investigator. 3.73 0.88 3. embrace, and to some extent, participate in the research mission in both fields of expertise. 3.84 0.67 4. provide a platform for the dissemination of nursing research that occurs throughout the academic and clinical setting. 3.78 0.81 5. commit to research and other scholarly endeavors in pursuit of excellence. 3.71 0.76 6. actively seek out interdisciplinary linkages within and outside of the academic and clinical community related to research, teaching, and service. 3.76 0.76 7. operationalize research related activities of the nursing education and clinical practice as a mandatory criterion measure for performance evaluation and upgrading of the career ladder. 3.66 0.84 8. develop written research agenda with execution of objectives in a time bound frame in which mentoring, interdisciplinary and collaborative scholarly initiatives. 3.66 0.72 overall mean 3.76 0.61 table 3. extent of collaboration in workforce development workforce development mean sd 1. the policies, procedures, protocols and standards set forth in nursing education and clinical practice are all anchored on national and international professional standards. 3.92 0.81 51 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (2), 2016, workforce development mean sd 2. collaborative partnerships between academic and service adhere and conform to the general policies of the hospital. 4.05 0.86 3. working on a cooperative mechanism between the employer and employee to the potential workers and create a continued commitment and loyalty to the institution. 4.10 0.82 4. there are sound personnel practices that resulting to a transparent written policies, procedures, protocols and standards reflecting the job, roles to be performed, quality services to be rendered and the purpose of the council and overall healthcare facility. 4.04 0.86 5. each job category is carefully studied and defined terms are clear, written and documented. 3.94 0.82 6. each job category is selected based on job specification and job analysis that yield job satisfaction to better individual performance and productivity. 4.05 0.74 overall mean 4.02 0.67 table 4. extent of collaboration in academic and clinical progression academic and clinical progression mean sd 1. facilitate discussions among faculty, students, practice partners, and other stakeholders across the nursing education and health profession communities regarding curriculum reform and promotion of academic progression. 3.99 0.88 2. increasing the quality of clinical education for the student as the highest priority for the nursing service and nursing education. 4.10 0.69 3. partner with practice colleagues to design creative collaborative initiatives to assure that the graduates are prepared to practice and to progress in their nursing education. 4.18 0.68 4. engage faculty, practice partners, and students by using the national roadmap and other international frameworks in guiding them to assume new roles through academic progression 3.95 0.79 5. develop programs and initiatives that support the ongoing academic progression of staff, enabling them to expand their competencies and implement new roles. 3.98 0.79 6. champion multi-site, research initiatives designed to test and evaluate the academic progression of students in all types of nursing educational programs. 3.70 0.78 52 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (2), 2016, academic and clinical progression mean sd 7. academic and clinical partners achieve higher levels of education and training through an improved education system that promotes the seamless academic environment. 3.88 0.79 8. supports collaboration of education and practice in creating accessible and affordable methods in healthcare and the academe. 3.85 0.73 9. provide faculty development opportunities create new academic and clinical progression curriculum models. 3.96 0.67 10. create partnerships with colleagues in education and practice to advocate for new curriculum models that will enable graduates to progress academically. 4.00 0.70 overall mean 3.96 0.57 table 5. extent of collaboration in faculty practice faculty practice mean sd 1. academic and clinical faculty meets regularly to discuss issues, share best practices, and coordinate clinical modalities. 4.06 0.70 2. formal communication processes between the clinical faculty coordinator and clinical instructors/teachers are regularly conducted. 4.14 0.67 3. receive orientation to prepare faculty for their clinical education role. 4.00 0.80 4. receive regular professional development and supervision. 4.00 0.84 5. ensure that the clinical curriculum objectives actively guide the learning experiences 4.05 0.80 6. revisit the educational program objectives of the curriculum 4.00 0.78 7. reexamine the learning tools and instructional materials. 4.00 0.83 8. provide various opportunities for the faculty practitioner regarding clinical services to keep skills current and meet licensure requirements. 4.15 0.81 overall mean 4.05 0.67 discussion nursing education redesign table 1 presents the extent of collaboration in building academic-service partnerships in terms of nursing education redesign. the overall mean of 3.92 reflected a great extent of evaluation. furthermore, it can be inferred, there was a deep understanding of the enduring concepts of the discipline, as anchors for the many details students must learn (m=4.17). in a rapid change of the healthcare delivery, nursing education institutions are required to produce highly skillful, innovation-driven, efficiency-driven, and results53 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (2), 2016, oriented practitioners in a highly regulated environment (boller & jones, 2010). in addition, frank (2008) surmised that effective partnerships could benefit both students and the agencies where clinical experiences take place. he further posited educators and service personnel must fully collaborate to provide the best education for future practitioners. in this regard, nursing education redesign aims to critically examine and identify the best teaching modalities and develop more effective and efficient methods to educate students. this domain aims to build collaborative, systematic, ongoing, and evidence-based approaches that assure a well-prepared nursing workforce will take the lead in optimizing the health of today and in the emerging future (boller & jones, 2010). with this, nursing education redesign is significant to be part of the collaboration between academic and service institutions in building a partnership. nursing education needs to consolidate efforts with the nursing service because they are both responsible and accountable for the development of lifelong learning, holistic preparation and practice orientation of graduate nurses from transitory to practice. becoming adaptive, responsive, integral component of the society and healthcare system are the key attributes of nurses who are locally and globally competent, conscientious, compassionate, and caring. research collaboration table 2 presents the extent of collaboration in building academic-service partnerships in terms of research as part of the academic-service partnerships. overall, participants assessed the extent of collaboration as being met to a “great extent” (m=3.76). furthermore, it can be gleaned in the results that participants agreed that academic and service institutions introduce nursing research and its contributions to the healthcare outcomes (m=3.94). the nursing research has become integral to the development of any healthcare system’s safety and overall quality. academic-service partnerships are an essential tool for initiating and realizing this paradigm shift. the nursing profession will play a key role in the process of redesigning the practice environment to bridge the gap between the fragmented care and the integrated multidisciplinary care processes, as the nurse is most closely connected to both the patient and the healthcare team (institute of medicine (iom) 2010). effective collaboration involves the interplay between the teams of interdisciplinary professionals, the organizational environment they practice in and the underlying cultural expectations that presuppose the possibilities for collaboration (bender, connelly, & brown, 2013). research capacity building engenders assets that allow communities to respond adequately to health issues and problems that are contextual, cultural and historical in nature (airhihenbuwa, 2011). henoch et al. (2014) concluded that nursing education has the potential to positively influence the nurses’ attitudes towards nursing research and evidence-based practice, which could result in better patient outcomes. workforce development table 3 presents the extent of collaboration in workforce development. overall, participants assessed the faculty practice as being met to a “great extent (m=4.02, sd=0.67). the results also revealed that the participants were working on a cooperative mechanism between the employers and employees to the potential workers and create a continued commitment and loyalty to the institution (m=4.10). a key focus of concern in relation to the future shape of the nursing workforce internationally and nationally has 54 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (2), 2016, been the perceived high attrition rate of graduates. this concern has been accompanied by a plethora of literature on the graduate transition to practice. many of studies have been carried out from the perspective of the employing organization and look at the graduate turnover, intent and retention strategies within the first year of practice (scott et al., 2011). the institute of medicine (iom) (2010) reported four key essential perspectives that would innovate the roles and functions of nurses as follows: (a) nurses should practice to the full extent of their education and training; (b) nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression; (c) nurses should be full partners with physicians and other health professionals, in redesigning health care in the united states; and (d) effective workforce planning and policymaking require better data collection and an improved information infrastructure. many studies have been conducted examining the factors in reducing the nursing shortage and would facilitate the workforce development including the graduate transition to practice, turnover intent and recruitment and retention strategies, from an employer perspective. these studies have usually focused on the retention in the first year following graduation (gaynor et al., 2006; rydon, rolleston, & mackie, 2008; salt, cummings, & profetto-mcgrath, 2008). the workforce development in nursing, leaders and policymakers are in the process of bridging the gap between theories and practice that will align the local and global needs for nurses as a growing body of the healthcare workforce. academic and clinical progression table 4 describes the extent of collaboration in academic and clinical progression. overall, the participants assessed faculty practice as being met to a “great extent (m=3.96, sd=0.57). partners work with practice colleagues to design creative collaborative initiatives to assure that the graduates are prepared to practice and to progress in their nursing education. (m=4.18, sd=0.68). despite a great extent of collaboration revealed in the findings, championing multi-site, research initiatives designed to test and evaluate the academic progression of students in bsn program were identified to have the lowest mean among the other indicators (m=3.70, sd=0.78). this reflects that in the academic community, there is a little evidence of developing a system from which graduates are monitored. the common measures of academic progression to date in the country include academic performance, clinical evaluation, and the licensure examination. few of the nursing schools are conducting tracer study to look into the success of the students from transitory to practice. thus, both academic and service institutions need to develop the partnership to orchestrate the art and science of nursing in the preparation of nurses and future of nursing. wolff et al. (2012) pointed out the agreement about the meaning of new graduate nurses' readiness for practice as having a generalist foundation and some jobspecific capabilities, providing safe client care, keeping up with the current realities of nursing practice, being well equipped with the tools needed to adapt to the future needs of clients, and possessing a balance of doing, knowing, and thinking. faculty practice table 5 presents the extent of collaboration in the faculty practice. overall, participants assessed the collaboration as being met to a “great extent” (m=4.05, sd=0.67). moreover, 55 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (2), 2016, as agreed by the participants, there were formal communication processes between the clinical faculty coordinators and clinical instructors/teachers which were regularly conducted (m=4.14, sd=0.67). the faculty practice as an interaction performed for or on behalf of clients and various roles are integrated such as consulting, teaching, research, caregiving, or counseling (beal et al., 2012). many authors concluded that faculty practice has many benefits, which include cost effectiveness, good patient outcomes, positive student learning, increased research productivity, and faculty satisfaction (beal et al., 2012). the preceptor role in undergraduate nursing education is complex and multifaceted. the undergraduate nursing students identify preceptors as a key to their learning in the clinical setting; however, staff nurse preceptors often feel unprepared to serve in this role (mcclure & black, 2013). according to roberts, kasal and flowers (2013) the ability to respond to the increasing need for nurses is directly related to the availability of adequate numbers of faculty. one solution that is currently being utilized by many educational institutions is the employment of adjunct clinical faculty. as more and more adjunct clinical faculties are being used to educate nursing students, the manner in which these clinicians are being prepared for an educator role must be examined. based on their findings, the participant perspectives revealed that their transition from a nurse clinician into the role of adjunct clinical faculty is one that should be intentionally guided and supported by a mentor, with a focus on the acquisition of educational skills needed for that role. cranford (2013) stated that one solution to the faculty shortage is to recruit faculty from clinical practice. this often becomes problematic resulting in intent to leave academia within five years. the possible factors contributing to this action are role ambiguity and role strain. ferguson, haantjens, and milosavljevic (2014) evaluated the role of the clinical educator position in a specific teaching hospital setting on its ability to increase clinical student supervision capacity while maintaining staff productivity and sustaining staff morale. the faculty practice partnerships offer a feasible, cost-effective option for the promotion of the staff development quality in the face of constrained health care and educational resources. the faculty practice can add significantly to the dimensions of educator roles. services in a healthcare organization in clinical, research, or administrative roles add a realistic and broader dimension to the faculty member's perspective on social issues. thus, the partnership built on collaboration would greatly impact both the academic and service institutions in achieving the goals of preparation and practice orientation for the next generation of nurses and nursing community. proposed enhancement program in strengthening academic–service partnerships in nursing this enhancement program covers areas that are timely and necessary to address the complex issues in nursing. in nursing education redesign, coordinated and continuous dialogues will identify gray spots to be improved. in research collaboration, the operationalization of research related activities is imperative along with the implemented of research agenda blueprint. it can be seen also from the figure that the academic faculty has significant roles in the development of a learner-centered environment through a reexamination of modalities, content inclusion in the course, and the program as a whole. 56 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (2), 2016, the part of the faculty roles is the continuing education that will make the academic community to be abreast with issues, concerns, and challenges. the transition from clinical staff to having academic roles and the inclusion of being mentors to the students and other stakeholders require a continuing orientation plan. there is scant evidence in the area of academic-clinical progression in relation to the building of collaboration. thus, it can be integrated into some areas for appraisal, which include a multi-site research identifying the concepts of transitory to practice. nursing graduates are expected to develop knowledge, skills, and attitudes. with this, conformity to both national and international standards in nursing practice is required. both academic and service institutions in nursing are striving to meet the challenges associated with globalization and the increasing demands on the healthcare delivery systems. on the other hand, nursing is not a standalone profession to experience the mounting oddities and issues. in fact, many academic disciplines are in the process of restructuring its system to meet the ever-changing local and global demands based on the service needs. in nursing, collaboration has been conceived as a significant instrument to facilitate the growth of scholarship in teaching, research, and practice. for instance, in nursing education, the partnership built in collaboration with the nursing service provided a platform on how both organizations can become more proactive and reactive to the rapidly changing environment. academic and service partnerships enable the realization of providing quality education and quality services through a continuous revisit in the following areas including nursing education redesign, research collaboration, faculty practice, academic and clinical progression, and nursing workforce development. the proposed academic service collaborative partnerships in nursing is further described in figure 1. conclusion the study revealed that the students, faculty, nursing administrators and staff nurses showed a great extent of collaboration in terms of nursing education redesign, research collaboration, faculty practice, academic and clinical progression, and workforce development. this study proposes an enhancement program in building academic – service partnerships in nursing which can be an instrument to strengthen the current status of nursing amidst radical reforms in the healthcare delivery. references airhihenbuwa, c. o., shisana, o., zungu, n., belue, r., makofani, d. m., shefer, t., simbayi, l. (2011). research capacity building: a us–south african partnership. global health promotion, 18(2), 27–35. http://doi.org/10.1177/1757975911404745 bender, m., connelly, c. d., & brown, c. (2013). interdisciplinary collaboration: the role of the clinical nurse leader. journal of nursing management, 21(1), 165174. boller, j., & jones, d. (2008). nursing education redesign for california: white paper and strategic action plan recommendations. california institute for nursing & health care, berkeley, ca. 57 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (2), 2016, cranford, j. s. (2013). bridging the gap: clinical practice nursing and the effect of role strain on successful role transition and intent to stay in academia. international journal of nursing education scholarship, 10(1), 1-7. cuellar, e. h., & zaiontz, r. g. (2013). salutogenic nursing education: a summative review. journal of nursing education and practice, 3(5), 89. frank, b. (2008). chapter 2. enhancing nursing education through effective academicservice partnerships. annual review of nursing education, 625-43. ferguson, a., haantjens, a., & milosavljevic, m. (2014). evolution of the clinical educator role to increase student placement capacity: from traditional to innovative. nutrition & dietetics, 71(1), 51-56. gaynor, l, gallasch, t., yorkston, e., stewart, s., & turner, c. (2006). where do all the undergraduate and new graduate nurses go and why?: a search for empirical research evidence. australian journal of advanced nursing, 24(2), 26-32. hanberg, a. (2006). bridging the theory-practice gap with evidence-based practice. the journal of continuing education in nursing, 37(6), 248. henoch, i., ung, e. j., ozanne, a., falk, h., falk, k., sarenmalm, e. k., ... & fridh, i. (2014). nursing students' experiences of involvement in clinical research: an exploratory study. nurse education in practice, 14(2), 188-194. institute of medicine (iom). (2010). a summary of the february 2010 forum on the future of nursing. washington, dc: the national academies press. mcclure, e., & black, l. (2013). the role of the clinical preceptor: an integrative literature review. journal of nursing education, 52(6), 335-341. roberts, k. k., kasal chrisman, s., & flowers, c. (2013). the perceived needs of nurse clinicians as they move into an adjunct clinical faculty role. journal of professional nursing, 29(5), 295-301. rydon, s. e., rolleston, a., & mackie, j. (2008). graduates and initial employment. nurse education today, 28(5), 610-619. salt, j., cummings, g. g., & profetto-mcgrath, j. (2008). increasing retention of new graduate nurses: a systematic review of interventions by healthcare organizations. journal of nursing administration, 38(6), 287-296. schmitt, madeline h. (2001). collaboration improves the quality of care: methodological challenges and evidence from us health care research. journal of interprofessional care 15 (1), 47-66. scott, p. a. (2014). lack of care in nursing: is character the missing ingredient? international journal of nursing studies, 51(2), 177-180. wolff, a. c., regan, s., pesut, b., & black, j. (2010). ready for what? an exploration of the meaning of new graduate nurses' readiness for practice. international journal of nursing education scholarship, 7(1). 58 copyright © 2016, nmjn,p-issn 2087-7811, e-issn 2406-87 nurse media journal of nursing, 6 (2), 2016, figure 1. proposed enhancement program in building academic – service partnerships in nursing nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://medianers.undip.ac.id 12(3): 414-422, december 2022 https://doi.org/10.14710/nmjn.v12i3.47811 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 original research relationship between nurses’ attitudes and satisfaction with bedside shift reports and patient safety culture samara jaber1, mirna fawaz1, ahmad rayan2, nisser alhroub3, mohammad suliman4, mohammed albashtawy4, rasmieh al-amer5, abdullah alkhawaldeh4 1faculty of health sciences, beirut arab university, beirut, lebanon 2faculty of nursing, zarqa university, zarqa, jordan 3faculty of nursing, jerash university, jerash, jordan 4princess salma faculty of nursing, al al-bayt university, mafraq, jordan 5faculty of nursing, isra university, amman, jordan article info abstract article history: received: 21 july 2022 revised: 23 december 2022 accepted: 25 december 2022 online: 28 december 2022 keywords: bedside shift report; nurse satisfaction; nursing communication; patient safety corresponding author: abdullah alkhawaldeh princess salma faculty of nursing, al al-bayt university, mafraq, jordan. email: dr-abd@aabu.edu.jo. abdo_752012@yahoo.com background: a thoroughly standardized nurse bedside shift report, including effective communication, may improve nurses’ satisfaction and patients’ safety. however, a few studies were found that measure the relationships between nurses’ attitudes and satisfaction with bedside shift reports and patient safety outcomes. purpose: this study aimed to measure nurses’ attitudes and satisfaction with bedside shift reports and their relationships with patient safety culture. methods: a cross-sectional and descriptive study was conducted between may to august 2021 among 90 bedside nurses conveniently recruited from a public hospital in lebanon. the bedside handover report staff nurses’ satisfaction survey and the survey on patient safety (sops) were used to collect data. data were analyzed using descriptive statistics such as mean and standard deviation and inferential statistics, i.e., pearson correlation coefficient. results: the results showed that satisfaction scores were high in all the questions in the bedside shift reporting. the participants showed relatively positive attitudes towards bedside shift reports where all the statements recorded above-average mean values. the highest-ranking statement “bedside shift report is completed in a reasonable time” was recorded with a mean value of 3.35 (sd=0.87), while the lowest-ranking statement was “bedside shift report is relatively stress-free” with a mean value of 2.03 (sd=0.86). there were significant relationships between nurses’ satisfaction with shift reports and some patient safety culture composites, such as between nurses’ satisfaction with bedside shift reports and communication about errors and reporting of patient safety events (p<0.05) and between nurses’ attitudes toward bedside shift reports and communication about errors (p<0.001) conclusion: implementation of the bedside shift report improves nurses’ levels of satisfaction, enhances positive attitudes toward work, and enhances patients' safety. nursing leaders should encourage nurses to implement bedside handover reports in their hospitals. how to cite: jaber, s., fawaz, m., rayan, a., alhroub, n., suliman, m., albashtawy, m., al-amer, r., & alkhawaldeh, a. (2022). relationship between nurses’ attitudes and satisfaction with bedside shift reports and patient safety culture. nurse media journal of nursing, 12(3), 414-422. https://doi.org/10.14710/nmjn.v12i3.47811 1. introduction ineffective communication between healthcare professionals is one of the biggest causes of medical errors; thus, hospitals are working hard to improve to prevent medical errors and sentinel occurrences (ayoub et al., 2021). the joint commission 2012 stated that ineffective hand-off endorsement is recognized as a critical patient safety problem in health care. it is estimated that 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients (joint commission, 2012). therefore, innovating and adopting a clear context of handoff communication is important to protect patient safety. traditional shift report is a process performed by healthcare professionals to communicate information, mainly registered nurses, during the change of shifts and transfer of patients between floors and patient care units (small & fitzpatrick, 2017). this process can be done verbally, through writing, or by recording, but not at the bedside of the patient (evans et al., 2012; https://crossmark.crossref.org/dialog/?doi=10.14710/nmjn.v12i3.47811&domain=pdf&date_stamp=2022-12-28 nurse media journal of nursing, 12(3), 2022, 415 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 maxson et al., 2012). on the other hand, the bedside hand-off shift report is a method of endorsement where communication takes place at the bedside with patients and family members. bedside shift report between nurses is an opportunity to involve patients and family members in their care. it also offers room for patients to participate in the decision-making process regarding their health (small & fitzpatrick, 2017). during bedside shift reports, the patients and their family can hear updates regarding the health status of the patients during the information exchange that takes place between nurses. they are also urged to ask questions, provide comments and make any suggestions they might have as the shift report process is taking place (maxson et al., 2012; reinbeck & fitzsimons, 2013; thomas & donohue-porter, 2012). the use of bedside shift reports enhances patient satisfaction, fosters teamwork, and improves nurse accountability and prioritizing at the start of the shift (sherman et al., 2013). a bedside shift report is considered a great opportunity for communication between the nurse and the patient and a better understanding of the patient’s urgent needs and concerns. nurses are better prepared and confident to discuss patient care issues with physicians and other health care providers immediately after the change-of-shift hand-off (maxson et al., 2012). according to novak and fairchild (2012), the number of extra hours per nurse reduced dramatically after introducing a standard bedside report because the report required less time. by boosting the effectiveness of reports, increasing nurse culpability, promoting coordination among staff members, and increasing mentorship amongst nurses, the bedside report contributes to nurse satisfaction (sand-jecklin & sherman, 2013). furthermore, the nursing bedside shift report covers all initiatives from the joint commission’s 2017 patient safety goals (joint commission, 2017). for example, the bedside shift report not only allows nurses to physically review their patients with a colleague but also allows patients to participate directly in the discussion of their treatment. according to a study conducted by sand-jecklin and sherman (2014), patient falls at shift change, and medication errors were minimized after implementing bedside shift reports. the use of a bedside shift report has been found to increase patient safety and reduce adverse occurrences such as patient falls (gregory et al., 2014; tage et al., 2021). the nurse shift report has been identified as one of the vulnerable communication points. some studies indicated that patients should be involved during nurse bedside shift reports, and important things such as wounds, incisions, drains, or central lines should be carefully assessed (shank, 2018). therefore, a thoroughly standardized nurse bedside shift report, including effective communication, may improve nurses’ satisfaction and patients’ safety. however, few studies were conducted to measure the relationships between these variables. also, there is no study in lebanon conducted to measure the relationships between these variables. accordingly, this study was conducted to measure nurses’ attitudes and satisfaction with bedside shift reports and their relationships with patient safety culture. 2. methods 2.1 research design a cross-sectional and descriptive research design was used in this study. this design enables the researcher to observe two or more variables at a time and is useful for describing a relationship between two or more variables (howitt & cramer, 2020). 2.2 setting and samples the setting for this research study was all nursing units practicing bedside shift reports on the medical and surgical floors at a public hospital located in lebanon. the population of interest for this study were the registered nurses who have been implementing the bedside shift report for at least the past year. the inclusion criteria were: (1) nurses practicing bedside shift reports, (2) nurses working on the medical-surgical floors, (3) nurses with more than 6 months of experience (a minimum of 6-month experience was chosen to allow nurses sufficient time to minimize confounding of results with issues related to bedside shift reports. meanwhile, nurses who were on a leave and did not deliver direct patient care were excluded. convenience sampling was utilized to recruit the samples. the sample size was calculated using the raosoft calculation website (raosoft, 2004). considering the population size of 111 nurses, the confidence level of 95%, and the margin of error of 0.05, a sample size of 87 is required. this study, however, included 90 nurses to meet the requirement for a representative sample. nurse media journal of nursing, 12(3), 2022, 416 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 2.3 measurement and data collection a demographic questionnaire, including the participant’s age, gender, years of experience, and other characteristics were used. the bedside handover report staff nurses’ satisfaction survey was also utilized. this questionnaire is a 7-item likert scale with scores ranging from 1 (strongly disagree) to 5 (strongly agree). the coefficient of reliability reported by a previous study was 0.80. this indicates that the tool is reliable to use for data collection (principe, 2018). a survey with eight questions based on previous research was used to assess nurses’ attitudes toward bedside shift reports (gadzama, 2017). the survey measures the importance of bedside shift reports and their effect on patient safety. the survey consisted of eight questions with a fivepoint likert response format; the likert responses ranged from 1 to 5, with 1 indicating strong disagreement and 5 indicating strong agreement. a previous study showed that the survey was reliable (cronbach alpha above 0.75 in all subscales) in measuring nurses’ attitudes toward bedside shift reports (gadzama, 2017). the survey on patient safety (sops) tool was employed to examine the patient safety culture at the respective hospital. five composites were adopted from the original tool that covered various aspects of patient safety, namely: organizational learning—continuous improvement, leadership support for patient safety, communications about the error, reporting of patient safety events, patient safety rating, and background information (nieva & sorra, 2003). previous studies showed good content validity (the scale-content validity index score yielded 0.80), and the reliability of the sops tool dimensions achieved acceptable levels of cronbach α (α≥0.6) (najjar et al., 2013; suliman et al., 2017). for this study, the questionnaire was piloted among nurses in the hospital who practiced bedside shift reports in order to test its reliability in collecting genuine data. after that, psychometric analysis was carried out to determine the coefficient of reliability “cronbach alpha” of the questionnaire, which turned out to be higher than 0.75 in all subscales, thus reflecting the adequate use of this tool. the data were collected by the researcher through a visit to the medical-surgical floors in the selected hospital. the researcher provided information about the aim, content, and duration of the study that was conducted and what nurses were required to do. nurses responded to the provided questionnaires after explaining the exact way to properly answer the questions, respond to any concerns, and clarify any terms. nurses received assurances that participation was voluntary and responses would be kept confidential. if they agreed to participate, they would be requested to complete the survey. the surveys were completely anonymous, and each nurse could decline participation without repercussions. the researcher gathered the completed surveys. only the researcher had access to the password-protected computer with all the data. 2.4 data analysis the data collected from the surveys were entered into spss version 21. descriptive statistics such as percentage, mean and standard deviation were used to describe nurses’ characteristics and their attitudes and satisfaction with bedside shift report, and inferential statistics, i.e., the pearson correlation coefficient was used to measure the relationships between nurses’ attitude and satisfaction with bedside shift report and patient safety outcomes. 2.5 ethical considerations ethical requirements were taken into consideration while conducting the study. approval from the institutional review board (irb) at bellevue medical center (irb no. eco-r-180) and from the approached clinical sites was obtained. the anonymity and confidentiality of all study participants were maintained. participants were sent a consent form with the purpose of the study, the means of data collection, and the benefits and possible harm. they were also informed that participation was completely voluntary and they had the right to withdraw from the study at any time without penalties. 3. results 3.1 sociodemographic characteristics the study included 90 participants. the majority were females (68.9%), single (67.8%) and hold bachelor’s degrees or their equivalent (77.8%). in addition, the participants were distributed across various shift durations; most participants (75.6%) worked during day shifts. it is also nurse media journal of nursing, 12(3), 2022, 417 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 noteworthy to mention that the majority of the participants were aged between 21-30 (72.3%) and had 1-10 years of experience (77.8%). the detailed results for the sociodemographic data are delineated in table 1. table 1. sociodemographic characteristics of the respondents characteristics frequency (f) percentage (%) gender male 28 31.3 female 62 68.9 work shift day shift 68 75.6 night shit 22 24.4 educational level bachelor 70 77.8 masters 20 22.2 marital status single 61 67.8 married 28 31.1 divorced 1 1.1 age 21-30 years 65 72.3 31-40 years 19 21.0 more than 40 years 6 6.7 years of experience 1-10 years 70 77.8 11-20 years 20 22.2 3.2 satisfaction with bedside shift report the nurses who took part in this study answered the nursing satisfaction with the bedside shirt report questionnaire, which comprised seven statements scored on a likert scale from 1 to 5. descriptive analysis was carried out, and the results showed that the participants reported high satisfaction with beside shift reports where all the statements recorded mean values higher than 3. the highest-ranking element was the one stating that bed bedside shift report provides a comprehensive communication process between registered nurses (rns) with a mean score of 3.31, while the least ranking statement was the statement indicating that a bedside shift report minimizes delays in patient care delivery with a mean score of 3.01 (sd=0.74) (see table 2). table 2. satisfaction with bedside shift report items minimum maximum mean sd 1. rn provides up-to-date patient care information 00.00 04.00 03.29 0.74 2. helps rns to prioritize patient care activities 01.00 04.00 03.26 0.61 3. provides time to verify patient care issues 00.00 04.00 03.16 0.92 4. provides a comprehensive communication process between rns 02.00 04.00 03.31 0.57 5. ensures rn's accountability 01.00 04.00 03.26 0.66 6. minimizes delays in patient care delivery 00.00 04.04 03.01 0.74 7. satisfied with the bedside handover report process 00.00 04.00 03.03 0.85 3.3 attitudes toward bedside shift report a descriptive analysis was carried out, and the results showed that the participants reported relatively positive attitudes toward bedside shift reports, where all the statements recorded an nurse media journal of nursing, 12(3), 2022, 418 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 above-average mean value. for example, the highest-ranking statement, “bedside shift report is completed in a reasonable time,” was recorded with a mean value of 3.35 (sd=0.87), while the lowest-ranking statement was “bedside shift report is relatively stress-free” with a mean value of 2.03 (sd=0.86) but still reflective positive attitudes (table 3). table 3. attitudes toward bedside shift report items minimum maximum mean sd 1. bedside shift report is an effective means of communication 2.00 4.00 3.31 0.59 2. bedside shift report helps identify changes in patient condition 0.00 4.00 3.21 0.77 3. bedside shift report helps assure accountability 1.00 4.00 3.17 0.69 4. bedside shift report promotes patient involvement in their care 2.00 4.00 3.26 0.57 5. bedside shift report improves patient safety and quality of care 2.00 4.00 3.28 0.64 6. bedside shift report is relatively stress-free 0.00 4.00 2.04 0.86 7. bedside shift report is completed in a reasonable time 0.00 4.00 2.35 0.88 8. i feel that there are challenges with bedside shift report 1.00 4.00 3.03 0.71 3.4 patient safety composites the participants responded to the hospital survey on patient safety (sops). the elements of the survey were grouped into comprised five composites. descriptive analysis was carried out, and the results showed that the nurses reported average levels of patient safety culture where a mean value of 2.8 was recorded on the level of the work environment composite, 3.31 on the level of leadership styles of nurse managers, which promote patient safety culture, 2.73 on the level of the communication composite, 3.12 on the level of reporting sentinel events and most importantly 1.95 which is a below-average value on the level of patient safety climate composite (table 4). table 4. patient safety composites patient safety composites minimum maximum mean sd 1. organizational learning—continuous improvement 0.00 4.33 2.80 0.57 2. leadership support for patient safety 0.00 4.55 3.31 1.48 3. communication about error 0.00 3.33 2.73 0.55 4. reporting of patient safety events 0.00 4.00 3.12 0.70 5. patient safety rating 0.00 4.45 1.95 0.71 3.5 the relationship between the study variables pearson correlation coefficients were carried out to determine if there were relationships between nurses’ satisfaction and attitudes regarding bedside shift report total scores on the one hand and the patient safety composites on the other hand. the results of the analysis showed that there are significant relationships between the mentioned variables. for example, there are significant relationships between nurses’ satisfaction with bedside shift reports and communication about errors and reporting of patient safety events (p<0.05), and between nurses’ attitudes toward bedside shift reports and communication about errors (p<0.001). however, the analysis revealed a strong and positive relationship between the satisfaction of nurses and their attitudes towards bedside shift reports (p<0.001) (table 5). nurse media journal of nursing, 12(3), 2022, 419 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 5. correlations between nurses’ satisfaction and attitude toward bedside shift reports and safety culture composites variables value a b c d e f g nurses’ satisfaction with bedside shift report r-value 1.00 0.77 -0.30 0.22 0.48 0.75 0.30 p-value 0.00** 0.07 0.09 0.04* 0.01* 0.07 nurses’ attitudes regarding bedside shift report r-value 0.77 1.00 -0.33 0.35 0.77 -0.35 -0.11 p-value 0.00** 0.07 0.06 0.00** 0.06 0.11 notes: a=nurses’ satisfaction with bedside shift report; b=nurses’ attitudes regarding bedside shift report; c=organizational learning—continuous improvement; d=leadership support for patient safety, e=communication about error; f=reporting of patient safety events; g=patient safety rating 4. discussion this study aimed to measure nurses’ attitudes and satisfaction with bedside shift reports and their relationships with patient safety culture. the results showed that the nurses reported high satisfaction scores and positive attitudes toward the implementation of bedside shift reports. this is consistent with a study by novak and fairchild (2012), which assessed the effect of bedside shift reporting and the sbar (situation, background, assessment, recommendation) method on communication and nurses’ satisfaction and patient safety. the study discovered that bedside reporting financially impacts an organization because it reduces report times, improves nurse satisfaction, nurse retention, and patient and family satisfaction, and reduces healthcare errors novak and fairchild (2012). our results were also consistent with another study that assessed the effect of the handover process on the performance indicators and job satisfaction of nurses (thomas & donahue-porter, 2012). the study found that incoming nurses who have access to a comprehensive patient report are better prepared to offer safe and satisfying care. according to the study, the handover process, which allows incoming nurses to raise questions and clarify patient care issues with outgoing nurses, improves their ability to prioritize the care they must deliver (thomas & donahue-porter, 2012). the results in this study also resembled those of evans et al. (2012), who looked at the implementation and outcomes of a bedside shift-to-shift nurse report. the study’s goal was to find a solution to the problem of staff discontent with nurse-to-nurse reports and the inability to finish shifts on time. the study found that having a bedside handover report boosted nurse satisfaction, helped nurses prioritize their workflow, and reduced the time it took to complete the report. greater nurse satisfaction was attained by obtaining a more detailed report without distractions. patients’ involvement in their care plan has also improved patient-centered care (evans et al., 2012). furthermore, bedside reporting has been demonstrated to increase patient involvement and satisfaction, improve nursing cooperation and responsibility, and improve provider communication efficacy (urisman et al., 2018). by putting patients at the center of their care and allowing them to be active participants in their rehabilitation, nurses can have a beneficial impact on their patient’s experiences. other advantages include increased quality and safety, as well as teamwork and peer responsibility. this study’s findings are similarly consistent with sand-jecklin and sherman’s (2014) study, which attempted to measure the effects of a practice change on a bedside shift report. the study examined how nurses felt about the shift report procedure and how patients felt about nursing care. patients saw an improvement in staff introductions, promoting patient involvement, exchanging vital information, and participation in a shift change conversation, according to the authors. the nursing staff valued the emphasis on patient safety and participation and discovered that communication at the bedside was more effective (sand-jecklin & sherman, 2014). similarly, jimmerson et al. (2021) found that a bedside shift report allows for face-to-face interaction with the patient, clarification and potential resolution of inaccurate information, introduction of the oncoming nurse, and a patient assessment during the report, allowing for visualization of the patient and the environment. face-to-face reporting, on the other hand, allows the incoming nurse to do a safety check with the incoming nurse. each nurse can then see the pumps, examine the working environment, inspect lines and devices, and so on. overall, nurse media journal of nursing, 12(3), 2022, 420 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 healthcare practitioners must ensure patient safety and quality when providing care. without the patients’ collaboration, the verbal reports alone can impact safety if the information is incomplete or communicated inadequately because of distractions or interruptions. the findings in this study also revealed that nurses reported excellent patient safety behaviors and culture once bedside shift reporting was implemented. this was supported by maxson et al. (2012), which found that comprehending the care plan improved patient satisfaction significantly. in addition, accountability, boosting communication at shift changes, connecting with physicians, and reducing medical errors and prescription errors were all areas where nursing staff reported considerable improvements. this was also supported by another study, which found that allowing patients to be active participants in clarifying and correcting mistakes improved patient safety and satisfaction (kullberg et al., 2018). they also stated that the collaboration with the nurses made them feel like their care was individualized and that their input was respected. the bedside shift report procedure has a big influence on patient safety, but it also has a big impact on nurse satisfaction with communication, collaboration, and teamwork. this study is also consistent with several other articles that have assessed the importance of communication patterns and styles on the level of nursing performance and have proved that communication patterns like sbar and exchanging patient information at the bedside were closely linked to nursing satisfaction (jones et al., 2015; melnyk & fineout-overholt, 2022). furthermore, the findings of this study were congruent with those of whitty et al. (2017), who investigated nurses’ experiences and perspectives of bedside handover communication to improve patient care. the preliminary findings of the study stated that after implementing the process, nurses reported high performance and satisfaction in providing care to their patients, requiring a long-term evaluation to prove its success, whereas nurses reported high performance and satisfaction in delivering care to their patients due to clear task communication direction (whitty et al., 2017). moreover, the present study also reported high rates of communication in the patient safety culture of the hospital. a study by radtke (2013) that was conducted to improve communication between patients and nurses at discharge time showed an increase in patients’ perceptions of continuity of care and satisfaction, thus enhancing patient quality of care and safety. our results also showed that upon implementation of bedside shift reports, a significant positive relationship emerged between nurses’ attitudes toward bedside shift reports and communication about errors. 5. implications and limitations the study implicates that this innovative handover strategy can be applied to other areas of practice and tested to see if patients are being satisfied. also, it is possible to conduct more research to see how the interdisciplinary team could strengthen this procedure. the use of convenience sample was one of the study’s limitations. nurses were not stratified into different units, and different units might be disproportionally represented. nurses in different units might have different perspectives due to different patient populations. nurses recently shifted from traditional handover to bedside handover and are trained in both models. the bedside handover inter-shift report was a major change in behavior and nursing practice for a significant number of rns. their attitudes and ideas might change with time the longer they practice bedside handover. the major obstacle that might affect the process was discussing patient care in semi-private rooms. the fear of patient confidentiality violation as information about the patient and patient care issues discussed at the bedside might have negatively impacted the reported nursing satisfaction results. 6. conclusion the implementation of the bedside shift report improves nurses’ levels of satisfaction and enhances positive attitudes toward work. in terms of patient safety, excellent communication among nurses during shift changes is critical to ensuring that patients receive safe, high-quality, and effective treatment. thus, the bedside handover procedure impacts patient safety and nurse satisfaction in terms of communication, collaboration, and teamwork. the study’s findings gave nurse managers and nursing leadership information and research they could use to start creating nursing bedside shift report recommendations tailored to their patient population. also, the results of this study recommend the conduct of a further investigation into the nursing bedside shift report, particularly the process’s adoption and sustainability. nurse media journal of nursing, 12(3), 2022, 421 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 acknowledgment the authors would like to acknowledge the administration of the clemenceau medical center as well as the efforts of the nurses who took part in this study. author contribution sj, mf, ar, na participated in the study conception and design. ms collected the data. ma, ra, and aa also participated in data analysis, and drafting of the article was done by ma, ms, sj, and mf. all authors critically revised the manuscript. conflict of interest none declared references ayoub, a. y., salim, n. a., hdaib, b. m., & eshah, n. f. 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(2018). impact of surgical intensive care unit interdisciplinary rounds on interprofessional collaboration and quality of care: mixed qualitative–quantitative study. intensive and critical care nursing, 44, 18-23. whitty, j. a., spinks, j., bucknall, t., tobiano, g., & chaboyer, w. (2017). patient and nurse preferences for implementation of bedside handover: do they agree? findings from a discrete choice experiment. health expectations, 20(4), 742-750. copyright © 2022 nmjn. this article is an open-access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). https://creativecommons.org/licenses/by-sa/4.0 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 nurse media journal of nursing, 10(2), 2020, 146-157 available online at http://ejournal.undip.ac.id/index.php/medianers doi: 10.14710/nmjn.v10i2.26803 self-efficacy affects cancer patients in solving problems, seeking support and avoiding problems as coping mechanisms yesiana dwi wahyu werdani1, pascalis arief ardiansyah silab2 1,2faculty of nursing widya mandala catholic university surabaya, indonesia corresponding author: yesiana dwi wahyu werdani (ywerdani@yahoo.com) received: 29 november 2020 revised: 20 august 2020 accepted: 21 august 2020 abstract background: cancer is a disease that causes various physical and mental problems. being diagnosed with cancer affects the self-efficacy and behavior of individuals to choose a coping mechanism in facing the problem. purpose: this study aimed to determine the effect of self-efficacy on solving problems, seeking support, and avoiding problems as coping mechanisms in cancer patients. methods: a cross-sectional study was conducted on 45 cancer patients selected using a total sampling technique from two public health centers in surabaya, indonesia. data were collected using the general self-efficacy scale and coping strategy indicator, and analyzed using the shapiro wilk for data normality, and linear regression to determine the effects of self-efficacy on solving problems, seeking support, and avoiding problems with p< 0.05. results: the results showed the participants’ rate of self-efficacy levels (m=3.26), and coping mechanism levels in solving problems (m=3.46), seeking support (m=2.88), and avoiding problems (m=3.27), as well as mean scores of self-efficacy (32.6±3.8), solving problems (34.6±3.8), seeking support (31.8±3.7), and avoiding problems (32.7±3.2). based on the linear regression test, there was a significant effect self-efficacy on solving problems (p<0.001; r2=0.97), seeking support (p<0.001; r2=0.98), and avoiding problems (p<0.001; r2=0.98) as coping mechanisms. conclusion: cancer patients who had high self-efficacy scores would choose solving problems and seeking support as the coping mechanisms, but those with lower scores on self-efficacy prefer to avoid the problems. keywords: avoiding problems; seeking support; self-efficacy; solving problems how to cite: werdani, y. d. w., & silab, p. a. a. (2020). self-efficacy affects cancer patients in solving problems, seeking support, and avoiding problems as coping mechanisms. nurse media journal of nursing, 10(2), 146-157. doi:10.14710/nmjn.v10i2.26803 permalink/doi: https://doi.org/10.14710/nmjn.v10i2.26803 background cancer is known as a deadly and incurable disease. globally, cancer is estimated to increase to 18.1 million new cases, and in 2018 there are an estimated 9.6 million deaths http://ejournal.undip.ac.id/index.php/medianers nurse media journal of nursing, 10(2), 2020, 147 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 from cancer. cancer deaths worldwide in 2018 is estimated to occur in asia, partly because this region has almost 60% of the global population. in europe, there are 20.3% and 14.4% in america. the proportion of cancer deaths in asia and africa (57.3% and 7.3%, respectively) is higher than the proportion of incident cases (48.4% and 5.8%, respectively) as these areas have a higher frequency (world health organisation, 2018). the prevalence of cancer in indonesia is 1.8 per thousand inhabitants. the highest prevalence is in yogyakarta province, while the lowest one is in west nusa tenggara. the highest prevalence of cancer is in the age group of 55-64 years old, at 4.6 per thousand inhabitants, while the lowest one is in children aged < 1-year-old. based on sex, women tend to have a higher risk than men (health research and development agency, 2018). fear, trauma, or feeling close to death are the first responses when diagnosed with cancer (robb, simon, miles, & wardle, 2014). the majority of cancer patients feel anxious and worried about an uncertain future (grupe & nitschke, 2013), and also feel severe stress (werdani, 2017). the high emotional stress affects the patients’ functional status and causes the patients to lose enthusiasm for life (saeedi-saedi, shahidsales, koochak-pour, sabahi, & moridi, 2015). cancer patients who experience anxiety and depression greatly influence their self-efficacy (omran & mcmillan, 2018), and are more likely to have low self-efficacy scores (rizeanu, bubulac, & popa-velea, 2018). self-efficacy has an influence on physical and mental health, quality of life, and health information-seeking behaviour in cancer patients (borjalilu, kaviani, helmi, karbakhsh, & mazaheri, 2017). a study stated that self-efficacy is considered a form of coping that can affect the quality of life in cancer patients (chirico et al., 2017). coping strategies that focus on emotions have a significant negative correlation with total symptoms and functional dimensions in the quality of life (kahrazei & maleknia, 2015). cancer management through therapy in patients has various side effects, such as pain, nausea, vomiting, fatigue, hair loss, excessive bleeding, weight loss, fever, diarrhea, and lumps (aslam et al., 2014), as well as sleeplessness, difficulty in breathing, anorexia, and constipation (afiyanti, wardani, & martha, 2019). these physical effects can cause changes in the psychological conditions of cancer patients, such as depression and stress. a study reported that cancer patients who experienced cancer-related fatigue (crf) feel stress, depression, and anxiety; furthermore, the stress is closely related to worse rates of survival and higher mortality in cancer patients (weber & o’brien, 2017). the individuals’ responses to stress are shown to be coping mechanisms. a study stated that cancer patients who experienced mild to moderate stress tend to have adaptive coping mechanisms, while those who experienced severe stress tend to prefer maladaptive coping mechanisms (werdani, 2017). coping strategies commonly used by cancer patients were seeking emotional support, positive reframing, self-blame, and denial, which affects the quality of life (nipp et al., 2016). a majority of previous studies examined psychological disorders such as stress, anxiety, and depression, which can affect self-efficacy, and coping strategies related to the quality of life, as well as the relationship between self-efficacy and general coping mechanisms (adaptive or maladaptive copings). however, no research studied the effects of self-efficacy on three dimensions of coping mechanism details (solving problems, seeking support avoiding problems), especially in cancer patients. it is, therefore, necessary to examine how selfnurse media journal of nursing, 10(2), 2020, 148 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 efficacy affects solving problems, seeking support, and avoiding problems as coping mechanisms in cancer patients. purpose this study aimed to determine the effects of self-efficacy on solving problems, seeking support, and avoiding problems as coping mechanisms in cancer patients. methods design and samples the present research was a cross-sectional study, involving simultaneous data collection on independent and dependent variables. the samples were 45 cancer patients were conscious and aged more than 17 years old in two public health centers in surabaya, indonesia. a total sampling technique was used to recruit the samples. instruments and data collection this study used the general self-efficacy scale (gse) adopted from a previous study by de las cuevas and peñate (2015) to measure self-efficacy’s scores, and the coping strategy indicator (csi) adopted from togas and alexias (2018) to measure the scores of solving problems, seeking support, and avoiding problems. the gse consists of 10 closed-ended questions using a 4-point likert scale (1=not at all true, 2=hardly true, 3=moderately true, 4=exactly true). meanwhile, the csi is composed of three parts. the first part consists of 11 closed-ended questions that describe solving problems, while the second and third part consists of 10 closed-ended questions each that describe seeking support and avoiding problems, respectively. the section of solving problems and seeking support uses a 4-point likert scale (1=never, 2=occasionally, 3=sometimes, 4=always), while the section of avoiding problems applies reversed likert scales (1=always, 2=sometimes, 3=occasionally, 4=never). the questionnaires had been backto-back translated into the indonesian version by reliable translators, and tested for their validity and reliability by the researchers. the general self-efficacy scale showed the r of 0.831-0.948 with a cronbach’s alpha of 0.921, while the coping strategy indicator showed the r of 0.890-0.932, with a cronbach’s alpha of 0.931. after consented for participation, respondents completed the demographic data and the questionnaires. the data were collected in april 2019. data analysis the collected data were entered into spss 25.0 and tested for normality using the shapiro wilk test (p>0.05). the results showed that the data were normally distributed (p=0.314 for self-efficacy; p=0.60 for solving problems; p=0.195 for seeking support, and p=0.165 for avoiding problems). a further analysis was performed using the step linear regression test to examine effects of self-efficacy on solving problems, seeking support, and avoiding problems. ethical considerations this study obtained ethical approval from the research ethics committee of medical faculty, widya mandala catholic university (no. 003/wm12/kepk/t/2019). prior to the study, all respondents were informed of the research purposes, advantages, procedures, and risks, as well as signed an informed consent. nurse media journal of nursing, 10(2), 2020, 149 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 results characteristics of participants the result showed that more than half of the participants were old, ranging from early older adults to the elderly. the stages of cancer varied from stage i-iv, and most of the participants have been diagnosed with cancer for 1-3 years. almost all participants had a support system from their nuclear families, such as their parents, daughter, or son. table 1. demographic characteristics of the respondents (n=45) variables n % age (years), m±sd = 54.1±13.8 17 – 25 (adolescent) 3 7 26 – 35 (early adulthood) 1 2 36 – 45 (late adulthood) 7 16 46 – 55 (early older adult) 11 24 56 – 65 (late older adult) 14 31 >65 (elderly) 9 20 gender female 34 76 male 11 24 cancer stage i 1 2 ii 20 44 iii 16 36 iv 7 16 unknown 1 2 duration of cancer diagnosed (year) < 1 3 7 1 – 3 23 51 4 – 6 8 18 > 6 11 24 support system nuclear families 38 85 extended families 5 11 others 1 2 alone 1 2 self-efficacy in cancer patients table 2 showed that in the level of self-efficacy in cancer patients, there were three top components of self-efficacy, comprised of managing to solve the difficult problems (m=3.47), ability to adapt to all situations (m=3.38), and finding a way out of the problems (m=3.33). table 2. self-efficacy in cancer patients (n=45) component of self-efficacy min max mean sd 1. i always manage to solve difficult problems 3 4 3.47 0.50 2. i can find a way out of problems 2 4 3.33 0.52 3. i have no difficulty in achieving a goal 2 4 3.02 0.58 nurse media journal of nursing, 10(2), 2020, 150 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 component of self-efficacy min max mean sd 4. i can adapt to all situations 2 4 3.38 0.58 5. i can solve problems in any situation and condition 2 4 3.31 0.56 6. i have a solution for every problem 2 4 3.24 0.57 7. i’m sure that i can solve a problem with the ability that i have 2 4 3.29 0.59 8. i have been able to overcome every difficulty because i had many ideas 2 4 3.16 0.47 9. if i am in trouble, i can think of a solution quickly 2 4 3.16 0.47 10. i am always ready to face problems 2 4 3.27 0.54 dimensions of coping mechanisms in cancer patients table 3 showed that there were three top components in solving problems (m=3.46), comprising of enthusiasm and effort in solving the problems (m=3.84), full attention to solve the problem (m=3.80), and planning an action carefully before doing something (m=3.60). for seeking support as a coping mechanism (m=2.88), there were two top components, comprising of the hope that the family will continue to help in solving a problem (m=3.49), and receiving help and support from friends and family in solving the problem (m=3.29). for avoiding problems as a coping mechanism (m=3.27), there were three top components in avoiding problems, comprising of staying away from others (m=3.73), avoiding others (m=3.64), and relieving stress by imagination (m=3.64). table 3. dimensions of coping mechanism in cancer patients (n=45) coping mechanisms min max mean sd solving problems 1. when i get into trouble, i think of a way out of my problem 1 4 3.33 0.74 2. i think first before making a decision 2 4 3.56 0.66 3. i have several ways to deal with difficult situations 1 4 3.00 0.80 4. in making choices, i'm always careful 2 4 3.49 0.73 5. i thought of a solution to the problem i was having 1 4 3.36 0.83 6. i turned my full attention to solving a problem 3 4 3.80 0.40 7. i have a plan for every problem i faced 1 4 3.13 0.99 8. i remained enthusiastic and made an effort to solve the problems i faced 2 4 3.84 0.42 9. i tried to solve the problem i was facing 2 4 3.56 0.72 10. i plan an action carefully before doing something 1 4 3.60 0.75 seeking support 1. i tell friends about my problems 1 4 2.58 0.69 2. even though i am in trouble, i still get the attention and support of others and my family 2 4 3.71 0.59 3. i feel better if i share the problem i am facing with others 1 4 2.80 0.87 4. i talk to my family about the fears and worries that i am experiencing now 1 4 2.64 0.98 5. telling others about my situation can help me find a solution 1 4 2.80 0.81 nurse media journal of nursing, 10(2), 2020, 151 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 coping mechanisms min max mean sd 6. i went to a health professional to help me feel better 1 4 2.56 0.87 7. i went to a friend to help me feel better about the problem 1 4 2.22 0.97 8. my friends always provide solutions when i am in trouble 1 4 2.82 0.96 9. i get sympathy and attention from people who have the same problem as me 1 4 2.84 0.98 10. i received help and support from friends and family in solving the problem i was experiencing 1 4 3.29 0.89 11. i hope my family will continue to help me in solving my problem 1 4 3.49 0.84 avoiding problems 1. i hid the problem i was experiencing 1 5 3.18 1.05 2. i relieve stress by imagining 1 4 3.64 0.68 3. i spent more time alone 1 4 3.40 0.84 4. i watched television more than usual 1 4 2.58 1.03 5. i avoid others because of the problems i faced 1 4 3.64 0.65 6. i avoid problems by doing activities that i like 1 4 2.44 1.27 7. i relieve stress with lots of sleep 1 4 3.09 1.00 8. i feel that the problem i experienced is not real 1 4 3.42 0.92 9. i feel that the problem i experienced is the same as a story in a movie or novel 1 4 3.60 0.69 10. i want others to stay away from me 1 4 3.73 0.72 effects of self-efficacy on solving problems, seeking support and avoiding problems table 4 showed that the mean score of all variables was high, meaning that most participants had high self-efficacy and positive problem-solving and positive support seeking, and less problem avoidance as a coping mechanism. while based on the linear regression, it is shown that there was a significant effect of self-efficacy on these three forms of coping mechanisms. self-efficacy had an effect of 97.7% on solving problems, 98.3% on seeking support and 98.4% on avoiding problems. table 4. effects of self-efficacy on solving problems, seeking support and avoiding problems (n=45) variable descriptive statistics self-efficacy min max mean sd r r 2 β p-value solving problem 25.00 40.00 34.6 3.8 0.988 0.977 0.937 <0.001 seeking support 22.00 43.00 31.8 3.7 0.992 0.983 1.251 <0.001 avoiding problem 26.00 38.00 32.7 3.2 0.992 0.984 0.721 <0.001 discussion the present study aimed to determine the effects of self-efficacy on solving problems, seeking support, and avoiding problems as coping mechanisms in cancer patients. results showed that cancer patients had a high score of self-efficacy, in which they managed and found a way out to solve difficult problems and could adapt to situations. self-efficacy helps overcome the problems that vary greatly from the consequences of cancer and the effects of treatment (foster et al., 2015). a similar result also reported nurse media journal of nursing, 10(2), 2020, 152 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 that 112 patients undergoing adjuvant endocrine therapy showed that those with higher self-efficacy were able to overcome physical symptoms of cancer and had a significant relationship related to greater functional, emotional, and social well-being (shelby et al., 2014). another study stated there was a positive relationship between self-efficacy and quality of life, the ability to adapt to cancer diagnosis, and reduce the distress of cancer patients (wang, liu, shi, & wang, 2016). someone with self-efficacy is more likely to be adaptable and has a high desire to live. the adaptation process of adult cancer patients starts from facing an unknown situation, followed by patients looking for relevant information and decision-making considerations, and also listening to healthcare professionals’ suggestions so that the patients get a chance to extend their life and the desire to survive (chao, wang, hsu, & wang, 2015). patients who have good self-efficacy will achieve a good quality of life. this was also reported by a study of 100 breast cancer patients that there was a significant relationship between self-efficacy and the quality of life of patients, including physical health, mental health, social relationships and satisfaction with the environment (moradi et al., 2017). another finding of this study showed a significant effect of self-efficacy on solving problems, which means that the participants who are eager to choose solving problems as a coping mechanism to respond to the stressors have an adaptive coping mechanism. this has been seen from the component of solving problems, that the participants were enthusiastic, full of attention, and could plan their actions to solve a problem. this result is supported by another study where patients who have high expectations resulted in the improvement of self-confidence, self-efficacy, and high welfare, and caused patients to have strong support for using strategies to achieve their goals in solving problems (bahryni, bermas, & tashvighi, 2016). a similar result declared that among 121 breast cancer patients undergoing surgery, those who had less emotional distress also had more positive problem-solving (heppner, armer, & mallinckrodt, 2009). based on the findings of this study, the majority of participants were in the old age (54.1 years), had cancer stage of ii and iii, and had also been diagnosed with cancer for more than 1 year. all of these participants chose to solve problems with adaptive and positive coping mechanisms. this result is supported by another study where 281 participants with gynecologic cancer having the mean age of 54.8 and in stage ii and iii of cancer predominantly also had resilience in psychologically adapting, and expressed three types of coping strategies, namely positive emotions, reframing cancer experiences positively, and fostering a sense of peace and meaning in life. this causes a good quality of life (manne et al., 2015). another research stated that positive coping was found in women cancer patients undergoing cancer treatment and were diagnosed for cancer for more than 6 months (kvillemo & bränström, 2014). our findings also showed that self-efficacy affected seeking support. the participants hoped for and received help and support from friends and family in solving the problem. seeking support is an effort made to seek help from those who are relevant to others to help to solve problems (zartaloudi & madianos, 2010). a study reported that patients who had problems were more likely to seek support from parents, friends, partners (chow & glaman, 2013). a study conducted for individuals who were depressed and anxious found that 47% sought support from professional experts to help solve their problems (wallerblad, möller, & forsell, 2012). this study found that the majority of nurse media journal of nursing, 10(2), 2020, 153 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 participants had been diagnosed with cancer for more than 1 year and the nuclear family lived with patients to provide support. a study stated that cancer patients who were diagnosed in the first 1-3 years experienced shock disorders such as physical, emotional, social, work, and financial stress, which made them in dire need of support from others (stanton, 2012). another study also explained that cancer survivors decided to seek support, especially from family members such as children, parents, siblings and more distant relatives to help them making treatment decisions, emotional support, inspiration, motivation, informational support, and spiritual support, and provide facilities (muhamad, afshari, & kazilan, 2011). a qualitative descriptive study of 14 breast cancer patients stated that family support could increase individual involvement in the fight against cancer (chung & hwang, 2012). seeking support, which is a finding of this research, is also caused by the active involvement of cancer survivors in community activities. the findings in this study are supported by the results of another study, which stated that the majority of cancer patients who were more than 50 years old and were active in online community groups had a better atmosphere and quality of life (van eenbergen, van de poll-franse, heine, & mols, 2017). the same results were also presented by a study which stated that the involvement of cancer patients in a support group in online communities could improve the ability to express emotions properly, and was beneficial for improving the health condition of patients (han et al., 2011). a study explained that breast cancer patients had a high awareness to know more about the disease and its treatment, therefore, the majority of patients visited health professionals to consult their problems (agbokey et al., 2019). participants in this study having low scores on self-efficacy are more likely to choose to avoid problems as an alternative coping mechanism. avoiding as coping is a form of individual behavior that seeks to avoid, deny, ignore and not solve problems properly which causes the individual to be in a stressful situation (holahan, moos, holahan, brennan, & schutte, 2005). a study of 97 gynecological cancer stated that patients who lacked self-confidence and were pessimistic had a significant association with the onset of anxiety and depression (zenger, glaesmer, hockel, & hinz, 2011). older people who are diagnosed with cancer are more anxious. it is supported by a study reporting that for patients diagnosed with cancer in late adulthood, 20% of them tend to report prolonged anxiety (mitchell, ferguson, gill, paul, & symonds, 2013). prolonged anxiety can cause an individual to feel hopeless; the hopelessness is related to cancer-related concerns, such as feeling different from others and feelings of alienation. together, this can affect a patient’s subjective responses, such as helpless responses, difficulty in resolving problems and affective disorders, and also poor general well-being (grassi et al., 2010). breast cancer patients experiencing a recurrence in four months after diagnosis reported feeling hopeless, feeling alone, and are very vulnerable to depression (brothers & andersen, 2009). cancer patients experiencing anxiety and depression at moderate levels are more likely to have coping strategies to avoid problems (karabulutlu, bilici, çayır, tekin, & kantarcı, 2010). avoiding problems is one of the maladaptive coping mechanisms. cancer patients experiencing excessive stress will perform maladaptive coping mechanisms, and use of maladaptive coping will further increase their psychological pressure and reduce their quality of life (ravindran, shankar, & murthy, 2019). a study of 346 patients undergoing palliative care with complex physical symptoms found that they had major coping strategies that focused on nurse media journal of nursing, 10(2), 2020, 154 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 emotions, such as cognitive avoidance and fatalism; this selection of coping was influenced by socio-demographic variables and disease (pereira & de brito santos, 2016). the similarity in results was also reported in study where 22 patients of breast cancer that received adjuvant therapy felt emotional encounters, isolationism, fatalism, feeling guilt and blaming others, and also avoided the problems, such as avoided threatening and unpleasant thoughts (hajian, mehrabi, simbar, & houshyari, 2017). this study has limitations. the participants in this study were cancer patients with all stages and types of cancer, and therefore, which might influence the patients’ responses to their condition. this study was also conducted with small sample size. despite the limitations, this study could describe the self-efficacy and coping mechanisms of cancer patients. conclusion the results of the study showed that self-efficacy affects the coping mechanism, where individuals who have positive self-efficacy will choose to solve problems and seek support as their coping mechanisms, while individuals with negative self-efficacy tend to choose to avoid the problem. the findings of this study are important to provide positive support to patients to increase self-efficacy, to be able to choose adaptive coping. based on the finding of this study, it is recommended to explore the internal and external motivation of cancer patients to choose coping mechanisms in future 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(2011). pessimism predicts anxiety, depression and quality of life in female cancer patients. japanese journal of clinical oncology, 41(1), 87-94. doi:10.1093/jjco/hyq168 nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://medianers.undip.ac.id 13(1):85-94, april 2023 https://doi.org/10.14710/nmjn.v13i1.49860 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 original research postpartum depression and its contributing factors among mothers during the covid-19 pandemic in north jakarta, indonesia venna yaasmiin aadillah1, irma nurbaeti1 1faculty of health sciences, universitas islam negeri syarif hidayatullah, jakarta, indonesia article info abstract article history: received: 27 october 2022 revised: 19 april 2023 accepted: 26 april 2023 online: 30 april 2023 keywords: childcare stress; covid-19; life stress; postpartum depression; unplanned/unwanted pregnancy corresponding author: irma nurbaeti faculty of health sciences, universitas islam negeri syarif hidayatullah jakarta, indonesia email: irma.nurbaeti@uinjkt.ac.id background: postpartum depression is a common psychological problem that occurs after birth. it has become especially prevalent in the era of the covid-19 pandemic. several factors contribute to postpartum depression. however, a limited study evaluated factors contributing postpartum depression among mothers during the covid-19 pandemic, particularly in indonesia. purpose: this study aimed to explore postpartum depression among mothers and its contributing factors during the covid-19 pandemic. methods: this study adopted a cross-sectional design. a total of 110 postpartum mothers were recruited by accidental sampling with the following inclusion criteria: mothers between one month and one year after birth, married, a singleton birth and the baby alive, and the mother is healthy with no complications. the edinburgh postnatal depression scale was used to measure postpartum depression. descriptive statistics, t-test, fisher exact test, one-way anova, and logistic regression were performed to analyze the data. results: the prevalence of postpartum depression during the pandemic period was 31.82%. factors contributing to postpartum depression were the mother’s age (p=0.011), childcare stress (p=0.001), stressful life events (p=0.003), and pregnancy status (p=0.0001). a logistic regression showed that pregnant status (unplanned/unwanted pregnancy) was the most contributor to postpartum depression (β=0.377, t=5.138, p=0.0001). conclusion: this study identified a high rate of postpartum depression with related factors, including mother’s age, childcare stress, life stress, and unplanned/ unwanted pregnancy. screening for postpartum depression is required to ensure early detection among postpartum mothers. how to cite: aadillah, v. y., & nurbaeti, i. (2023). postpartum depression and its contributing factors among mothers during the covid-19 pandemic in north jakarta, indonesia. nurse media journal of nursing, 13(1), 8594. https://doi.org/10.14710/nmjn.v13i1.49860 1. introduction the postpartum period is a time of adaptation to a non-pregnant state after childbirth, during which mothers experience physical, emotional, and mental changes (sylven et al., 2017). postpartum depression (ppd) is one of the mental health effects that mothers can experience after giving birth. as a mood disorder, mothers can experience ppd for up to one year after delivery. the symptoms of ppd include anxiety, irritability, difficulty sleeping, no appetite, and difficulty paying attention to the baby (o’hara & mccabe, 2013). ppd can occur during the first year after birth (american psychiatric association, 2013) and will negatively impact the mother, husband, family, and baby. when experiencing ppd, mothers tend to have difficulty thinking clearly when making decisions. furthermore, they may have appetite disorders, persistent low mood, and a feeling of sadness, while also perceiving that they are not good mothers to their babies (sulfianti et al., 2021). over the longer term, the potential negative impacts of ppd include a deterioration in the mother–infant relationship, delays in infant development, and the effect on child behavior (potter et al., 2019). studies conducted before the covid-19 pandemic showed through meta-analysis that the rate of prevalence of ppd stood at 17% among healthy postpartum women (wang et al., 2021), with the highest incidence in middle eastern and asia countries (26%) and the lowest incidence in european countries (8%) (shorey et al., 2018). meanwhile, the prevalence of ppd in indonesia stood at 11.76%–18.37% (nurbaeti et al., 2019; wang et al., 2021). during the covid-19 nurse media journal of nursing, 13(1), 2023, 86 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 pandemic, certain countries recorded a higher prevalence of ppd in the range of 31.82%–44.44%, for example, myanmar, mexico, italy, turkey, and the uk (chen et al., 2022). after the world health organization (who) declared the outbreak of covid-19 a pandemic in january 2020, including in indonesia in march 2020, the psychological impact on the community led to many responses, including anxiety, depression, and post-traumatic stress (who, 2020). ongoing psychological impacts during pregnancy and childbirth can result in mothers experiencing psychological disorders during their postpartum period. however, amid the covid-19 pandemic, the psychological well-being of women during the postpartum period was neglected and often overlooked (chen et al., 2022). many previous studies worldwide have documented the contributing factors to ppd before the covid-19 pandemic, such as depression during pregnancy, stress in childcare, stress in live events, social support, anxiety during pregnancy, marital satisfaction, history of previous depression, infant temperament, maternity blues, and self-esteem (franck et al., 2016; o’hara & mc cabe, 2013), as well as socioeconomic status (chang et al., 2016), marital status, and unplanned/unwanted pregnancy (falah-hassani et al., 2016; o’hara & mc cabe, 2013; smorti et al., 2019). the covid-19 pandemic has influenced women’s mental health, particularly in vulnerable groups such as mothers after birth (who, 2020). as a result, the prevalence of ppd increases higher than in non-pandemic era. studies on ppd were conducted in various countries during the covid-19 pandemic (safi-keykaleh et al., 2022; shuman et al., 2022; usmani et al., 2021). meanwhile in indonesia, solikhah et al. (2022) found that the determinant factor of ppd during the covid-19 was first-time mothers and attitudes. at the same time, other factors have not been documented. therefore, it is important to develop the knowledge of ppd and its contributing factors. accordingly, this study was conducted to explore postpartum depression among mothers and its contributing factors, including childcare stress, life stress, social support, marital satisfaction, and pregnancy status. 2. methods 2.1 research design this study employed a cross-sectional research design. this research design was adopted to measure the independent and dependent variables simultaneously at the same time. 2.2 setting and samples the study was conducted from april to may 2022. the study setting was the maternal and child clinic of the public health center in north jakarta, indonesia, as an entry point to find the proposed participants. the accidental sampling technique was used to recruit the participants following the inclusion criteria: mothers with a postpartum period of one month to one year after delivery, a live baby, healthy and with no complications, and married. meanwhile, twin babies, mothers with preterm labor, and mothers who had been diagnosed with mental problems were excluded from the study. the number of samples was 110 postpartum mothers determined using the g-power analysis. 2.3 measurement and data collection six questionnaires were used in this study. the demographic data consisted of respondents’ characteristics and the babies, including the mother’s education, mother’s age, working status, family income, previous exposure to covid-19, baby’s gender, number of children, and pregnancy status. other instruments were the edinburgh postnatal depression scale (epds) questionnaire developed by cox et al. (1987) to measure postpartum depression, childcare stress inventory (csi) questionnaire developed by cutrona (1983) to measure childcare stress, the modified life events questionnaire (leq) developed by norbeck (1984) to measure life stress, postpartum support questionnaire (psq) developed by logsdon et al., (1994) to assess respondents’ perceptions of the support received during the postpartum period, and the dyadic adjustment scale (das) questionnaire developed by spanier (1976) to measure marital satisfaction. all instruments have been translated into bahasa indonesia in a previous study (nurbaeti et al., 2018). the epds consists of 10 question items with a score of 0 to 3 on each item; it thus produces a total score in the range of 0–30, where a score of 12 or more indicates ppd (bhusal et al., 2016; nurbaeti et al., 2019; sylven et al., 2017). in addition, the instrument’s validity and reliability have nurse media journal of nursing, 13(1), 2023, 87 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 already been proven; the validity test results in the range of 0.333-0.694, and the reliability test produced a cronbach’s alpha value of 0.80 (nurbaeti et al., 2019). the csi consists of 20 question items, each of which has a score of 0 (not disappointing) to 100 (disappointing). this instrument produces scores in the range of 0-2000; the cut-off score was 342. a score of 342 and more indicated experience of stress in childcare. a validity test result in the range of 0.155-0.488 and a reliability test result of 0.74 (nurbaeti et al., 2019). the original leq contained 10 question items, and nurbaeti et al. (2018) added five items to make it suitable for use with postpartum mothers. this modified leq thus contains 15 question items with scores ranging from 0 (no effect) to 3 (excellent effect). it gives a total score in the range of 0-45, where a total score of more than 14 shows that life stress occurred. the validity test showed a value in the range of 0.267-0.611, while the reliability test revealed a cronbach’s alpha value of 0.83 (nurbaeti et., 2019). psq comprises 34 question items, with each item being scored from 0 (not helpful) to 7 (much help). the total scores range from 0 to 238, with a cut-off score of 191 indicating more support received. the result of the validity test was in the range of 0.155-0.448, and the reliability test result was 0.98 (nurbaeti et al., 2019). the das consists of 32 questions. the total score is in the range of 0-151, with a cut-off score of <100 indicating dissatisfaction in the marital relationship. the validity test is in the range of 0.157-0.629, and the reliability test result showed a cronbach’s alpha value of 0.73 (nurbaeti et al., 2019). the data were collected through home visits. candidates of the participants who met the inclusion criteria from the maternal and child clinic in the public health center were persuaded to participate in the study. if they concurred to participate, the researcher requested their phone number and home address and made an appointment to visit. the researcher then visited the participants’ homes as agreed. after each participant had provided their consent, they filled out the questionnaire, which took around 20 minutes. the researcher and participant did a health protocol such as hand wash before and after contact, wearing a face mask, and keeping a distance during data collection. 2.4 data analysis univariate statistics were used to describe the respondents’ characteristics and the variables studied. bivariate analysis was performed using t-test to analyze the relationship between mother’s age and the number of children with ppd and fisher exact test was used to analyze the relationship between working status, covid-19 survivor, baby gender, childcare stress, life stress, social support, marital satisfaction, and unplanned/unwanted pregnancy with ppd. furthermore, one-way anova was performed to analyze the relationship of mothers’ education and family income with ppd. the enter logistic regression method was performed to analyze the factors that contribute to ppd. 2.5 ethical considerations the ethical approval of this study was obtained from the health research ethics committee of the faculty of health sciences, uin syarif hidayatullah jakarta with a reference number of un.01/f.10/kp.01.1/ke.sp/04.08.023/2022. the principle of anonymity in the data collection was considered. it relates to the questions posed to respondents about names to prevent double data. prior to the recruitment of participants, the researcher explained the purpose and benefits of the research to the candidate respondents. they signed an informed consent letter for their participation. 3. results 3.1 characteristics of respondents table 1 contains a brief summary of the respondents’ characteristics and the babies. the youngest mothers were 20 years old, and the oldest were 45 years old. the majority graduated from senior high school (60.90%) and were housewives (69.10%). furthermore, 81.82% have an average monthly family income of idr 5.000.000 (us$ 400) or less and 20.90% had a history of exposure to covid-19. the analysis found that the mother’s age contributed to ppd while the other characteristics did not. nurse media journal of nursing, 13(1), 2023, 88 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 1. characteristics of respondents (n=110) variable n (%) postpartum depression no postpartum depression p-value mothers’ education elementary school junior high school senior high school university 7 (6.37%) 7 (6.37%) 67 (60.90%) 29 (26.36%) 2 2 23 8 5 5 44 21 0.918 mothers’ age (years) min – max = 20 45 mean = 28.56 (sd= 5.745) median = 27.00 mean= 26.20 mean=29.67 0.011 working status working housewives 34 (30.90%) 76 (69.10%) 9 26 25 50 0.559 family income in idr (equal us$) < 2.500.000 (200) 2.500.000-5.000.000 (200-400) > 5.000.000 (>400) 46 (41.82%) 44 (40.00%) 20 (18.18%) 16 14 5 30 30 15 0.735 covid-19 exposure yes no 23 (20.90) 87 (79.10%) 5 30 18 57 0.360 baby’s gender boy girl 55 (50.00%) 55 (50.00%) 17 18 38 37 1.000 number of children min-max = 1-5 mean = 1.78 (sd=0.971) median = 1.00 mean=1.60 mean=2.35 0.324 note: the t-test was used to analyze mother’s age and the number of children with ppd; the fisher exact test was sued to analyze the relationship between working status, covid-19 survivor, baby gender; one-way anova was used to analyze mothers’ education and family income with ppd. 3.2 the prevalence of postpartum depression as shown in table 2, the prevalence of ppd among mothers during the covid-19 pandemic era in this study was 31.82%. table 2. the prevalence of postpartum depression among mothers during the covid-19 pandemic postpartum depression no postpartum depression n % n % 35 31.82 75 68.18 3.3 contributing factors of postpartum depression: childcare stress, life stress, social support, marital satisfaction, and unplanned/unwanted pregnancy table 3 presents the bivariate analysis using chi-square analysis to test the relationship between the various contributing factors and ppd. the results show that childcare stress (p=0.001), stressful life events (p=0.003), and planned/wanted pregnancy (0.0001) have a significant contribution to ppd, while social support (p=1.000) and marital satisfaction (p=1.000) have not contributed to ppd. to complete the analysis, the researcher performed a logistic regression using the enter method. all the significant variables were included in the analysis. it showed that the mother’s age, childcare stress, life stress, and pregnancy status could explain 49% of the variance in ppd (r2=0.490; f=25.190; p=0.0001). pregnancy status explained the most variance (β=0.377, t=5.138, p=0.0001) followed by life stress (β=0.304, t=3.920, p=0.0001), mother’s age (β= 0.223, t=-3.123, p=0.002), and childcare stress (β=0.221, t=2.776, p=0.007) (table 4). nurse media journal of nursing, 13(1), 2023, 89 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 3. contributing factors to ppd: child care stress, life stress, social support, marital satisfaction and unplanned/unwanted pregnancy and postpartum depression (n=110) variable postpartum depression x2 p-value no yes childcare stress no yes 46 (41.81%) 29 (26.37%) 9 (8.19%) 26 (23.63%) 10.728 0.001 life stress no yes 41 (37.27%) 34 (30.90%) 8 (7.27%) 27 (24.55%) 8.530 0.003 social support high low 36 (32.73%) 39 (35.45%) 23 (20.91%) 12 (10.91%) 2.341 0.126 marital satisfaction yes no 66 (60.00%) 9 (8.18%) 31 (28.18%) 4 (3.64%) 0.000 1.000 pregnant status planned/wanted unplanned/unwanted 74 (67.27%) 1 (0.91%) 22 (20.00%) 13 (11.82%) 24.420 0.0001 note: analysis was conducted by using the fisher exact test table 4. contribution of mother’s age, childcare stress, life stress, and pregnancy status to ppd during the covid-19 pandemic in north jakarta, indonesia (n=110) unstandardized coefficients standardized coefficients t p 95.0% ci for b b std. error beta lower bound upper bound (constant) 5.044 2.308 2.185 0.031 0.467 9.621 mothers age -0.214 0.068 -0.223 -3.123 0.002 -0.350 -0.078 childcare stress 0.004 0.001 0.221 2.776 0.007 0.001 0.006 life stress 0.152 0.039 0.304 3.920 0.0001 0.075 0.229 pregnancy status 6.198 1.206 0.377 5.138 0.0001 3.807 8.590 r=0.700; r2 = 0.490; f= 25.190; p= 0.0001 4. discussion this study aimed to determine ppd among mothers and its contributing factors, including childcare stress, life stress, social support, marital satisfaction, and unplanned/unwanted pregnancy. in this study, the prevalence of ppd among mothers during the covid-19 pandemic in north jakarta, indonesia, using a cut-off score of 12, was 31.82%. this rate was much higher than those found in studies conducted before the pandemic. for instance, nurbaeti et al. (2019) found that 19.88% of postpartum mothers in south jakarta, indonesia, experienced depressive symptoms following childbirth. more recently, a study by solikhah et al. (2022) found that 57% of mothers experienced ppd in malang, east java, indonesia. in the general population, sarfika et al. (2021) found higher about 71.70% of the population in indonesia with depressive symptomatology during the pandemic. this study’s finding is similar to that of chen et al. (2022) who concluded that the prevalence of ppd was 34%. mcfarland et al. (2021) reported that women in new jersey, usa, who gave birth in march 2020, at the beginning of the covid-19 pandemic, were more likely to have higher levels of depressive symptoms than women who gave birth before the covid-19 pandemic. hummel et al. (2022) found that 32.9% of kenyan women tended to experience ppd symptoms during the covid-19 pandemic. these research findings show that the covid-19 pandemic could have had a detrimental effect on maternal mental well-being among women after childbirth (chen et al., 2021). this study showed that unwanted or unplanned pregnancy was the strongest contributor to ppd with or 95%; ci 3.807–8.590. this explains why mothers with unplanned or unwanted pregnancies tended to experience ppd 3-8 times more often than mothers who planned or wanted to become pregnant. an unwanted or unplanned pregnancy can considerably alter the lives of women and their families as well as their socio and economic condition. the present study amplified previous studies (abbasi et al., 2013; brito et al., 2015; kettunen et al., 2016; surkan et nurse media journal of nursing, 13(1), 2023, 90 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 al., 2018). surkan et al. (2018), in a study in bangladesh, found that mothers with unwanted pregnancies tended to be at higher risk of experiencing depressive symptoms compared with mothers who wanted their pregnancies. women who perceived that their husbands did not want the pregnancy were also at higher risk of prenatal and postnatal depressive symptoms. furthermore, brito et al. (2015) reported a frequency of unwanted pregnancy of 60.2%; among those women, 25.9% experienced ppd symptoms. therefore, women who perceived their pregnancy was unwanted had higher symptoms of ppd (brito et al., 2015). similarly, abbasi et al. (2013) identified a higher prevalence of ppd among first-time mothers if they perceived their pregnancy was unwanted compared with wanted pregnancies; however, unwanted pregnancy was not significantly associated with ppd. wanted pregnancy relates to women’s readiness to become a mother and assume the role of motherhood. the covid-19 pandemic increased the tension and anxiety for many people, particularly in vulnerable communities such as postpartum mothers. communities were forced to adapt in the face of the pandemic; for example, maternal health facilities were closed at the start of the outbreak, regional quarantines were imposed, and lockdowns and social distancing became part of people’s lives (bhattacharjee & ghosh, 2022). in our study, life stress was found to significantly contribute to ppd. this finding is consistent with those from previous studies conducted before the covid-19 pandemic. qobadi et al. (2016) reported depressive symptomatology among postpartum women associated with life stress. women who notified more scores of life stress experienced a much higher level of ppd symptoms compared to those who had lower levels of life stress. such events included trauma-related stress, financial stress, and emotional stress. similarly, al nasr et al. (2020) and nurbaeti et al. (2019) identified that stressful life events were the strongest contributor to ppd. during the covid-19 pandemic, cameron et al. (2020), in a study conducted in canada, found a significant correlation between stress and ppd. they reported a greater stress score during the previous month, of 1.03-2.99, thus indicating that time can predict maternal depression. salm ward et al. (2017), despite conducting their study before the covid-19 pandemic, also identified that life stress, such as dissent with a partner, hardship in bill payables, and separation or divorce, was relevant as significant predictors of an increased likelihood of ppd. experiencing high stress in any domain has been found to significantly predict ppd, followed by a combination of high relational and financial stress. furthermore, kettunen et al. (2016) reported that negative life events such as the death of a loved one, sickness (self or child/family), marital relationship problems, and socioeconomic problems also contributed to ppd. our study showed that childcare stress made a significant contribution to ppd. during the postpartum period, mothers experience physical, emotional, and psychological changes as part of the adjustment to a non-pregnant state. in indonesian culture, a woman must also take care of her babies. during the covid-19 pandemic, when mobility was restricted, some women’s inability to involve their extended family in care for their newborns posed a challenge. therefore, readiness to become a parent can lead to stress, which includes taking care of the baby. mothers also faced the added fear of either themselves or their babies becoming infected with covid-19. the present study aligns with previous studies (kettunen et al., 2016; kim et al., 2019; nurbaeti et al., 2018 and 2019) on aspects of childcare stress. kettunen et al. (2016), for example, found that a deterioration in the relationship between infant and mother tended to increase the risk of ppd by 1–2 times. in korea, postpartum period women who received attended sanhujori care facilities felt comfortable and could be rested and relaxed. this type of intervention during the postpartum period could therefore reduce depressive symptoms. after they came back to their returning homes, they became worried about taking care of their babies (kim et al., 2019). according to our study, the mother’s age significantly contributed to ppd, with a negative beta score. as such, the youngest women had higher depressive symptom scores than the older women, thus indicating that maternal age is linked to women’s maturity to deal with the role of motherhood. in this regard, this study was consistent with other studies conducted during the covid-19 pandemic. suárez-rico et al. (2021) reported that the mother’s age was a significant predictor of ppd. in a literature review, chen et al. (2022) found that respondents’ sociodemographic characteristics, marital status, woman’s age, and employment status were significantly correlated with ppd. iwata et al. (2016) identified that younger and first-time mothers tended to experience depressive symptoms during the postpartum period compared to older first-time mothers or more than one child. moreover, maturity, stability of the marriage nurse media journal of nursing, 13(1), 2023, 91 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 relationship, and experience in taking care of the baby were the possible factors that older firsttime mothers and mothers who have more than one child are more likely to have less depressive symptoms (iwata et al., 2016). interestingly, marital satisfaction and social support did not significantly contribute to ppd, which was contrary to the findings of previous studies (al nasr et al., 2020; chen et al., 2022; nurbaeti et al., 2018; nurbaeti et al., 2019). this may reflect the fact that during the covid-19 pandemic, communities received support from the government in the form of social service programs and direct cash assistance. restrictions on movement may also have led to increased levels of domestic help for postpartum women from husbands or relatives. 5. implications and limitations this study has implications for nursing practices and health policies concerning the prevention of ppd among postpartum mothers and the preservation of their mental health. early detection is needed to prevent ppd, for instance, conducting socialization with all postpartum mothers on the independent use of postpartum depression screening applications. health workers can also provide maximum support regarding the prevention and management of ppd. this would assist mothers in knowing when to seek help for further treatment. in addition, by learning about the factors that contribute to ppd, nurses and other health workers can provide support in the form of knowledge about physical and psychological changes during the postpartum period, psychological adaptation of postpartum, how to take care of the baby, breastfeeding, and the things that postpartum mothers need, especially in the context of the covid-19 pandemic. this study, nevertheless, has some limitations. first, while it adopted a cross-sectional design, the independent and dependent variables were explored only once with no follow-up. second, the use of accidental sampling in this study to identify participants who met the criteria did not fully represent indonesian mothers in jakarta. 6. conclusion in conclusion, our findings revealed a greater prevalence of ppd during the covid-19 pandemic than before it began. factors including the mother’s age, childcare stress, life stress, and unplanned/unwanted pregnancy were identified as contributors to ppd. collaboration between maternity nurses, community nurses, and midwives is needed to promote knowledge about ppd through offline and online media. collaboration with medical doctors and psychologists may also be required in terms of helping mothers deal with mental health problems through counseling or therapeutic regimens. there is a need to develop nursing interventions among antenatal and postpartum mothers to prevent ppd. further research is also needed to explore the impact of ppd on the mother–child relationship and couples’ relationships in a longitudinal study. acknowledgment this study was supported by uin syarif hidayatullah jakarta, indonesia. the authors are grateful to all the participants. author contribution all authors have contributed to this study, including the concept, design, data collection, management, and analysis, and the drafting and writing up of the manuscript. conflict of interest no conflict of interest is stated among the authors. references abbasi, s., chuang, c. h., dagher, r., zhu, j., & kjerulff, k. 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(2023). trends in maternal mental health during the covid-19 pandemic–evidence from zambia. plos one, 18(2), e0281091. https://doi.org/10.1371/journal.pone.0281091 franck, e., vanderhasselt, m.-a., goubert, l., loeys, t., temmerman, m., & de raedt, r. (2016). the role of self-esteem instability in the development of postnatal depression: a prospective study testing a diathesis-stress account. journal of behavior therapy and experimental psychiatry, 50, 15–22. https://doi.org/10.1016/j.jbtep.2015.04.010 hummel, a. d., ronen, k., bhat, a., wandika, b., choo, e. m., osborn, l., batra, m., kinuthia, j., kumar, m., & unger, j. a. (2022). perinatal depression and its impact on infant outcomes and maternal-nurse sms communication in a cohort of kenyan women. bmc pregnancy and childbirth, 22(1), 1–16. https://doi.org/10.1186/s12884-022-05039-6 iwata, h., mori, e., sakajo, a., aoki, k., maehara, k., & tamakoshi, k. (2016). prevalence of postpartum depressive symptoms during the first 6 months postpartum: association with maternal age and parity. journal of affective disorders, 203, 227–232. https://doi.org/10.1016/j.jad.2016.06.002 kettunen, p., koistinen, e., & hintikka, j. (2016). the connections of pregnancy-, delivery-, and infant-related risk factors and negative life events on postpartum depression and their role in first and recurrent depression. depression research and treatment, 2016, 1–7. https://doi.org/10.1155/2016/2514317 https://doi.org/10.3389/fpsyt.2021.661903 http://doi.org/10.1192/bjp.150.6.782 nurse media journal of nursing, 13(1), 2023, 93 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 kim, y., sookbinim, s., dee, v., brandt, c., & hong, e. (2019). feelings, self-care, and infant care reported by korean women at risk for postpartum depression. international journal of nursing, 6(1) , 1-11. https://doi.org/10.15640/ijn.v6n1a1 logsdon, m. c., mcbride, a. b., & birkimer, j. c. (1994). social support and postpartum depression. research in nursing & health, 17(6), 449–457. https://doi.org/10.1002/nur.4770170608. mcfarland, m. j., mcfarland, c. a. s., hill, t. d., & d’oria, r. (2021). postpartum depressive symptoms during the beginning of the covid-19 pandemic: an examination of population birth data from central new jersey. maternal and child health journal, 25(3), 353–359. https://doi.org/10.1007/s10995-020-03116-w norbeck, j.s. (1984). modification of life event questionnaire for use with female respondents. research in nursing & health. 7(1), 67–71. https://www.ncbi.nlm.nih.gov/pubmed/6565302. nurbaeti, i., deoisres, w., & hengudomsub, p. (2019). association between psychosocial factors and postpartum depression in south jakarta, indonesia. sexual & reproductive healthcare, 20, 72–76. https://doi.org/10.1016/j.srhc.2019.02.004 nurbaeti, i., deoisres, w., & hengudomsub, p. (2018). postpartum depression in indonesian mothers: its changes and predicting factors. pacific rim international journal of nursing research, 22(2), 93–105. available from: https://he02.tcithaijo.org/index.php/prijnr/article/view/84760 o’hara, m. w., & mccabe, j. e. (2013). postpartum depression: current status and future directions. annual review of clinical psychology, 9(1), 379–407. https://doi.org/10.1146/annurev-clinpsy-050212-185612 potter, p. a., perry, a. g., stockert, p. a., hall, a., novieastari, e., ibrahim, k., & deswani, d. (2019). fundamentals of nursing vol 29th indonesian edition (deswani, e. novieastari, k. ibrahim, & s. ramdaniati (eds.)). elsevier health sciences. qobadi, m., collier, c., & zhang, l. (2016). the effect of stressful life events on postpartum depression: findings from the 2009–2011 mississippi pregnancy risk assessment monitoring system. maternal and child health journal, 20(s1), 164–172. https://doi.org/10.1007/s10995-016-2028-7 safi-keykaleh, m., aliakbari, f., safarpour, h., safari, m., tahernejad, a., sheikhbardsiri, h., & sahebi, a. (2022). prevalence of postpartum depression in women amid the covid-19 pandemic: a systematic review and meta-analysis. international journal of gynaecology and obstetrics, 157(2), 240–247. https://doi.org/10.1002/ijgo.14129 salm ward, t., kanu, f. a., & robb, s. w. (2017). prevalence of stressful life events during pregnancy and its association with postpartum depressive symptoms. archives of women's mental health, 20(1), 161–171. https://doi.org/10.1007/s00737-016-0689-2 sarfika, r., malini, h., putri, d. e., buanasari, a., abdullah, k. l., & freska, w. (2021). factors influencing depression among indonesians during the covid-19 outbreak. nurse media journal of nursing, 11(3), 380–388. https://doi.org/10.14710/nmjn.v11i3.36783 shorey, s., chee, c. y. i., ng, e. d., chan, y. h., tam, w. w. s., & chong, y. s. (2018). prevalence and incidence of postpartum depression among healthy mothers: a systematic review and meta-analysis. journal of psychiatric research, 104, 235–248. https://doi.org/10.1016/j.jpsychires.2018.08.001 shuman, c. j., peahl, a. f., pareddy, n., morgan, m. e., chiangong, j., veliz, p. t., & dalton, v. k. (2022). postpartum depression and associated risk factors during the covid-19 pandemic. bmc research notes, 15, 102. https://doi.org/10.1186/s13104-022-05991-8 smorti, m., ponti, l., & pancetti, f. (2019). a comprehensive analysis of postpartum depression risk factors: the role of socio-demographic, individual, relational, and delivery characteristics. frontiers in public health, 7 (295), 1-10. https://doi.org/10.3389/fpubh.2019.00295 spanier, g. b. (1976). measuring dyadic adjustment: new scales for assessing the quality of marriage and similar dyads. journal of marriage and family, 38, 15-28. http://dx.doi.org/10.2307/350547 solikhah, f. k., nursalam, n., subekti, i., winarni, s., & yudiernawati, a. (2022). determination of factors affecting postpartum depression in primary healthcare during the covid-19 https://doi.org/10.15640/ijn.v6n1a1 nurse media journal of nursing, 13(1), 2023, 94 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 pandemic. journal of public health in africa, 13(s2). https://doi.org/10.4081/jphia.2022.2408 suárez-rico, b. v., estrada-gutierrez, g., sánchez-martínez, m., perichart-perera, o., rodríguezhernández, c., gonzález-leyva, c., osorio-valencia, e., cardona-pérez, a., helguerarepetto, a. c., espino y sosa, s., solis-paredes, m., & reyes-muñoz, e. (2021). prevalence of depression, anxiety, and perceived stress in postpartum mexican women during the covid19 lockdown. international journal of environmental research and public health, 18(9), 4627. https://doi.org/10.3390/ijerph18094627 sulfianti, s., nardina, e. a., hutabarat, j., astuti, e. d., muyassaroh, y., yuliani, d. r., hapsari, w., azizah, n., hutomo, c. s., argahen, n. b., & others. (2021). asuhan kebidanan pada masa nifas [maternity care during postpartum period]. yayasan kita menulis. surkan, p. j., strobino, d. m., mehra, s., shamim, a. a., rashid, m., wu, l. s.-f., ali, h., ullah, b., labrique, a. b., klemm, r. d. w., west, k. p., & christian, p. (2018). unintended pregnancy is a risk factor for depressive symptoms among socio-economically disadvantaged women in rural bangladesh. bmc pregnancy and childbirth, 18(1), 490. https://doi.org/10.1186/s12884-018-2097-2 sylvén, s. m., thomopoulos, t. p., kollia, n., jonsson, m., & skalkidou, a. (2017). correlates of postpartum depression in first time mothers without previous psychiatric contact. european psychiatry, 40, 4–12. https://doi.org/10.1016/j.eurpsy.2016.07.003 usmani, s., greca, e., javed, s., sharath, m., sarfraz, z., sarfraz, a., salari, s. w., hussaini, s. s., mohammadi, a., chellapuram, n., cabrera, e., & ferrer, g. (2021). risk factors for postpartum depression during covid-19 pandemic: a systematic literature review. journal of primary care & community health, 12, 21501327211059348. https://doi.org/10.1177/21501327211059348 wang, z., liu, j., shuai, h., cai, z., fu, x., liu, y., xiao, x., zhang, w., krabbendam, e., liu, s., liu, z., li, z., & yang, b. x. (2021). mapping global prevalence of depression among postpartum women. translational psychiatry, 11(1), 543. https://doi.org/10.1038/s41398021-01663-6 world heath organisation. (2020). coronavirus disease (covid-19) pandemic. world health organization. https://www.who.int/europe/emergencies/situations/covid-19 copyright © 2023 nmjn. this article is an open-access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). https://www.who.int/europe/emergencies/situations/covid-19 https://creativecommons.org/licenses/by-sa/4.0 app. 1 copyright © 2021, nmjn, p-issn 2087-7811, e-issn 2406-8799 1. focus and scope the nurse media journal of nursing (nmjn) is a nursing journal that publishes the scientific works of nurses, academics, and practitioners. nmjn welcomes and invites original and relevant research articles in nursing as well as reviews (systematic and metaanalysis) and case reports. 2. general guidelines manuscripts submitted to the journal are not yet published. nmjn does not accept any manuscripts which are also sent to other journals for publication at the same time. the writer should ensure that all members of his/her team have approved the manuscript for publication. any research report on humans as the subject should enclosure the signed informed consent, and prior ethical approval was obtained from a suitably constituted research ethics committee or institutional review board. if any financial support was received or relationship(s) existed, the authors should mention that no conflict of interest of any financial support or any relationship or other exists during a research project. those points should mention in the cover letter to the editor of nmjn. 3. review process each manuscript is reviewed by the editors, and if of a sufficient standard, sent for blinded reviewed by at least two editorial board members or reviewers who come from a range of countries as chosen by the journal team based on their expertise. the result may be accepted with no revision, accepted with minor correction, accepted with major revision, and refused. the sending author is given an opportunity to correct the article based on suggestions received from the reviewers. the specific information of whether the article is accepted and published or refused is given to the sending author in written. 4. manuscript guidelines the manuscript should be written in english on an essay format which is outlined as follow: 4.1 title page this includes the title of the manuscript, the full names without academic and professional credentials with commas between names. in addition, a number (1) is to be used to designate the corresponding author with academic and professional credentials, institutional affiliation(s), postal and email addresses of each author. 4.2 abstract abstract for research articles, reviews, and case reports should use a maximum of 300 words. the abstract should consist of background, purpose, methods, results, and conclusion. the abstract is clearly written and is short to help readers get an understanding of the new and important aspects without reading the whole article. keywords are written on the same page with abstract separated from each other with a semicolon (;). please use a maximum of 5 appropriate words for helping with the indexing. 4.3 manuscript of original research 4.3.1 introduction the introduction provides the state of the art of the study and consists of an adequate background, previous research in order to record the existing solutions/method to show which is the best, and the main limitation of previous research, to show the scientific merit or novelties of the paper. avoid a detailed literature survey or a summary of the results. the purpose of the study should state the major aim of the research and is written at the end of the introduction section. author guidelines editorial team app. 2 copyright © 2021, nmjn, p-issn 2087-7811, e-issn 2406-8799 4.3.2 methods methods should be structured as follow: 4.3.2.1 research design describe the specific research design used, such as correlational, experimental, quasiexperimental, cross-sectional, and others. provide relevant descriptions regarding the design applied in the study. 4.3.2.2 setting and samples/participants state when and where the study was conducted without mentioning the specific name of the research site. identify the sampling strategy used to recruit the samples/participants as well as the inclusion and exclusion criteria. how samples/participants were recruited should also be stated. also, identify the sample size (and the population, if applicable) and sample size justification, including sample size calculation or power analysis, if applicable. 4.3.2.3 intervention (applies to experimental studies) describe the intervention, setting, and those who provided the intervention. if the study included a control group, explain what kind of intervention was provided to this group. 4.3.2.4 measurement and data collection mention and describe the instrument used for data collection. clearly state whether the researchers develop, adopt, or modify the instrument from previous studies, including its citations and references. mention the validity and reliability of the instrument, the scale, interpretation, and administration. if a translation was conducted from the original language, authors should explain the procedures used to maintain the validity and reliability of the translated instruments. describe how data were collected. if the data were collected by research assistants, please identify this in the manuscript. 4.3.2.5 data analysis clearly describe the techniques used for data analysis, including the computer software used, if appropriate. please provide relevant references for specific analytic approaches/ techniques (for qualitative studies). 4.3.2.6 trustworthiness/rigor (applies to qualitative studies) the manuscript should describe strategies used to maintain the trustworthiness/rigor of the qualitative data, such as credibility, transferability, dependability, and confirmability. 4.3.2.7 ethical considerations please describe the ethical issues in the study, including how informed consent was obtained from respondents/participants. provide a statement of approval from the health research ethics committee, including its reference number. 4.3.3 results results state the major findings of the research instead of providing data in great detail. results should be clear, concise, and can be reported on texts or graphics. please provide some introduction for the information presented on tables or figures. 4.3.4 discussion the discussion should explore the significance of the results of the study. the following components should be covered in the discussion: (1) how do your results relate to the original question or objectives outlined in the background section (what)? (2) do you provide an interpretation scientifically for each of your results or findings presented (why)?, app. 3 copyright © 2021, nmjn, p-issn 2087-7811, e-issn 2406-8799 and (3) are your results consistent with what other investigators have reported (what else)? or are there any differences? 4.3.5 implication and limitations the manuscript should describe the implications of the study on nursing practices and policies based on the findings and also the limitations. 4.3.6 conclusion conclusions should answer the research objectives, telling how advanced the result is from the present state of knowledge. conclusions should be clear in order to know it merits publication in the journal or not. provide a clear scientific justification and indicate possible applications and extensions. a recommendation should also be pointed out to suggest future research and implication in the nursing practice. 4.3.7 acknowledgments briefly acknowledge research funders and any research participants in this section. 4.3.8 author contribution we encourage authors to provide statements outlining their individual contributions or roles to the manuscript. 4.3.9 conflict of interest state whether there is a conflict of interest among authors. 4.3.10 reference the reference consists of all references used to write the manuscript and adhere to the apa 7th edition. ensure that citations used are as contemporary as possible, including those from the current year of writing. delete older literature citations (more than 10 years) unless these are central to your study. the number of references should be at least 30, of which 80% of them should be from journal articles. references should avoid the use of secondary citations. self-citations are allowed up to 15% of the total references. 4.4 manuscript of reviews (systematic or meta-analysis) 4.4.1 introduction the introduction provides the state of the art of the study and consists of an adequate background, previous research in order to record the existing solutions/method to show which is the best, and the main limitation of previous research, to show the scientific merit or novelties of the paper. avoid a detailed literature survey or a summary of the results. the purpose of the study should state the major aim of the research and is written at the end of the introduction section. 4.4.2 methods methods should be structured as follow: 4.4.2.1 research design describe the specific research design used: systematic review or meta-analysis. provide relevant descriptions regarding the design applied in the study. 4.4.2.2 search methods identify the electronic databases searched, keywords, and search methods (range of years). use a table if necessary to show readers the number of articles you search from each database. app. 4 copyright © 2021, nmjn, p-issn 2087-7811, e-issn 2406-8799 4.4.2.3 inclusion and exclusion criteria identify the inclusion and exclusion criteria for selecting the articles. 4.4.2.4 screening of articles include the reviewers who did the first screening for selection and screening for content analysis. 4.4.2.5 data extraction identify how data were extracted. please use a table that contains authors' names, year, country name, objective, conceptual framework, sample, design, instrument, and results. 4.4.2.6 quality appraisal include a description of approaches used, the outcome of the appraisal process, and the audit of discarded studies. make clear the criteria that were used for discarding studies. if the quality appraisal was not undertaken, provide a convincing and robust explanation, and in the limitations section, outline the potential impact on the credibility of the review findings. 4.4.2.7 data analysis explain how you analyze the contents. 4.4.3 results results should include the search outcomes, quality assessment results, and analytical findings. please describe the search outcome using the prisma flow diagram. describe the results of the assessment as indicated in the method. the analytical findings should be presented using themes, categories, patterns, and so on. 4.4.4 discussion the discussion should explore the significance of review findings. please draw out the applicability, theoretical and practical implications of the findings. clarify the contribution of the review to existing knowledge, highlight gaps in knowledge and understanding, and outline future research. 4.4.5 implication and limitations provide the implications/ recommendations for policies or practices, as well as the limitations of the review. 4.4.6 conclusion the conclusion should summarize important aspects of reviewed studies and evaluate the current state of the literature reviewed, identify significant flaws or gaps in existing knowledge, outline areas for future study, and link your research to existing knowledge. 4.4.7 acknowledgments briefly acknowledge research funders and any parties that contribute to the study. 4.4.8 author contribution we encourage authors to provide statements outlining their individual contributions or roles to the manuscript. 4.4.9 conflict of interest state whether there is a conflict of interest among authors. app. 5 copyright © 2021, nmjn, p-issn 2087-7811, e-issn 2406-8799 4.4.10 reference the reference consists of all references used to write the manuscript and adhere to the apa 7th edition. ensure that citations used are as contemporary as possible, including those from the current year of writing. delete older literature citations (more than 10 years) unless these are central to your study. the number of references should be at least 50, and 80% of them should be from journal articles. references should avoid the use of secondary citations. self-citations are allowed up to 20% of the total references. 4.5 manuscript of case studies 4.5.1 introduction the introduction should explain the background of the case (the rarely found case), including the disorder or nursing problems and usual presentation and progression. it should also include a brief literature review that introduces the case report from the standpoint of those without specialist knowledge in the area. it should also end with a very brief statement of what is being reported in the article. the introduction should be clear, focused, concise, and attract the reader's attention and interest. 4.5.2 case presentation provide a clear picture of the patient's condition and presentation, and it is best presented in chronological order with sufficient detail and explanation, including: (1) patient description (without providing details that could lead to the identification of the patient), (2) case history, (3) physical examination results, (4) results of pathological tests and other investigations, (5) treatment plan, (6) expected outcomes of the treatment plan, and (7) actual outcomes. the author should ensure that all the relevant details are included and unnecessary ones excluded. 4.5.3 discussion the discussion is a significant part of case reports and should start by expanding on what has been said in the introduction, focusing on why the case is noteworthy and the problem that it addresses. discussion should contain major interpretations from the findings and results in comparison to previous studies. the significance of the findings and case presentation should be emphasized in this section against previous findings in the subject area. also, this section should evaluate the patient case for accuracy, validity, and uniqueness and compare or contrast the case report with the published literature. finally, the authors should briefly summarize the published literature with recent references. 4.5.4 implication and limitations provide the implications/ recommendations for policies or practices, as well as the limitations of the review. 4.5.5 conclusions the conclusion should briefly give readers the key points covered in the case report. it should conclude the case report and how it adds value to the available information. authors can give suggestions and recommendations to clinicians, teachers, or researchers. 4.5.6 consent clearly state that the patient gave his informed consent for publication, and a statement indicating that should be clearly narrated in the report. in the case of the child, the parent or legal guardian should have consented instead, and if the child is a teenager (<18 years old), then both patient and his parent should have consented. app. 6 copyright © 2021, nmjn, p-issn 2087-7811, e-issn 2406-8799 4.5.7 acknowledgments briefly acknowledge research funders and any parties that contribute to the study. 4.5.8 author contribution we encourage authors to provide statements outlining their individual contributions or roles to the manuscript. 4.5.9 conflict of interest state whether there is a conflict of interest among authors. 4.5.10 reference the reference consists of all references used to write the manuscript and adhere to the apa 7th edition. ensure that citations used are as contemporary as possible, including those from the current year of writing. delete older literature citations (more than 10 years) unless these are central to your study. the number of references should be at least 30, and 80% of them should be from journal articles. references should avoid the use of secondary citations. self-citations are allowed up to 15% of the total references. 5. tables every table is typed in 1 space. the number of tables is systematic as mentioned in the texts and completed with a short title each. provide an explanation on the footnotes instead of on the title. please explain on footnotes all non-standards information mentioned in the table. the total table should not be more than 6 tables. 6. layout the manuscript is to be written in a4 paper with a margin of at least 2.5 for each using microsoft word, times new roman font, and single-spaced. each page is numbered starting from the title until the last page of the manuscript. please check the text carefully before submission to check for correct content and typographic errors. 7. word count manuscripts submitted to the journal should not exceed 7,000 words, including abstract and references. this word count excludes references for review manuscripts. 8. references authors are required to use reference management software in writing citations and references. reference and citation use bracketed citation (name, year). direct citation on references should include the page number of the citation. american psychological association 7th edition applies in writing the manuscript. see examples of referencing below: 8.1 journal article grady, j. s., her, m., moreno, g., perez, c., & yelinek, j. (2019). emotions in storybooks: a comparison of storybooks that represent ethnic and racial groups in the united states. psychology of popular media culture, 8(3), 207–217. https://doi.org/10.1037/ppm0000185 8.2 journal article with an article number jerrentrup, a., mueller, t., glowalla, u., herder, m., henrichs, n., neubauer, a., & schaefer, j. r. (2018). teaching medicine with the help of “dr. house.” plos one, 13(3), article e0193972. https://doi.org/10.1371/journal.pone.0193972 https://doi.org/10.1037/ppm0000185 https://doi.org/10.1371/journal.pone.0193972 app. 7 copyright © 2021, nmjn, p-issn 2087-7811, e-issn 2406-8799 8.3 whole authored book jackson, l. m. (2019). the psychology of prejudice: from attitudes to social action (2nd ed.). american psychological association. https://doi.org/10.1037/0000168-000 8.4 whole edited book kesharwani, p. (ed.). (2020). nanotechnology based approaches for tuberculosis treatment. academic press. 8.5 report by a government agency references national cancer institute. (2019). taking time: support for people with cancer (nih publication no. 18-2059). u.s. department of health and human services, national institutes of health. https://www.cancer.gov/publications/patienteducation/takingtime.pdf 8.6 conference proceedings published in a journal duckworth, a. l., quirk, a., gallop, r., hoyle, r. h., kelly, d. r., & matthews, m. d. (2019). cognitive and noncognitive predictors of success. proceedings of the national academy of sciences, usa, 116(47), 23499–23504. https://doi.org/10.1073/pnas.1910510116 8.7 conference proceedings published as a whole book kushilevitz, e., & malkin, t. (eds.). (2016). lecture notes in computer science: vol. 9562. theory of cryptography. springer. https://doi.org/10.1007/978-3-662-49096-9 8.8 published dissertation or thesis references kabir, j. m. (2016). factors influencing customer satisfaction at a fast food hamburger chain: the relationship between customer satisfaction and customer loyalty (publication no. 10169573) [doctoral dissertation, wilmington university]. proquest dissertations & theses global. 8.9 unpublished dissertation or thesis references harris, l. (2014). instructional leadership perceptions and practices of elementary school leaders [unpublished doctoral dissertation]. university of virginia 9. screening for plagiarism the journal applies the policy of screening for plagiarism. all articles in this publication are original: the content (either in full or in part) in each article has not been knowingly republished without specific citation to the original release. a turnitin plagiarism checker is applied to all submitted papers during initial screening. the journal accepts a maximum similarity index of 20%. papers leading to plagiarism or self-plagiarism will be immediately rejected. 10. author fee all authors should pay for article processing charges (apc) when the manuscript is editorially accepted for publication. the apc is idr. 2,000,000 (for indonesian authors) or usd 130 (for non-indonesian authors). the payment can be made by bank transfer/paypal. information regarding the bank/paypal account is sent via email to the corresponding author. 11. authorship and changes to authorship all authors should have made substantial contributions to the manuscript, including (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted. https://doi.org/10.1037/0000168-000 https://www.cancer.gov/publications/patient-education/takingtime.pdf https://www.cancer.gov/publications/patient-education/takingtime.pdf https://doi.org/10.1073/pnas.1910510116 https://doi.org/10.1007/978-3-662-49096-9 app. 8 copyright © 2021, nmjn, p-issn 2087-7811, e-issn 2406-8799 authors should carefully consider the list and order of authors before submitting their manuscripts. any addition, deletion, or rearrangement of author names should be made only before the manuscript has been accepted and only if approved by the journal editor. 12. reporting guidelines the reporting guidelines endorsed by the journal are listed below: observational cohort, case-control, and cross-sectional studies – strobe (strengthening the reporting of observational studies in epidemiology), http://www.equator-network.org/reporting-guidelines/strobe/ qualitative studies – coreq (consolidated criteria for reporting qualitative research), http://www.equator-network.org/reporting-guidelines/coreq quasi-experimental/non-randomized evaluations – trend (transparent reporting of evaluations with non-randomized designs), http://www.cdc.gov/trendstatement/ randomized (and quasi-randomized) controlled trials – consort (consolidated standards of reporting trials), http://www.equator-network.org/reportingguidelines/consort/ study of diagnostic accuracy/assessment scale – stard (standards for the reporting of diagnostic accuracy studies), http://www.equatornetwork.org/reporting-guidelines/stard/ systematic review of controlled trials – prisma (preferred reporting 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medical sciences, iran eni nuraini agustini : uin syarif hidayatullah, indonesia fatikhu yatuni asmara : department of nursing, faculty of medicine, universitas diponegoro, indonesia faustino jerome g. babate : beta nu delta nursing society, philippines fitria handayani : department of nursing, faculty of medicine, universitas diponegoro, indonesia fitri mailani : faculty of nursing, universitas andalas, indonesia forouzandeh jannat : tehran university of medical sciences, tehran, iran janet alexis a. de los santos : college of nursing, visayas state university, philippines luky dwiantoro : department of nursing, faculty of medicine, universitas diponegoro, indonesia mansour ghafourifard : faculty of nursing and midwifery, tabriz university of medical sciences, iran mardiyono mardiyono : department of nursing, poltekkes kemenkes semarang, indonesia megah andriany : department of nursing, faculty of medicine, universitas diponegoro, indonesia meidiana dwidiyanti : department of nursing, faculty of medicine, universitas diponegoro, indonesia meira erawati : department of nursing, faculty of medicine, universitas diponegoro, indonesia nana rochana : department of nursing, faculty of medicine, universitas diponegoro, indonesia niken s. d. kusumaningrum : department of nursing, faculty of medicine, universitas diponegoro, indonesia nur setiawati dewi : department of nursing, faculty of medicine, universitas diponegoro, indonesia ric-an artemio s. gadin : beta nu delta nursing society, philippines rizki fitryasari : faculty of nursing universitas airlangga, indonesia ryan michael f. oducado : college of nursing, west visayas state university, philippines sadeq al-fayyadh : college of nursing, university of baghdad, iraq sri padma sari : department of nursing, faculty of medicine, universitas diponegoro, indonesia suhartini ismail : department of nursing, faculty of medicine, universitas diponegoro, indonesia untung sujianto : department of nursing, faculty of medicine, 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(signature and name) ▪ please send the filled form along with the payment receipt to the editorial office of nmjn via email: media_ners@live.undip.ac.id ▪ in the case of (*), choose one subscription information nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://ejournal.undip.ac.id/index.php/medianers 12(1):122-132, april 2022 https://doi.org/10.14710/nmjn.v12i1.35626 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 original research the role of organizational culture in moderating effect of emotional labor strategies on nursing professionalism resekiani mas bakar1, yaumil khaerah1, nurul hidayati1, andi nasrawaty hamid1 1faculty of psychology, universitas negeri makassar, makassar, indonesia article info abstract article history: received: 9 january 2021 revised: 9 january 2022 accepted: 16 march 2022 online: 27 april 2022 keywords: deep acting; nursing professionalism; organizational culture; surface acting corresponding author: resekiani mas bakar faculty of psychology, universitas negeri makassar, makassar, indonesia email: resekiani_masbakar@unm.ac.id background: emotional labor strategies are necessary for nurses to provide nursing care for society through friendliness, caring, and positive emotion. the results of a meta-analysis of emotional labor research have proven that previous studies focused more on the impact of deep and surface acting strategies only at the individual level of the nurses. this study emphasizes the impact of emotional labor strategies at the individual and organizational levels. purpose: the study aimed to measure the effect of emotional labor strategy (surface and deep acting strategy) toward nursing professionalism mediated by organizational culture. methods: this research design is a quantitative survey. the respondents were 124 hospital nurses recruited by accidental sampling technique. the instrument in this study used emotional labor, organizational culture, and nursing professionalism scale. the mediation model technique by hayes’s process was used to analyse the data. results: the result showed an indirect effect of the role of organizational culture in mediating deep acting strategy toward nursing professionalism (b=0.03, 95% ci [-0.00–0.94]). nurses who displayed deep acting strategies to their patients indirectly affected professionalism through the mediation of organizational culture. however, the surface acting strategies did not show a significant effect on nursing professionalism (b=-0.02, 95% ci [-0.05–0.00]) . conclusion: deep acting strategies indirectly affect nursing professionalism through organizational culture as a mediation variable compared to surface acting strategies. this study supports the control theory that emotional strategies implemented by nurses as organizational culture are a comparator to engage in nurse professionalism to provide healthcare. the deep acting strategies through organizational culture are essentially recommended for nurses in the hospital to improve their professionalism. how to cite: bakar, r. m., khaerah, y., hidayati, n., & hamid, a. n. (2022). the role of organizational culture in moderating effect of emotional labor strategies on nursing professionalism. nurse media journal of nursing, 12(1), 122-132. https://doi.org/10.14710/nmjn.v12i1.35626 1. introduction nurses in various public health centers and hospitals show significant numbers in quantity. the ministry of health republic of indonesia shows that nurses occupy the highest level compared to other medical personnel, namely 29.66% (ministry of health republic indonesia, 2017). meanwhile, in order to achieve the third sustainable development goals (sdgs), health and welfare, who estimates the need for nurses around the world to reach nine million by 2030 (world health organization, 2022). one of the nurse’s responsibilities is to enhance the service quality for patients. the health professionals need to rapidly adapt and respond in fulfilling the demand of society for the health-care system, either at the level of a person, family, or community (akhtar-danesh et al., 2013). the complexity that happens in the medical field and technology development results in several changes in nurses’ working environments such as maintaining professionalism. professionalism for the nurse is the crucial aspect to show credibility and positive evaluation from surroundings. professionalism performed by nurses during work time will directly affect people’s judgment (primm, 2010), so they required to perform their jobs and functions well (jang et al., 2016). professionalism has eight aspects namely continuous learning, accountability and initiative, self-care and professional growth, responsibility and a sense of duty, compassion and https://ejournal.undip.ac.id/index.php/medianers https://crossmark.crossref.org/dialog/?doi=10.14710/nmjn.v12i1.35626&domain=pdf&date_stamp=2022-04-27 nurse media journal of nursing, 12(1), 2022, 123 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 respect for others, integrity and trustworthiness, teamwork and professional demeanour, and concern for the welfare of others. the service quality perceived by patients depends on nurse performance (lombarts et al., 2014). understanding professionalism will help nurses to provide a better service to patients (bunkenborg et al., 2012). some previous studies showed that professionalism in nurse environment is also influenced by several factors, such as educational level, work experience, work environment, and position in the office (solomon et al., 2015; tanaka et al., 2014), organization type, rewarding system, nurse involvement in the hospital, and organizational culture (ghadirian et al., 2014). organizational culture refers to beliefs, ideology, principal, and values that are followed by society in a certain environment. creating an organizational culture that can raise teamwork among the members is the current focus of hospital management instead of material profit (kamel & aref, 2017). the improvement of patient safety as the main hospital responsibility is started by creating and maintaining the culture (stock et al., 2017). this improvement can accelerate standard achievement in applying norms and regulations in the workplace (manley et al., 2011), enables the improvement of nurses’ performance, job satisfaction, and problem-solving skill (kamel & aref, 2017; kim, et al., 2016). furthermore, it will encourage the nurses to apply initiative and show professionalism during work (manojlovich & ketefian, 2002). therefore, hospital management needs to create a working environment that supports communication and coordination between nurses and other hospital staff. this atmosphere can lower negative behaviors during work (yeun & han, 2016). organizational culture is influenced by several aspects, such as internal communication, work balance, leadership style, employee satisfaction, reward system, and organization’s performance (kamel & aref, 2017). if the hospital can maximize those factors, it will help to improve interpersonal relations among medical professionals and respect every single achievement. organizational culture strongly relates to performance and communication processes in the workplace (sass, 2000), decreases turnover intention (lee & jang, 2020), gives understanding to organization members regarding values and procedures (scott-findlay & estabrooks, 2006), and affects strategies of emotion (choi & guy, 2020). most health practitioners, especially nurses, feel several emotions during their interaction with the patients (bagdasarov & connelly, 2015). occupation as a nurse, which requires face-toface interaction with patients, allows nurses to experience unpleasant feeling even when they are not able to display a proper strategy (altuntaş & altun, 2015; ghalandari et al., 2012). the incompetence of nurses to regulate their emotions will affect to ability degrading in applying ethical code. this kind of strategy is called emotional labor. emotional labor is a strategy used in regulating emotions or feelings to give the appearance of the body and face according to the demands of the job (hochschild, 1983) and to preserve the external appearance and good impression to others (gray, 2010). emotional labor strategy is commonly applied into two types: deep acting and surface acting. the strategies of emotional labor relate to internal emotion regulation and emotional expression display (grandey & melloy, 2017). nurses who display deep acting strategies can regulate their internal emotions and the demand of patient’s needs in order to enhance service quality to patients. therefore, they can serve healthcare according to the hospital’s standards. on the other hand, nurses who perform surface acting strategy will not feel positive emotion, yet they just try to show fake emotion as a work demand (grandey & sayre, 2019). the meta-analysis of emotional labor research has focused more on the impact of deep and surface acting strategies only at the level of individual of nurses, such as burnout (kim, 2020; zaghini et al., 2020), self-efficacy, and type-a behavior patterns (jeung et al., 2018), yet at organizational aspect. the mechanism of emotional labor strategy towards nursing professionalism mediated by organizational culture can be explained with control theory. control theory consists of four components: input, standard, comparator, and output. when the nurse interacts with patients, there is an emotional exchange between them. the emotional exchange is affected by the self-perception of the nurse in terms of display rules in their working unit. this factor then influences the type of regulation strategy that will be displayed (surface or deep acting). apart from self-perception, service delivery is also influenced by obligation as a nurse, including health rules and emotional aspects when serving the patients. emotional display standard (display rule) will be different based on organizational culture in each hospital. therefore, organizational culture becomes a mediate variable that affects emotional labor towards nurse media journal of nursing, 12(1), 2022, 124 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 nursing professionalism. different emotional displays will indirectly influence professionalism which is mediated by perception about the organization’s culture. nurses who display deep acting strategy are presumed to indirectly show professionalism with mediation of organizational culture perception (diefendorff & gosserand, 2003). research that examines the impact of emotional labor strategies from the organizational level, such as organizational culture, is still limited. in fact, the emotional labor strategy occurs because of the display rules that nurses must obey, and this is rooted in the organizational culture (diefendorff et al., 2011). the gap in this study provides an opportunity for researchers to examine organizational culture variables that mediate the indirect effect of emotional labor strategies on nurse professionalism. this study aims to measure the indirect effect between surface and deep acting strategy mediated by organizational culture perception towards nursing professionalism. 2. methods 2.1 research design the research design was a quantitative survey. the respondents filled out self-reports in the form of emotional labor, organizational culture, and nursing professionalism scale. 2.2 setting and samples from 136 respondents who had completed the questionnaire, 12 respondents were eliminated because of incomplete responses in emotional labor form. therefore, the number of respondents analysed in this study was 124. determination of the number of participants was done by a prior analysis of g*power. recruitment of respondents was carried out through manual announcements by distributing an informed consent sheet to participate as respondents. the sampling technique used was accidental sampling. the respondents of this study were regular full-time nurses in three public hospitals in makassar. the characteristics of the respondents were: (1) regular full-time nurse, (2) having a minimum of one year of service as a nurse, and (3) willing to participate in the study. the selection of the hospital under study was based on the minimum criteria for type-b general hospital. 2.3 measurement and data collection the data were collected in may 2019. the respondents received surveys manually. the participation of respondents was conducted voluntarily. each participating nurse received a survey package containing three types of questionnaires. the indonesian version of the questionnaires was given to the respondents. the original questionnaire was adapted from the english to indonesian version. the process of adapting the measuring instrument was done by translation-back translation method. from the translation result, expert judgments, involving three experts in the field of psychology were used to assess the translated questionnaires based on the theoretical content of instrument. the expert panel indicated the suitability and relevance above 80 percent of each questionnaire. 2.3.1 emotional labor strategy scale emotional labor strategies were measured using nine items. this instrument adopted the scale of gosserand and diefendorff (2005). the emotional labor strategy scale consists of surface acting (5 items) and deep acting (4 items), with cronbach alpha of english version ranging from 0.89 to 0.85. each respondent was measured with deep and surface acting because, in its application, the nurse can display deep or surface acting consecutively when interacting with patients. one of the examples of surface acting items is “i fake the emotional expression which must be displayed during interaction with patients” and the example of deep acting items is “i try to feel the emotion that i should display when encountering the patients”. item content validity was carried out using the expert judgment. the reliability of indonesian version of this instrument showed good internal consistency (α=0.84). the respondents of the reliability test were nurses in the city of makassar. the measurement of emotional labor ranged from 1 (strongly inappropriate) to 5 (strongly appropriate). scoring was done by calculating the total score of surface and deep acting items separately. nurse media journal of nursing, 12(1), 2022, 125 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 2.3.2 organizational culture scale the organizational culture variable was measured using the scale from jafree et al. (2016). the original scale has a cronbach alpha ranging from 0.74 to 0.88. the reliability of indonesian version of this instrument showed a cronbach alpha of 0.88 for 27 items. the respondents of the reliability test were nurses in the makassar city. content validity of the instrument was done through expert judgment. organizational culture consisted of six aspects: 1) nursing participation in governance, 2) nurse manager ability leadership and support, 3) nurse participation in hospital affairs, 4) nurse foundations for quality of care, 5) nurse co-worker relations, and 6) nursing staffing and resource. one of the item examples is “nurse applies written planning in delivering service to patients.” the organizational culture score was measured from 1 (strongly inappropriate) to 5 (strongly appropriate). 2.3.3 nursing professionalism scale nursing professionalism attribute was measured by a-12-scale from lombarts et al. (2014). the original scale has a cronbach alpha 0.81. cronbach alpha analysis of the indonesian version of the scale was 0.87. expert judgments were used to test the validity of the instrument. nursing professionalism consists of four aspects: 1) improving the quality of care, 2) maintaining professional competence, 3) fulfilling professional competence, 4) shared education and collaboration. one of the item examples is: “i am responsible for supervising the result of medical treatment for patients.” nursing professionalism score was measured from 1 (strongly inappropriate) to 5 (strongly appropriate). 2.4 data analysis to answer the study hypothesis, analysis of mediation by hayes’s process was applied to analyze the data (hayes, 2018). hayes process is a method for analyzing data in order to measure the mediation model, which is a part of regression analysis and measures both direct and indirect effects between one variable to another (field, 2013). there were two hypotheses in this study. there was a significant effect between surface acting strategy to professionalism with organizational culture as mediation (h1), and there was a significant effect between deep acting strategy to professionalism with organizational culture as mediation (h2). 2.5 ethical considerations in considering the ethics of the study, the researchers used a peer review of two lecturers of psychology to provide an assessment of whether there is any risk arising from the planned research procedure. the authors also applied for permits to three public hospitals in makassar. another effort made to ensure that this research did not violate ethics was to provide an informed consent form. the nurses who participated in this study obtained informed consent forms, including an explanation of the research objectives, procedures, and their rights in this study. this includes maintaining the confidentiality of respondent data. permissions from the authorities of the hospital were obtained first before collecting the data. the nurses were assured that their participation would not affect their performance appraisal. 3. results 3.1 characteristics of respondents table 1 depicts the result of this study. the majority of respondents were female (98.4%), aged around 22-30 years old (46.7%), having tenure from 5 to 10 years (68.4%), and having diploma in nursing as the educational background (30.1%). out of 124 respondents, 53 respondents (42.7%) tend to perform surface acting strategies, while 71 nurses (57.3%) tend to perform deep acting strategies. this result indicated that the sample group of nurses in this study generally displayed deep acting than surface acting strategies when working. the levels of nursing professionalism and organizational culture were categorized in the high level; for each category was 98 respondents (79%). 3.2 organizational culture in mediating the effect of surface acting strategies on nursing professionalism the results in table 2 show the hayes process analysis that the independent variable, namely surface acting strategy, did not have a significant effect on the mediating variable of nurse media journal of nursing, 12(1), 2022, 126 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 organizational culture (b=-0.07, p=0.09) and nursing professionalism (b=-0.02, p=0.66). however, organizational culture variables had an effect on nursing professionalism (b=0.24, p=0.02). table 1. characteristics of respondents variables f % gender female 122 98.4 male 2 1.6 tenure 1-5 year 34 27.4 5-10 year 60 48.4 10-15 year 19 15.6 > 15 year 9 7.4 age 22 30 years old 57 46.7 31 – 39 years old 53 43.5 40 – 50 years old 14 9.8 education d3 46 30.1 s1 29 20.4 s2 3 3.2 ners 14 11.8 emotional labor strategies surface acting 53 42.7 deep acting 71 57.3 nursing professionalism low 1 0.8 moderate 25 20.2 high 98 79.0 organizational culture moderate 26 21.0 high 98 79.0 table 2. the effect of surface acting strategies toward nursing professionalism mediated by organizational culture antecedent consequence m (oc) y (np) coeff. se p coeff. se p x (sa) a -0.07 0.04 0.09 c’ -0.02 0.05 0.66 m (oc) b 0.24 0.10 0.02 constant i1 4.31 0.13 0.00 i2 3.11 0.49 0.00 r2=0.02 f(1,122)=2.91, p=0.09 r2=0.04 f(2,121)=2.87, p=0.06 sa = surface acting, np = nursing professional, oc = organizational culture, se =sum of error figure 1 shows that organizational culture as mediation variable on surface acting had no significant relationship to nursing professionalism (b=-0.02, 95% ci [-0.05–0.00]). therefore, h1 was declined. there was no significant effect between surface acting strategy to professionalism with organizational culture as mediation. 3.3 organizational culture in moderating the effect of deep acting strategy on nursing professionalism the results of table 3 show that the independent variable, namely deep acting strategy, had a significant effect on the mediating variable of organizational culture (b=0.16, p=0.001) and nursing professionalism (b=0.12, p=0.09) the mediating variable of organizational culture also had an effect on nursing professionalism (b=0.21, p=0.05). thus, the deep acting variable had an indirect effect on nursing professionalism. nurse media journal of nursing, 12(1), 2022, 127 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 figure 1. the hypothesis test of surface acting strategies data on the effect of deep acting strategies on nursing professionalism with the mediation of organizational culture is shown in table 3 below. table 3. the effect of deep acting strategies towards nursing professionalism with the mediation of organizational culture antecedent consequence m (oc) y (np) coeff. se p coeff. se p x (da) a 0.16 0.06 0.00 c’ 0.12 0.07 0.09 m (oc) b 0.21 0.11 0.05 constant i1 3.53 0.21 0.00 i2 2.76 0.45 0.00 r2=0.06 f(1,122)=7.32, p=0.00 r2=0.07 f(2,121)=4.25, p=0.01 da = deep acting, np = nursing professional, oc = organizational culture, se =sum of error the process analysis in figure 2 shows that there was a significant effect of deep acting on nursing professionalism through an organizational culture which was indirect (b=0.03, 95% ci [0.00–0.94]). therefore, h2 was accepted. deep acting strategies indirectly affected nursing professionalism through organizational culture as a mediation variable. figure 2. the hypothesis test of deep acting strategies 4. discussion the aim of this study was to measure the effect of emotional labor strategy toward nursing professionalism mediated by organizational culture. the result of research found that surface acting did not affect nursing professionalism through organizational culture as a mediation variable. in contrast, the result of this study showed that there were positive effects of deep acting strategy on the increase of organizational culture and nursing professionalism which occurred significantly. the results of this study are different from previous study which have shown that surface acting has positive effect on the desire to leave work. nurses who display surface acting strategies can modify their emotional expression when interacting with patients, although it does not fit with current feelings. when dealing with patients, the nurse tries to suppress the negative organizational culture surface acting strategy direct effect, b=-0.02, 95% ci [-0.05-0.00] p=0.66 nursing professionalism direct effect, b=0.12, p=0.09 organizational culture deep acting strategy nursing professionalism indirect effect, b=0.03, 95% ci [-0.00-0.94], p= 0.001 nurse media journal of nursing, 12(1), 2022, 128 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 emotion and pretend to show positive emotion (diefendorff et al., 2011). generally, modifying emotional expression for a nurse is no violation at all. the nurses who display surface acting is a part of obedience to display rule. display rule is a root of an organization or hospital norm. however, nurse obedience when displaying surface acting is based on job condition, not hospital or organization culture. therefore, surface acting strategy performed by nurses did not significantly affect organizational culture. in addition, modifying surface acting expression when providing healthcare service does not influence nursing professionalism. this is because nurses who display surface acting can still provide service based on professionalism context in their operational procedure (wanninayake et al., 2021) this study revealed that deep acting strategy indirectly influenced nursing professionalism through organizational culture. the deep acting strategy does not only obey the display rule, but it can provide health service more than the existing standard operational procedure. the display rule, which becomes the basic rule in showing emotion, is the reflection of the company’s organizational culture. an individual who can perform their job in deep acting strategy will have stronger value to organizational culture. previous research had shown that deep acting had a positive impact on the performance of nurses, because it was able to harmonize internal emotions with emotions that were the organizational culture in treating patients (koh et al., 2018). these findings also support the previous study, which states that deep acting strategy relates to the display rule (allen et al., 2010). nurses’ responses that display surface acting strategies during work tend to improve service quality by 88.7%, while display deep acting strategies improve service quality by 99%. moreover, an initiative to enhance service showed the difference between surface acting and deep acting strategies, with 86.8% and 94.3% respectively. this study showed that nurses with a high perception of organizational culture correlate with nursing professionalism. nurses can assess whether the hospital provides a chance to participate in hospital service improvement so they can improve themselves and enhance the service quality through self-evaluation during work (sarıköse & göktepe, 2022). nursing professionalism is performed by responsibility and dedication to fulfil the health service standard, attention to selfcompetence, self-responsibility, and willingness to collaborate with other parties in an organization. nursing professionalism is also performed through a commitment to show warmness, caring, ethical code, and sustainability self-improvement in order to reach patients' well-being (lombarts et al., 2014). the previous study found that organizational culture is the fundamental factor in determining professionalism among nurses (manojlovich & ketefian, 2002; ghadirian et al., 2014). nurses in a supportive environment are likely to participate in service delivery and monitoring for patients and work together with other medical staff in a collaboration. this result supported a study of lee and jang (2020) that an organizational culture has effect on turnover intention. nurses who obtain a positive work environment, correlated with their interprofessional collaboration (ghasemi et al., 2021). every nurse has a self-perception about display rules of emotional labor (surface or deep acting) when interacting with patients. self-perception regarding display rules must be understood and applied in every work unit. a company or hospital always has a standard for their employee to perform a job, which has to be applied by nurses, especially the emotional aspect when delivering a service. nurses’ self-perception will be adapted with a standard from the comparator. if the gap happens between personal emotion and display rule standards, nurses will apply emotional regulation to decrease that gap. emotional display which nurses perform, can be surface or deep acting (lee & madera, 2019). based on control theory (carver, 2018), organizational culture variable has a role as the comparator for nurses in order to strengthen its positive effect to work behaviors by maintaining professionalism (pedrosa et al., 2021). the comparator aspect in this theory will continuously happen and become guidance for nurses (diefendorff & gosserand, 2003). nurses who perform deep acting strategy as the emotional display will have higher perception input to improve professionalism. this condition happens because service is delivered sincerely and appropriately with organizational culture. in addition, an individual who delivers deep acting will have a stronger input self-perception to organizational culture (han et al., 2018). this enables a person to apply the work value properly, especially when offering health services. deep acting strategy with self-willingness to apply professionalism during work allows strengthening self-perception to hospital management in order to collaborate with nurses in providing healthcare system (liu et al., 2020) nurse media journal of nursing, 12(1), 2022, 129 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 5. implications and limitations this study contributes in providing a description and explaining the effect of surface and deep acting on the organizational culture, which is still limited in previous studies, especially in the context of health service between nurses and patients. a deep acting strategy could be implemented in sincere service and beyond the organization’s expectations. therefore, this condition could represent high organizational culture and professionalism value in every task. deep acting strategy has an effect on the nursing professionalism indirectly. the organizational culture which has been internalized enabled the achievement of professionalism standards through the same understanding among all members in an organization. therefore, the hospitals should maintain their service quality by training and development as well as monitoring nurses to display deep acting strategy. some of the limitations of this study that might affect the results of the study were limitations in the process of instrument validity and the absence of ethical approval at the beginning of the research process. however, reliability test had been carried out; and research study permits from the hospitals and informed consent from the respondents were obtained before the data collection in order to improve the rigor of the study. in addition, other individual aspects which might affect the perception of organizational culture such as personality types, emotional intelligence or job autonomy, self-efficacy, burnout, and behavior types were not controlled in this study. 6. conclusion this study provided new significant finding which positively affects deep acting strategies to organizational culture and nursing professionalism, while surface acting strategies did not significantly provide negative effect in lowering organizational culture and professionalism. deep acting strategy indirectly affects nursing professionalism through organizational culture as a mediation variable. the findings of this study recommend the hospitals to nurture supportive organizational culture and to encourage as well as to monitor nurses to display deep acting strategies. the future study can be developed by using a larger sample size and more thorough instrument’s validity process. moreover, the level classification or work unit of respondents should be examined. those factors were necessary to consider because the researcher could acquire a more detailed description. the future study also could measure other individual aspects which might affect the perception of organizational culture. acknowledgment the authors would like to thank the hospitals for allowing the authors to collect data. the authors would also like to thank the nurses who had participated as respondents in this study, as well as all those who had helped in collecting research data. author contribution rmb: conceptualization, methodology, writing-original draft, project administration, validation, resources, writing-review & editing. yk: 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(2020). the role of occupational stress in the association between emotional labor and burnout in nurses: a cross-sectional study. applied nursing research, 54, 151277. https://doi.org/10.1016/j.apnr.2020.151277 copyright © 2022 nmjn. this article is an open access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). https://creativecommons.org/licenses/by-sa/4.0 app. 1 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 1. focus and scope the nurse media journal of nursing (nmjn) is a nursing journal that publishes the scientific works of nurses, academics, and practitioners. nmjn welcomes and invites original and relevant research articles in nursing as well as reviews (systematic and metaanalysis) and case reports. 2. general guidelines manuscripts submitted to the journal are not yet published. nmjn does not accept any manuscripts which are 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the specific research design used, such as correlational, experimental, quasiexperimental, cross-sectional, and others. provide relevant descriptions regarding the design applied in the study. 4.3.2.2 setting and samples/participants state when and where the study was conducted without mentioning the specific name of the research site. identify the sampling strategy used to recruit the samples/participants as well as the inclusion and exclusion criteria. how samples/participants were recruited should also be stated. also, identify the sample size (and the population, if applicable) and sample size justification, including sample size calculation or power analysis, if applicable. 4.3.2.3 intervention (applies to experimental studies) describe the intervention, setting, and those who provided the intervention. if the study included a control group, explain what kind of intervention was provided to this group. 4.3.2.4 measurement and data collection mention and describe the instrument used for data collection. clearly state whether the researchers develop, adopt, or modify the instrument from previous studies, including its citations and references. mention the validity and reliability of the instrument, the scale, interpretation, and administration. if a translation was conducted from the original language, authors should explain the procedures used to maintain the validity and reliability of the translated instruments. describe how data were collected. if the data were collected by research assistants, please identify this in the manuscript. 4.3.2.5 data analysis clearly describe the techniques used for data analysis, including the computer software used, if appropriate. please provide relevant references for specific analytic approaches/ techniques (for qualitative studies). 4.3.2.6 trustworthiness/rigor (applies to qualitative studies) the manuscript should describe strategies used to maintain the trustworthiness/rigor of the qualitative data, such as credibility, transferability, dependability, and confirmability. 4.3.2.7 ethical considerations please describe the ethical issues in the study, including how informed consent was obtained from respondents/participants. provide a statement of approval from the health research ethics committee, including its reference number. 4.3.3 results results state the major findings of the research instead of providing data in great detail. results should be clear, concise, and can be reported on texts or graphics. please provide some introduction for the information presented on tables or figures. 4.3.4 discussion the discussion should explore the significance of the results of the study. the following components should be covered in the discussion: (1) how do your results relate to the original question or objectives outlined in the background section (what)? (2) do you provide an interpretation scientifically for each of your results or findings presented (why)?, app. 3 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 and (3) are your results consistent with what other investigators have reported (what else)? or are there any differences? 4.3.5 implication and limitations the manuscript should describe the implications of the study on nursing practices and policies based on the findings and also the limitations. 4.3.6 conclusion conclusions should answer the research objectives, telling how advanced the result is from the present state of knowledge. conclusions should be clear in order to know it merits publication in the journal or not. provide a clear scientific justification and indicate possible applications and extensions. a recommendation should also be pointed out to suggest future research and implication in the nursing practice. 4.3.7 acknowledgments briefly acknowledge research funders and any research participants in this section. 4.3.8 author contribution we encourage authors to provide statements outlining their individual contributions or roles to the manuscript. 4.3.9 conflict of interest state whether there is a conflict of interest among authors. 4.3.10 reference the reference consists of all references used to write the manuscript and adhere to the apa 7th edition. ensure that citations used are as contemporary as possible, including those from the current year of writing. delete older literature citations (more than 10 years) unless these are central to your study. the number of references should be at least 30, of which 80% of them should be from journal articles. references should avoid the use of secondary citations. self-citations are allowed up to 15% of the total references. 4.4 manuscript of reviews (systematic or meta-analysis) 4.4.1 introduction the introduction provides the state of the art of the study and consists of an adequate background, previous research in order to record the existing solutions/method to show which is the best, and the main limitation of previous research, to show the scientific merit or novelties of the paper. avoid a detailed literature survey or a summary of the results. the purpose of the study should state the major aim of the research and is written at the end of the introduction section. 4.4.2 methods methods should be structured as follow: 4.4.2.1 research design describe the specific research design used: systematic review or meta-analysis. provide relevant descriptions regarding the design applied in the study. 4.4.2.2 search methods identify the electronic databases searched, keywords, and search methods (range of years). use a table if necessary to show readers the number of articles you search from each database. app. 4 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 4.4.2.3 inclusion and exclusion criteria identify the inclusion and exclusion criteria for selecting the articles. 4.4.2.4 screening of articles include the reviewers who did the first screening for selection and screening for content analysis. 4.4.2.5 data extraction identify how data were extracted. please use a table that contains authors' names, year, country name, objective, conceptual framework, sample, design, instrument, and results. 4.4.2.6 quality appraisal include a description of approaches used, the outcome of the appraisal process, and the audit of discarded studies. make clear the criteria that were used for discarding studies. if the quality appraisal was not undertaken, provide a convincing and robust explanation, and in the limitations section, outline the potential impact on the credibility of the review findings. 4.4.2.7 data analysis explain how you analyze the contents. 4.4.3 results results should include the search outcomes, quality assessment results, and analytical findings. please describe the search outcome using the prisma flow diagram. describe the results of the assessment as indicated in the method. the analytical findings should be presented using themes, categories, patterns, and so on. 4.4.4 discussion the discussion should explore the significance of review findings. please draw out the applicability, theoretical and practical implications of the findings. clarify the contribution of the review to existing knowledge, highlight gaps in knowledge and understanding, and outline future research. 4.4.5 implication and limitations provide the implications/ recommendations for policies or practices, as well as the limitations of the review. 4.4.6 conclusion the conclusion should summarize important aspects of reviewed studies and evaluate the current state of the literature reviewed, identify significant flaws or gaps in existing knowledge, outline areas for future study, and link your research to existing knowledge. 4.4.7 acknowledgments briefly acknowledge research funders and any parties that contribute to the study. 4.4.8 author contribution we encourage authors to provide statements outlining their individual contributions or roles to the manuscript. 4.4.9 conflict of interest state whether there is a conflict of interest among authors. app. 5 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 4.4.10 reference the reference consists of all references used to write the manuscript and adhere to the apa 7th edition. ensure that citations used are as contemporary as possible, including those from the current year of writing. delete older literature citations (more than 10 years) unless these are central to your study. the number of references should be at least 50, and 80% of them should be from journal articles. references should avoid the use of secondary citations. self-citations are allowed up to 20% of the total references. 4.5 manuscript of case studies 4.5.1 introduction the introduction should explain the background of the case (the rarely found case), including the disorder or nursing problems and usual presentation and progression. it should also include a brief literature review that introduces the case report from the standpoint of those without specialist knowledge in the area. it should also end with a very brief statement of what is being reported in the article. the introduction should be clear, focused, concise, and attract the reader's attention and interest. 4.5.2 case presentation provide a clear picture of the patient's condition and presentation, and it is best presented in chronological order with sufficient detail and explanation, including: (1) patient description (without providing details that could lead to the identification of the patient), (2) case history, (3) physical examination results, (4) results of pathological tests and other investigations, (5) treatment plan, (6) expected outcomes of the treatment plan, and (7) actual outcomes. the author should ensure that all the relevant details are included and unnecessary ones excluded. 4.5.3 discussion the discussion is a significant part of case reports and should start by expanding on what has been said in the introduction, focusing on why the case is noteworthy and the problem that it addresses. discussion should contain major interpretations from the findings and results in comparison to previous studies. the significance of the findings and case presentation should be emphasized in this section against previous findings in the subject area. also, this section should evaluate the patient case for accuracy, validity, and uniqueness and compare or contrast the case report with the published literature. finally, the authors should briefly summarize the published literature with recent references. 4.5.4 implication and limitations provide the implications/ recommendations for policies or practices, as well as the limitations of the review. 4.5.5 conclusions the conclusion should briefly give readers the key points covered in the case report. it should conclude the case report and how it adds value to the available information. authors can give suggestions and recommendations to clinicians, teachers, or researchers. 4.5.6 consent clearly state that the patient gave his informed consent for publication, and a statement indicating that should be clearly narrated in the report. in the case of the child, the parent or legal guardian should have consented instead, and if the child is a teenager (<18 years old), then both patient and his parent should have consented. app. 6 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 4.5.7 acknowledgments briefly acknowledge research funders and any parties that contribute to the study. 4.5.8 author contribution we encourage authors to provide statements outlining their individual contributions or roles to the manuscript. 4.5.9 conflict of interest state whether there is a conflict of interest among authors. 4.5.10 reference the reference consists of all references used to write the manuscript and adhere to the apa 7th edition. ensure that citations used are as contemporary as possible, including those from the current year of writing. delete older literature citations (more than 10 years) unless these are central to your study. the number of references should be at least 30, and 80% of them should be from journal articles. references should avoid the use of secondary citations. self-citations are allowed up to 15% of the total references. 5. tables every table is typed in 1 space. the number of tables is systematic as mentioned in the texts and completed with a short title each. provide an explanation on the footnotes instead of on the title. please explain on footnotes all non-standards information mentioned in the table. the total table should not be more than 6 tables. 6. layout the manuscript is to be written in a4 paper with a margin of at least 2.5 for each using microsoft word, times new roman font, and single-spaced. each page is numbered starting from the title until the last page of the manuscript. please check the text carefully before submission to check for correct content and typographic errors. 7. word count manuscripts submitted to the journal should not exceed 7,000 words, including abstract and references. this word count excludes references for review manuscripts. 8. references authors are required to use reference management software in writing citations and references. reference and citation use bracketed citation (name, year). direct citation on references should include the page number of the citation. american psychological association 7th edition applies in writing the manuscript. see examples of referencing below: 8.1 journal article grady, j. s., her, m., moreno, g., perez, c., & yelinek, j. (2019). emotions in storybooks: a comparison of storybooks that represent ethnic and racial groups in the united states. psychology of popular media culture, 8(3), 207–217. https://doi.org/10.1037/ppm0000185 8.2 journal article with an article number jerrentrup, a., mueller, t., glowalla, u., herder, m., henrichs, n., neubauer, a., & schaefer, j. r. (2018). teaching medicine with the help of “dr. house.” plos one, 13(3), article e0193972. https://doi.org/10.1371/journal.pone.0193972 https://doi.org/10.1037/ppm0000185 https://doi.org/10.1371/journal.pone.0193972 app. 7 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 8.3 whole authored book jackson, l. m. (2019). the psychology of prejudice: from attitudes to social action (2nd ed.). american psychological association. https://doi.org/10.1037/0000168-000 8.4 whole edited book kesharwani, p. (ed.). (2020). nanotechnology based approaches for tuberculosis treatment. academic press. 8.5 report by a government agency references national cancer institute. (2019). taking time: support for people with cancer (nih publication no. 18-2059). u.s. department of health and human services, national institutes of health. https://www.cancer.gov/publications/patienteducation/takingtime.pdf 8.6 conference proceedings published in a journal duckworth, a. l., quirk, a., gallop, r., hoyle, r. h., kelly, d. r., & matthews, m. d. (2019). cognitive and noncognitive predictors of success. proceedings of the national academy of sciences, usa, 116(47), 23499–23504. https://doi.org/10.1073/pnas.1910510116 8.7 conference proceedings published as a whole book kushilevitz, e., & malkin, t. (eds.). (2016). lecture notes in computer science: vol. 9562. theory of cryptography. springer. https://doi.org/10.1007/978-3-662-49096-9 8.8 published dissertation or thesis references kabir, j. m. (2016). factors influencing customer satisfaction at a fast food hamburger chain: the relationship between customer satisfaction and customer loyalty (publication no. 10169573) [doctoral dissertation, wilmington university]. proquest dissertations & theses global. 8.9 unpublished dissertation or thesis references harris, l. (2014). instructional leadership perceptions and practices of elementary school leaders [unpublished doctoral dissertation]. university of virginia 9. screening for plagiarism the journal applies the policy of screening for plagiarism. all articles in this publication are original: the content (either in full or in part) in each article has not been knowingly republished without specific citation to the original release. a turnitin plagiarism checker is applied to all submitted papers during initial screening. the journal accepts a maximum similarity index of 20%. papers leading to plagiarism or self-plagiarism will be immediately rejected. 10. author fee all authors should pay for article processing charges (apc) when the manuscript is editorially accepted for publication. the apc is idr. 2,000,000 (for indonesian authors) or usd 130 (for non-indonesian authors). the payment can be made by bank transfer/paypal. information regarding the bank/paypal account is sent via email to the corresponding author. 11. authorship and changes to authorship all authors should have made substantial contributions to the manuscript, including (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted. https://doi.org/10.1037/0000168-000 https://www.cancer.gov/publications/patient-education/takingtime.pdf https://www.cancer.gov/publications/patient-education/takingtime.pdf https://doi.org/10.1073/pnas.1910510116 https://doi.org/10.1007/978-3-662-49096-9 app. 8 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 authors should carefully consider the list and order of authors before submitting their manuscripts. any addition, deletion, or rearrangement of author names should be made only before the manuscript has been accepted and only if approved by the journal editor. 12. reporting guidelines the reporting guidelines endorsed by the journal are listed below: observational cohort, case-control, and cross-sectional studies – strobe (strengthening the reporting of observational studies in epidemiology), http://www.equator-network.org/reporting-guidelines/strobe/ qualitative studies – coreq (consolidated criteria for reporting qualitative research), http://www.equator-network.org/reporting-guidelines/coreq quasi-experimental/non-randomized evaluations – trend (transparent reporting of evaluations with non-randomized designs), http://www.cdc.gov/trendstatement/ randomized (and quasi-randomized) controlled trials – consort (consolidated standards of reporting trials), http://www.equator-network.org/reportingguidelines/consort/ study of diagnostic accuracy/assessment scale – stard (standards for the reporting of diagnostic accuracy studies), http://www.equatornetwork.org/reporting-guidelines/stard/ systematic review of controlled trials – prisma (preferred reporting items for systematic reviews and meta-analyses), http://www.equatornetwork.org/reporting-guidelines/prisma/ systematic review of observational studies – moose (meta-analysis of observational studies in epidemiology), http://www.ncbi.nlm.nih.gov/pubmed/10789670 case reports – case (case report guidelines), https://www.care-statement.org/ 13. submission each submitted manuscript must conform to the instructions to authors and should be submitted online at http://ejournal.undip.ac.id/medianers. the instructions for registering, submission, and revision are provided on the website. if any difficulties are found, authors can contact the editorial office via email: media_ners@live.undip.ac.id. the author should first register as an author and/or is offered as a reviewer through the following address: http://ejournal.undip.ac.id/index.php/medianers/about/submissions#onlinesubmissions the author should fulfill the form as detailed as possible where the star-marked form must be entered. after all forms of textbox were filled, the author clicks on the "register" button to proceed with the registration. therefore, the author is brought to an online author submission interface where the author should click on "new submission." in the start of a new submission section, click on "’click here’: to go to step one of the five-step submission process." the following are five steps in the online submission process: 1. step 1 starting the submission: select the appropriate section of t h e journal, i.e., original research articles, review article, or case report. thus, the author must checkmark on the submission checklists. the author may type or copy-paste the covering letter in letter to editor. 2. step 2 – uploading the submission: to upload a manuscript to this journal, click browse on the upload submission file item and choose the manuscript document file (.doc/.docx) to be submitted; then, click the "upload" button until the file has been uploaded. http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/stard/ http://www.equator-network.org/reporting-guidelines/stard/ http://ejournal.undip.ac.id/medianers mailto:media_ners@live.undip.ac.id http://ejournal.undip.ac.id/index.php/medianers/about/submissions#onlinesubmissions http://ejournal.undip.ac.id/index.php/medianers/about/submissions#onlinesubmissions app. 9 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 3. step 3 – entering submission’s metadata: in this step, detailed authors metadata should be entered, including the marked corresponding author. after that, the manuscript title and abstract must be uploaded by copying the text and paste in the textbox, including keywords. 4. step 4 – uploading supplementary files: supplementary files should be uploaded, including covering/submission letter and signed copyright transfer agreement form. click on the browse button, choose the files, and then click on the upload button. 5. step 5 – confirming the submission: the author should final check the uploaded manuscript documents in this step. to submit the manuscript to nurse media journal of nursing, click the finish submission button after the documents are accurate. the corresponding author or the principal contact will receive an acknowledgment by email and will be able to view the submission's progress through the editorial process by logging into the journal web address site. after this submission, authors who submit the manuscript will get a confirmation email about the submission. therefore, authors are able to track their submission status anytime by logging into the online submission interface. the submission tracking includes the status of the manuscript review and editorial process. app. 10 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 authors submitting a manuscript do so on the understanding that if accepted for publication, the copyright of the article shall be assigned to nurse media journal of nursing and department of nursing, faculty of medicine, universitas diponegoro as the publisher of this journal. copyright encompasses exclusive rights to reproduce and deliver the article in all forms and media, including reprints, photographs, microfilms, and any other similar reproductions, as well as translations. the reproduction of any part of this journal, its storage in databases, and its transmission by any forms or media, such as electronic, electrostatic, and mechanical copies, photocopies, recordings, magnetic media, and others, will be allowed only with written permission from nurse media journal of nursing and department of nursing, faculty of medicine, universitas diponegoro. nurse media journal of nursing and department of nursing, faculty of medicine, universitas diponegoro make every effort to ensure that no wrong or misleading data, opinions, or statements be published in the journal. in any way, the contents of the articles and advertisements published in nurse media journal of nursing are the sole and exclusive responsibility of their respective authors and advertisers. the copyright transfer agreement form can be downloaded at the nmjn website (https://medianers.undip.ac.id). the copyright form should be filled with respect to the article and be signed originally and sent to the editorial office in the form of an original email or scanned document file (softcopy) to: meira erawati (editor-in-chief) nurse media journal of nursing department of nursing, faculty of medicine, universitas diponegoro jl. prof. soedarto, tembalang, semarang, central java, indonesia 50275 telp.: +62-24-76480919; fax.: +62-24-76486849 email: media_ners@live.undip.ac.id copyright transfer agreement app. 11 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 name of principal author(s) : address of principal author(s) : phone number / fax. number : email : name of author (s) : title of manuscript : 1. i/we submit to the nurse media journal of nursing for the above manuscript. i/we certify that the work reported here has not been published before and contains no materials the publication of which would violate any copyright or other personal or proprietary right of any person or entity. 2. i/we hereby agree to transfer all rights, title, interest, and copyright ownership to nurse media journal of nursing, faculty of medicine, universitas diponegoro for the copyright of the above manuscript. date : signature (original) : (when there is more than one author, only one signature will suffice) author’s name : copyright transfer agreement form app. 12 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 nurse media journal of nursing (nmjn) is a peer-reviewed electronic international journal. this statement clarifies the ethical behavior of all parties involved in the act of publishing an article in this journal, including the author, the chief editor, the editorial board, the peer-reviewers, and the publisher (universitas diponegoro). this statement is based on cope’s best practice guidelines for journal editors. 1. ethical guidelines for journal publication the publication of an article in a peer-reviewed nmjn journal is an essential building block in the development of a coherent and respected network of knowledge. it is a direct reflection of the quality of the work of the authors and the institutions that support them. peer-reviewed articles support and embody the scientific method. it is therefore important to agree upon standards of expected ethical behavior for all parties involved in the act of publishing: the author, the journal editor, the peer reviewer, the publisher, and the society. universitas diponegoro (diponegoro university), as the publisher of nmjn, takes its duties of guardianship over all stages of publishing extremely seriously, and we recognize our ethical and other responsibilities. we are committed to ensuring that advertising, reprint, or other commercial revenue has no impact or influence on editorial decisions. in addition, the department of nursing universitas diponegoro and editorial board will assist in communications with other journals and/or publishers where this is useful and necessary. 2. duties of editor 2.1 publication decisions the editor of the nmjn journal is responsible for deciding which articles submitted to the journal should be published. the validation of the work in question and its importance to researchers and readers must always drive such decisions. the editors may be guided by the policies of the journal's editorial board and constrained by such legal requirements as shall then be in force regarding libel, copyright infringement, and plagiarism. the editors may confer with other editors or reviewers in making this decision. 2.2 fair play an editor at any time evaluates manuscripts for their intellectual content without regard to race, gender, sexual orientation, religious belief, ethnic origin, citizenship, or political philosophy of the authors. 2.3 confidentiality the editor and any editorial staff must not disclose any information about a submitted manuscript to anyone other than the corresponding author, reviewers, potential reviewers, other editorial advisers, and the publisher, as appropriate. 2.4 disclosure and conflicts of interest unpublished materials disclosed in a submitted manuscript must not be used in an editor's own research without the express written consent of the author. 3. duties of reviewers 3.1 contribution to editorial decisions peer review assists the editor in making editorial decisions, and through the editorial communications with the author may also assist the author in improving the paper. publication ethics and malpractice statement app. 13 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 3.2 promptness any selected referee who feels unqualified to review the research reported in a manuscript or knows that its prompt review will be impossible should notify the editor and excuse himself from the review process. 3.3 confidentiality any manuscripts received for review must be treated as confidential documents. they must not be shown to or discussed with others except as authorized by the editor. 3.4 standards of objectivity reviews should be conducted objectively. personal criticism of the author is inappropriate. referees should express their views clearly with supporting arguments. 3.5 acknowledgment of sources reviewers should identify relevant published work that has not been cited by the authors. any statement that an observation, derivation, or argument had been previously reported should be accompanied by the relevant citation. a reviewer should also call to the editor's attention any substantial similarity or overlap between the manuscript under consideration and any other published paper of which they have personal knowledge. 3.6 disclosure and conflict of interest privileged information or ideas obtained through peer review must be kept confidential and not used for personal advantage. reviewers should not consider manuscripts in which they have conflicts of interest resulting from competitive, collaborative, or other relationships or connections with any of the authors, companies, or institutions connected to the papers. 4. duties of authors 4.1 reporting standards authors of reports of original research should present an accurate account of the work performed as well as an objective discussion of its significance. underlying data should be represented accurately in the paper. a paper should contain sufficient detail and references to permit others to replicate the work. fraudulent or knowingly inaccurate statements constitute unethical behavior and are unacceptable. 4.2 data access and retention authors are asked to provide the raw data in connection with a paper for editorial review and should be prepared to provide public access to such data (consistent with the alpsp-stm statement on data and databases), if practicable, and should, in any event, be prepared to retain such data for a reasonable time after publication. 4.3 originality and plagiarism the authors should ensure that they have written entirely original works, and if the authors have used the work and/or words of others that this has been appropriately cited or quoted. 4.4 multiple, redundant or concurrent publication an author should not, in general, publish manuscripts describing essentially the same research in more than one journal or primary publication. submitting the same manuscript to more than one journal concurrently constitutes unethical publishing behavior and is unacceptable. app. 14 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 4.5 acknowledgment of sources proper acknowledgment of the work of others must always be given. authors should cite publications that have been influential in determining the nature of the reported work. 4.6 authorship of the paper authorship should be limited to those who have made a significant contribution to the conception, design, execution, or interpretation of the reported study. all those who have made significant contributions should be listed as co-authors. where there are others who have participated in certain substantive aspects of the research project, they should be acknowledged or listed as contributors. the corresponding author should ensure that all appropriate co-authors and no inappropriate co-authors are included on the paper, and that all co-authors have seen and approved the final version of the paper and have agreed to its submission for publication. 4.7 hazards and human or animal subjects if the work involves chemicals, procedures, or equipment that have any unusual hazards inherent in their use, the author must clearly identify these in the manuscript. 4.8 disclosure and conflicts of interest all authors should disclose in their manuscript any financial or other substantive conflicts of interest that might be construed to influence the results or interpretation of their manuscript. all sources of financial support for the project should be disclosed. 4.9 fundamental errors in published works when an author discovers a significant error or inaccuracy in his/her own published work, it is the author’s obligation to promptly notify the journal editor or publisher and cooperate with the editor to retract or correct the paper. app. 15 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 nurse media journal of nursing (nmjn) appreciates the reviewers (alphabetically ordered) who have commented the manuscripts for the present volume (volume 11, 2021): anggorowati : department of nursing, faculty of medicine, universitas diponegoro, indonesia ashokka balakrishnan : national university hospital, singapore asih nurakhir : department of nursing, faculty of medicine, universitas diponegoro, indonesia cyrus p. tuppal : st. paul university, philippines elnaz asghari : faculty of nursing and midwifery, tabriz university of medical sciences, iran eni nuraini agustini : uin syarif hidayatullah, indonesia fatikhu yatuni asmara : department of nursing, faculty of medicine, universitas diponegoro, indonesia faustino jerome g. babate : beta nu delta nursing society, philippines fitria handayani : department of nursing, faculty of medicine, universitas diponegoro, indonesia fitri mailani : faculty of nursing, universitas andalas, indonesia forouzandeh jannat : tehran university of medical sciences, tehran, iran janet alexis a. de los santos : college of nursing, visayas state university, philippines luky dwiantoro : department of nursing, faculty of medicine, universitas diponegoro, indonesia mansour ghafourifard : faculty of nursing and midwifery, tabriz university of medical sciences, iran mardiyono mardiyono : department of nursing, poltekkes kemenkes semarang, indonesia megah andriany : department of nursing, faculty of medicine, universitas diponegoro, indonesia meidiana dwidiyanti : department of nursing, faculty of medicine, universitas diponegoro, indonesia meira erawati : department of nursing, faculty of medicine, universitas diponegoro, indonesia nana rochana : department of nursing, faculty of medicine, universitas diponegoro, indonesia niken s. d. kusumaningrum : department of nursing, faculty of medicine, universitas diponegoro, indonesia nur setiawati dewi : department of nursing, faculty of medicine, universitas diponegoro, indonesia ric-an artemio s. gadin : beta nu delta nursing society, philippines rizki fitryasari : faculty of nursing universitas airlangga, indonesia ryan michael f. oducado : college of nursing, west visayas state university, philippines sadeq al-fayyadh : college of nursing, university of baghdad, iraq sri padma sari : department of nursing, faculty of medicine, universitas diponegoro, indonesia suhartini ismail : department of nursing, faculty of medicine, universitas diponegoro, indonesia untung sujianto : department of nursing, faculty of medicine, universitas diponegoro, indonesia zubaidah zubaidah : department of nursing, faculty of medicine, universitas diponegoro, indonesia reviewer acknowledgment app. 16 copyright © 2023, nmjn, p-issn 2087-7811, e-issn 2406-8799 all manuscripts should be submitted to the nmjn editorial office by the online submission and tracking interface at: https://medianers.undip.ac.id. the following materials should accompany the submitted manuscripts to the editorial office: (1) signed copyright transfer agreement form (a copy reproduced from the website); (2) a covering letter outlines the basic findings of the paper and their significance, which are uploaded as supplementary materials (step 4) in the submission interface. however, if for any reason authors are unable to use the above methods, authors may also contact the editorial office according to the following address for technical assistance: meira erawati (editor-in-chief) nurse media journal of nursing department of nursing, faculty of medicine, universitas diponegoro jl. prof. soedarto, tembalang, semarang, central java, indonesia 50275 telp. +62-24-76480919; fax. +62-24-76486849 email: media_ners@live.undip.ac.id three types of manuscripts are acceptable for publication in the nmjn: original research articles, reviews (systematic and meta-analysis), and case reports. preparation of manuscripts manuscript of the research article, case study, or reviews should be prepared in the 'camera ready' templates, according to the guidelines on the website: http://ejournal.undip.ac.id/index.php/medianers/about/submissions reviewing of manuscripts every submitted manuscript is independently reviewed by at least two peers. the decision for publication, amendment, or rejection is based upon their reports. if two or more reviewers consider a manuscript unsuitable for publication in this journal, a statement explaining the basis for the decision will be sent to the authors within three months of the submission date. the rejected 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(signature and name) ▪ please send the filled form along with the payment receipt to the editorial office of nmjn via email: media_ners@live.undip.ac.id ▪ in the case of (*), choose one subscription information nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://ejournal.undip.ac.id/index.php/medianers 11(2):244-254, august 2021 https://doi.org/10.14710/nmjn.v11i2 34258 copyright © 2021, nmjn, e-issn 2406-8799, p-issn 2087-7811 original research parental challenges in promoting the well-being of talented youths in indonesia: a phenomenological study nur setiawati dewi1, piyanuch jittanoon2, wantanee wiroonpanich2 1department of nursing, faculty of medicine, universitas diponegoro, indonesia 2faculty of nursing, prince of songkla university, thailand article info abstract article history: received: 18 november 2020 revised: 12 july 2021 accepted: 9 august 2021 online: 27 august 2021 keywords: indonesia; javanese muslims; parenting challenges; talented youth; well-being corresponding author: nur setiawati dewi department of nursing, faculty of medicine, universitas diponegoro, indonesia email: nurse.tiawatidewi@fk.undip.ac.id background: parenting talented youths is a challenging task since most talented youths experience role complexities in their lives. thus, raising talented youths can lead to increased challenges of parenting. purpose: this study aimed to explore the challenges faced by javanese muslim parents in promoting the well-being of talented youths. methods: a descriptive phenomenological approach was chosen to guide this study. thirteen javanese muslim parents of talented youth (nine men and three women) were recruited using snowball and purposive sampling techniques. the data were obtained by conducting semi-structured interviews and field notes. the collected data were transcribed using verbatim transcription and analyzed using giorgi’s method of analysis. results: three themes were found after data analysis, i.e., challenges coming from the youths, challenges from the community, and the existence of financial constraints in the family. challenges coming from the youth were related to the oppositional behavior of talented youths and difficulties in managing children’s activities as students and as talented youths. challenges from the community included low commitment and belittling behavior from teachers or lecturers, ridicule from their neighbors, gender-based discrimination, and the absence of support from the organization. another theme was related to financial constraints in the family which made it difficult for parents to finance their youth’s education and talent activities. conclusion: identifying the actual problems experienced by the talented youths’ parents could help nurses develop appropriate family programs, consider, and incorporate holistic aspects into the programs to obtain optimal results. how to cite: dewi, n. s., jittanoon, p., & wiroonpanich, w. (2021). parental challenges in promoting the well-being of talented youths in indonesia: a phenomenological study. nurse media journal of nursing, 11(2), 244-254. https://doi.org/10.14710/nmjn.v11i2 34258 1. introduction talented youths are people who have extraordinary abilities in at least one human activity, which places them in the top 10% of their peer group with similar expertise in that field (dewi et al., 2021). approximately 2-5% of indonesian children are identified as talented youths (dewi et al., 2021; janah et al., 2018). to be parents of talented youth is not an easy task (reis & renzulli, 2021) since most talented youths experience role complexities in their lives. talented youths mostly achieve the highest performance level in certain areas at a very young age (scantlebury et al., 2020). consequently, their routines are usually regulated under strict management for training time, travel time for competitions, and studies (henriksen et al., 2020; phibbs et al., 2018; slaten et al., 2020). at the same time, they must learn how to deal with the stress they encounter in every tournament, organization, and in their personal life (phibbs et al., 2018; scantlebury et al., 2020; slaten et al., 2020). all these factors certainly influence their academic achievement and peer relationships (slaten et al., 2020). thus, raising talented and/or gifted children may be more challenging than raising their peers (rouquette, in press; tessitore et al., 2021). the challenges faced by parents may significantly increase as these children demand the most extraordinary parenting requirements (baimukanova, 2020; tessitore et al., 2021). the constituents of interconnected communities in the environment where parents are involved will give a unique meaning to their experiences (clarke & harwood, 2014). this meaning https://crossmark.crossref.org/dialog/?doi=10.14710/nmjn.v11i2.34258&domain=pdf&date_stamp=2021-08-28 nurse media journal of nursing, 11(2), 2021, 245 copyright © 2021, nmjn, e-issn 2406-8799, p-issn 2087-7811 can also affect the lives of the parents (renati et al., 2017) and the parenting patterns. for example, the javanese muslim community believes that parenting aims to build the main character and fulfill children’s rights. these characters include the character of being a good muslim (possessing akhlakul kharimah good behavior based on religion) (karimah & ummah, 2020; vinayastri, 2015) and the character of being a good javanese person (ali & arenggoasih, 2020). on the other hand, parents must also be responsible for fulfilling children’s rights; therefore, javanese muslim parents expect their children’s health from childhood (ali & arenggoasih, 2020; hartono et al., 2017). accordingly, community, religiosity, and cultural features can be highly significant for exploring the challenges of parents in raising talented youths. most studies concerning talented youth have tended to explore parenting challenges from the western perspective (baimukanova, 2020; reis & renzulli, 2021; tessitore et al., 2021; wellisch, 2021). however, there is still no empirical research to describe the challenges from the perspective of javanese muslim parents. therefore, the author proposes further research on the influence of javanese muslim social and cultural features, which are needed to improve theoretical understanding of parents' perceptions of the challenges in promoting the well-being of talented youth. therefore, this study aimed to explore the challenges that parents experience in promoting the well-being of talented youths from the perspective of javanese muslim parents. 2. methods 2.1 research design this study used a descriptive phenomenological approach to understand the essence of parents’ challenges to promote the well-being of talented youth from the perspective of javanese muslim parents, which is still not clearly understood. descriptive phenomena can describe the meaning of javanese muslim parents about parental challenges that they deal with. 2.2 setting and participants this study was conducted from august 2017 to april 2018. this study chose east java and central java provinces in indonesia as the research location due to the fact that 98% of the javanese population lives in these provinces, and around 80% are muslims. the participants of this study were 13 javanese muslim parents of talented youth, including three mothers and nine fathers. these participants were recruited based on the following criteria: (1) a mother or father who identified her/himself as a javanese muslim; (2) having talented children who had received any awards at least at the national level, and (3) able to communicate in both indonesian and javanese. purposive and snowball techniques were used to select the participants. 2.3 data collection the principal researcher conducted all the interview processes. the researcher collected the data through semi-structured interviews and field notes. the interviews were conducted twice with each participant; the first and the second interviews were held on different days. during the first interview, the researcher asked several questions based on the interview guidelines. several questions need to be investigated further to obtain the participants’ answers eventually. the first interview session took 60 to 90 minutes. after making a verbatim transcript of the recording, the researcher read and reread the transcript. then, the researcher identified the answers which required clarification through follow-up interviews at a later time. the principal researcher conducted the second interview to obtain additional data when the first interview required more in-depth data. the second interview lasted for approximately 30 to 45 minutes. all interviews were recorded using a voice recorder. during the interviews, the researcher used mixed languages between javanese and indonesian. to open the interview process, the researcher used general introductory questions. an example of this question was: “do you have any idea if your child is talented?.” after the parents responded to the initial questions, the following interview aimed to clarify the initial responses, such as “what are the challenges as parents in raising your child?.” this question aimed to explore parents further and to enable them to continue to talk about their experiences. other questions, such as “how are the challenges affecting your daily life?” were designed to bring out the parental experience in detail. while exploring the parents’ experiences during the interviews, the researcher clarified some vague statements to ensure that the researcher’s understanding of the experiences was consistent nurse media journal of nursing, 11(2), 2021, 246 copyright © 2021, nmjn, e-issn 2406-8799, p-issn 2087-7811 with how the parents experienced them. to gather further information, the researcher followed up using inquiry questions about the focused issues. during the interview process, the researcher also took field notes to improve the quality of the data. 2.4 data analysis giorgi (2012) stated that researchers are trying to understand the meaning of the description as presented. however, before the process begins, descriptive phenomenology suggests that the researcher isolates his or her own parenting experience as it will influence the perception of the data during the data analysis process. the researchers reread the transcribed text while listening to the audio recording to make sure the material was transcribed literally and accurately. after the researchers were sure that they had obtained a complete and accurate transcript, the raw data were analyzed in several steps, as illustrated. first, the researchers read the transcribed data several times to obtain an overall sense of the transcript being read. second, the researchers identified the meaning unit. third, the researchers converted meaning units into transformed unit meaning. the natural attitude of each parent was changed into phenomenological and psychologically sensitive expressions. finally, the structure can be determined (broome, 2011; giorgi, 2012). the example in the data analysis process was provided in table 1. table 1. example in the data analysis process step and transformation statement transcription i am disappointed with her teachers’ attitude. some of them do not support her talent. they asked why my daughter preferred taking part in competitions to school activities. sports cannot support her future life. i do not understand her teachers’ perception. they tend to belittle her talent. they are not true teachers. unit of meaning i am disappointed with the attitude of my daughter’s teachers. they tend to reject her talent. they are not real teachers. unit of transformation meaning parents are disappointed with teachers who do not support their youth’s talents. the teachers commented negatively on the athlete’s life. parents think that teachers’ attitudes of ignoring and/or even belittling students’ talents are not appropriate. sub-theme belittling attitudes from the teachers synthesis of the theme structure challenges from the community 2.5 trustworthiness the researchers used bracketing and reflection journaling during the research process. the researcher deliberately ignored all knowledge, opinions, or views concerning the researchers’ background to minimize bias. instead, the researcher locked all knowledge, beliefs, and thoughts about aspects that might influence the research process into a reflective journal. when the researchers reviewed the literature, the researchers focused on previous relevant research studies to find any knowledge gaps rather than to gather evidence that would probably influence the researchers’ perceptions. the researchers then triangulated data from interviews and field notes to ensure the reliability and validity (rigor) of the research. the researchers worked together to check whether the research process was acceptable, essentially regarding the research method, which included sampling selection, data collection, procedures, and data analysis. then, the researchers assessed the internal consistency of whether the data supported the findings. the researchers also examined the consistency of the results, interpretations, and conclusions of the study. furthermore, since this study was a part of a dissertation, the dissertation committee members reviewed and audited all research processes and findings. nurse media journal of nursing, 11(2), 2021, 247 copyright © 2021, nmjn, e-issn 2406-8799, p-issn 2087-7811 2.6 ethical considerations the institutional review board (irb) of the faculty of nursing, prince of songkla university, thailand, had approved this study (no. 2017 nst–qn 029). informed consent was conveyed both orally and in written to the participants. this informed consent consisted of four important elements of ethical considerations, including the purpose of the study, what would happen during the interview, potential benefits, and any risks regarding the interview process. the researchers allowed parents to ask any questions related to the given informed consent and then let them decide whether to participate in the study or not. 3. results 3.1 characteristics of participants the javanese muslim parents were recruited from two provinces in indonesia: central java and east java. three mothers and nine fathers aged between 50 and 62 years participated in this study. except for three parents (one was a housewife and the other two were retired), the rest were public servants or self-employed/entrepreneurs. almost all of them completed their undergraduate education (6 participants) or senior high school degree (5 participants); the other two had finished elementary and junior high school. one participant was a widow, while the others were married (12 participants). six participants were included in middle-income, four in high-income, and the other three were categorized as low-income families. demographic characteristics of participants were provided in table 2. table 2. demographic characteristics of the research participants (n=13) characteristics number of parents age (years old) 40 – 55 5 56 – 61 8 gender male 10 female 3 education level elementary school 1 junior high school 1 senior high school 5 bachelor degree 6 marital status married 12 widow 1 economic status low 3 middle 6 high 4 occupation public servant 5 entrepreneur/self-employee 5 retired 2 housewife 1 3.2 participants’ perspectives in promoting the well-being of talented youths based on the participants’ perspectives, three themes were found: (1) challenges coming from the youths, including the children’s oppositional behavior and difficulties in managing children’s activities, as students and as talented youths; (2) community challenges were resulted from belittling attitudes from their children's teachers/lecturers, ridicule from their neighbors, genderbased discrimination, and lack of support from organizations; and (3) the existence of financial restrictions in the family. 3.2.1 challenges from the youths the participants stated that their main challenges were related to their children’s oppositional behavior and difficulties in managing activities for the children with dual roles: as nurse media journal of nursing, 11(2), 2021, 248 copyright © 2021, nmjn, e-issn 2406-8799, p-issn 2087-7811 students and as talented youths. parents described parenting youths as the most challenging parenting period because youths, during this age, tend to be in opposition to their parents. they reported that quarrels and strained relationships between parents and teens were common during this time. moreover, breaking parental rules was a common problem for parents. for example, parents of youths with the talent of memorizing the qur’an implemented some rules for their children. their children were forbidden to watch television, listen to music, and sing songs. they believed that music and television materials could reduce the ability to memorize the qur’an. however, the youths often broke these rules. they listened to music, sang songs, and watched television elsewhere, which could make their parents angry. “...when my son sings songs, i am angry. they will find it difficult to memorize the qur’an. they know it exactly (listening to music, singing songs, and watching television) are forbidden in our family. they often violate my rules. my son watches television at his friend’s or relative's house. when i caught them, they argued me with some reasons...” (p11) other participants, whose children were youth athletes, stated that they experienced a strained relationship with their children. young athletes often neglected training when they felt bored and stressed and needed to relax. talented youths experienced social estrangement due to the lack of time they had. this causes them to become bored and stressed. “sometimes, he gets bored and stressed with training and needs to relax. i’m mad at him for not training. a table tennis athlete has to train regularly. this often strains our relationship...” (p1). "sometimes he misses regular training when she feels tired, bored and needs to relax. her training center is located in another city; she has to go to the training center by train every saturday morning and has to return to her hometown on sunday evening. she rarely spends time with friends. maybe, it causes her to become bored and stressed. she needs to relax.” (p6) according to parents, the main difficulty they experienced was how to manage the balance of the two main activities of university students, i.e., completing assignments from campus and participating in joint training schedules. as university students, the youths tended to pile the campus assignments on and completed them when the deadline for submitting the assignments was approaching. as a result, most of the campus assignments were eventually not completed by the required deadline. parents complained that their teenagers did not have perseverance in doing their assignments. even though they knew that unfinished tasks would affect the arranged schedule related to their athletic activities, reducing the time for training would decrease their physical stamina and lower the target set by the trainer. “... as a university student, she should manage her campus assignments. most of the courses she took have assignments with deadlines. however, she, again and again, delays doing the assignments. as a result, her assignments pile up. when the deadlines for the assignments come, she is often absent from training at the table tennis club. because of this, she frequently doesn't achieve her training target.” (p7) “she has to finish her assignments before the deadline because she has a busy schedule as an athlete and as a university student. she sometimes misses them. she delays finishing her homework ...” (p4) 3.2.2 challenges from the community this theme refers to the attitudes and behaviors of teachers, neighbors, and/or sports/arts organizations that do not support talented youths and their families. the main source of these obstacles is the lecturers/teachers. one athlete’s father complained about his son’s bachelor thesis advisor, who often delayed meetings or rescheduled thesis consultation appointments. the parent felt that his son’s advisor had a low commitment to support the talented youth. this resulted in nurse media journal of nursing, 11(2), 2021, 249 copyright © 2021, nmjn, e-issn 2406-8799, p-issn 2087-7811 their children having to extend the length of their studies. accordingly, this caused parents to worry about their children’s academic future. “his advisor often reschedules thesis consultation appointments. she (advisor) did not have a good commitment to help my son. my son has trouble meeting his thesis advisor, so his study was extended. as a result, we had to reschedule some of the tournaments which he should have attended. we gave up on participating in some tournaments held in other provinces because he needed to consult his thesis with his advisor regularly. i'm afraid; if this continues, he might not be able to finish his study within this semester...” (p1) another parent was disappointed with teachers who did not support their youth’s talents. the teachers commented negatively on the athlete's life. parents thought that teachers’ attitudes of ignoring and/or even belittling students’ talents were not appropriate. “i am disappointed with her teachers’ attitudes. some of them do not support her talent. they asked why my daughter preferred taking part in competitions to school activities. sports cannot support her future life. i don't understand her teachers' perceptions. they tend to belittle her talent. they are not true teachers.” (p6) another challenge that parents had was coming from their neighbors’ comments. the neighbors would say that pursuing a career as an athlete leaves their life full of uncertainty in the future. the neighbors stated that because the talent was just a hobby, not a job. for example, the father of a female table tennis athlete (p7) stated, “my neighbor said that all athletes face uncertain financial conditions in the future. most of them become poor in their old age. they do not have enough money to live...” such unsupportive comments make parents feel uncomfortable and disappointed. they find it difficult to stop the ridicule from some people in their social circle. “...why are they so unsympathetic? i feel uncomfortable and disappointed. my daughter just stays at home. she doesn’t want to meet them (neighbors) and listen to their ridicule. it’s hard to stop their comments...” (p13) gender-based discrimination is another challenge faced by parents of female athletes (soccer and kempo athletes). in addition, some neighbors thought that some kinds of sports were considered inappropriate and incompatible or even violate the nature of a woman. “my neighbors said that it (being a soccer player) is inappropriate for a woman; it’s a men’s sport.” (p3). “my schoolmates told me that joining kempo made my daughter masculine.” (p10) in addition, some people would consider it taboo if women traveled far from home alone even though they went abroad to bring the name of the nation to international events. “my daughter often goes abroad to dance to bring the name of indonesia. my neighbors asked me why i allowed my daughter to go abroad alone. they said she is a woman.” (p8) in addition, parents of young athletes perceived that the sports association which houses their children's talent did not adequately support their talent potential. they felt like the sports association was just exploiting them. “the women’s soccer organization never made a significant contribution to my daughter. they just want her achievements. they exploit her.” (p3) “he was ranked the first and was selected as the player to join the national team, but the lower-ranked player who had connections with the officials beat him. his friend did nepotism. the table tennis association couldn't do anything. the association official nurse media journal of nursing, 11(2), 2021, 250 copyright © 2021, nmjn, e-issn 2406-8799, p-issn 2087-7811 couldn't defend my son from being in the first team. i complained about it, but no one answered my protest.” (p2) 3.2.3 financial constraints in the family the theme of financial constraints in the family refers to the financial pressure condition of the family that made it difficult for them to meet the needs of their children as students and talented youth. parents often experienced financial constraints, especially the low and middleincome parents. all participants were from middle and low economic income classes. it was difficult for them to finance the needs of an athlete; besides, their children also did not receive scholarships for their undergoing education. this situation caused their children to be unable to focus on their studies or in competitions due to the lack of financial resources. participants felt a heavy burden to meet the needs of athletes, such as sports equipment, sports clothing, club administration fees, competitions, and living costs to participate in competitions. such types of expenses were very costly, which they frequently could not afford. “we fight very hard. i buy everything i need for him. most of the necessities are related to equipment, such as rackets, shoes, rubber, club administration fees, competitions and living expenses for competitions.” (p1) “as a public servant, my wife and i have a limited salary; it is even only to meet our daily needs; it is difficult.” (p2) “we have financial problems. our business went bankrupt. we have no money at all. so, it put a tremendous amount of pressure on our family. as a result, we have difficulty paying for our children’s education. she doesn't get any scholarships. we also have difficulty not only in education but also in preparing food.” (p12) 4. discussion this study showed that parenting talented youths is the most challenging period since breaking parental rules at this age is a common problem that parents face. talented youths often have asynchronous development, exhibit unusual behavior, have difficulty in accepting rules and routines, and have school problems, which cause frustration and increase parenting stress on parents (renati et al., 2017). also, this study identified difficulties faced by parents, mainly from father participants, to balance time management for their children that have dual roles of being a university student and for their talents’ exercise. fathers always try to meet the needs of their children and optimize their children’s development (khasanah & suratni, 2013), including making strict time management for their gifted children. this research also explains the reason for time management difficulty due to the habit of their children to procrastinate on completing campus assignments and prefer to do them when they are approaching deadlines, which has an impact on failure to complete assignments thoroughly. consequently, they often forget the exercise and training that must be undertaken. these talented youths also experience social estrangement due to the lack of time they have. this causes them to become bored and stressed. many causes of stress experienced by talented students include heavy workload, preparing for the future, academic responsibilities, extracurricular activities, and social life (kregel, 2015). commitment to training can also be a stressor for the youth when they want to spend quality time with friends (elliott et al., 2018). this study, however, identified that the low commitment and belittling behavior from lecturers/teachers in helping talented youth creates confusion for parents in managing the balance of roles played by their children. this makes parents worried about their children’s academic future. the harmonious relationship between the lecturers and the students is an important aspect that contributes to the success of talented youths (bonner, 2001). previous studies identified that lecturers could cause stress for parents through their unsupportive behavior or statements regarding talent-related activities which their children need to attend (bartley, 2014; free, 2014; geake & gross, 2008; renati et al., 2017). patronization, humiliation, and threats are some of the university/school stressors that can highly trigger the well-being of talented youth (free, 2014). lack of support from most lecturers for these youths and their families may be due to a lack of knowledge about talented people (free, 2014). nurse media journal of nursing, 11(2), 2021, 251 copyright © 2021, nmjn, e-issn 2406-8799, p-issn 2087-7811 moreover, this study also found that neighbors cause another stress felt by parents who have worked hard for the well-being of their talented youth. a previous study identified that one of the challenges that parents face stems from negative societal attitudes, i.e., stigmatization of talented youths who are seen as having poorer physical or mental health (free, 2014). this study also shows similarities regarding the role of the community in increasing parental stress. that stigmatization is linked to academic achievement and anecdotally lower prospects in the future life of someone who chooses to pursue their talents over academics. the stigmatization has led some youths to stay at home instead of meeting neighbors after hearing their comments. in addition, parents and their talented youths often experience isolation (renati et al., 2017). gender-based discrimination is another difficulty faced by parents of talented female youth. parents admitted that some javanese still believe in tasks difference based on gender. khilmiyah (2017), in her study, found that usually, the community believes that women’s duties include everything related to the use of tenderness and feelings; on the contrary, men’s duties include everything related to physical and mental strength. in addition, there is a dichotomy of public and domestic roles rooted in the ideology that a woman’s role is to be at home, and a man’s role is to be the breadwinner (wage earner). in turn, this helps perpetuate the division between the productive and reproductive functions of men and women at home. some javanese people still think that the duties of javanese women consist of make-up (macak), cooking (masak), and giving babies (manak) only (tuapattinaya & hartati, 2014). therefore, it is not surprising that parents also experience gender discrimination regarding the selection of their children’s talents, especially parents whose daughters pursue sports that are predominantly done by males or are engaged in the male gender, such as kempo, dominate, and soccer. some parents also voiced their dissatisfaction with the lack of support from the sports associations their children belong to. being ignored by sports associations is an example of rejection from their talented youths. renati et al. (2017) found that parents of talented youths perceive that the organization does not support them or their talented youths. however, a previous study reported that problems with organizations assisting talented youth are caused by some factors such as funds and personnel availability, spending on traveling competitions, and so on (free, 2014). this study states that some parents (middle and low-income families) face difficulties paying campus tuition and living expenses for students at university, meeting routine needs (e.g., equipment, membership fees) to support their children’s talents, and participating in talent competitions held. these results confirm the previous research stating that parents of talented youth have to make adjustments and even sacrifice for their regular family routines. supporting talented youths is expensive (aujla et al., 2014). 5. implication and limitation this study provides several implications for nursing practices and nursing research. understanding cultural and contextual experiences of javanese muslim parents with talented youth have implications for nursing practice that seeks to support parents to get through several challenges. nurses can develop family-based programs by considering and incorporating holistic aspects into the program. in addition, this study also has implications for further research. the results of this study can be used as basic data in developing a parenting intervention model to improve the well-being of talented youths. this study has limitations since the sampling selection used the snowball sampling method. fathers as participants tended to direct the researchers to refer to the next participant of the same gender, i.e., male. therefore, the majority of participants in this study were fathers. in addition, the selection of talented youths by using the snowball method has limited the selection of talents possessed by the youths. in this study, the majority of talented youth are in the sports field. 6. conclusion this study identified the real challenges faced by talented youths’ parents, including the challenges coming from the youths, the community, and family financial constraints that affected the lives of parents. nurses should be aware of and develop family-based programs to support parents in promoting the well-being of talented youths by considering holistic aspects in making their interventions. nurse media journal of nursing, 11(2), 2021, 252 copyright © 2021, nmjn, e-issn 2406-8799, p-issn 2087-7811 acknowledgment the authors gratefully thank all parents who participated in this study. we also thank the directorate general of higher education, ministry of research and technology, the republic of indonesia, for the financial support of this research. author contribution nsd: study design, conceptualization, data collection, data analysis, manuscript writing; pj: study design, manuscript writing; ww: study design, data analysis, manuscript writing. conflict of interest the authors declare that there is not any conflict of interest. references ali, m., & arenggoasih, w. 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(2021). parenting with eyes wide open: young gifted children, early entry and social isolation. gifted education international, 37(1), 3-21. https://doi.org/10.1177/ 026142941989 9946. copyright © 2021 nmjn. this article is an open-access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). https://creativecommons.org/licenses/by-sa/4.0 nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://medianers.undip.ac.id 13(1):121-131, april 2023 https://doi.org/10.14710/nmjn.v13i1.47694 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 original research perception of covid-19 vaccination based on health belief model and the acceptance of covid-19 booster vaccination risma eka putri arlyani kusuma dewi1 jon hafan sutawardana2, ana nistiandani2 1faculty of nursing, universitas jember, east java, indonesia 2medical-surgical nursing department, faculty of nursing, universitas jember, east java, indonesia article info abstract article history: received: 18 july 2022 revised: 12 april 2023 accepted: 27 april 2023 online: 30 april 2023 keywords: covid-19 booster vaccine; covid-19 vaccination; health belief model; covid-19 corresponding author: jon hafan sutawardana medical-surgical nursing department, faculty of nursing, universitas jember, east java, indonesia email: hafan@unej.ac.id background: the covid-19 booster vaccination proposes a spike in cases due to new infection variants. according to the health belief model (hbm), vaccination acceptance is a health change behavior measured by perception. however, more information is needed about the relationship between public perception and future acceptance of the covid-19 booster vaccination. purpose: this research aimed to analyze the relationship between the perception of covid-19 vaccination based on the hbm and the acceptance of covid-19 booster vaccination. methods: the research used observational analytics design with a cross-sectional approach conducted at the community of a public health center in jember regency, indonesia. purposive sampling was used to recruit 387 respondents. the inclusion criteria were people aged >18 who had received a complete primary vaccination. the research instruments consisted of some questionnaires: respondent characteristics, perceptions of covid-19 vaccination based on the hbm, and the acceptance of covid-19 booster vaccination. data were analyzed using chi-square and a logistic regression test. results: the results showed that most respondents accepted the covid-19 booster vaccine (67.4%). there was a significant relationship between perception’s subscales of covid-19 vaccination, such as perceived susceptibility (p=0.001), perceived severity (p=0.001), perceived benefits (p=0.001), perceived barriers (p=0.001), cues to action (p=0.001) and the acceptance of the covid-19 booster vaccination. cues to action were the most dominant factor related to the acceptance of the covid-19 booster vaccination (or=5.265; 95%ci=3.073-9.022; p<0.001). conclusion: positive perceptions of all hbm subscales, which showed a good perception in the community, indicated the high acceptance of the covid-19 booster vaccine. for clinical practice, this research can be developed by surveying patients who have comorbidities. how to cite: dewi, r. e. p. a. k., sutawardana, j. h., & nistiandani, a. (2023). perception of covid-19 vaccination based on health belief model and the acceptance of covid-19 booster vaccination. nurse media journal of nursing, 13(1), 121-131. https://doi.org/10.14710/nmjn.v13i1.47694 1. introduction coronavirus disease 2019 (covid-19) cases increased in december 2021 due to the new variant, namely omicron (world health organization [who], 2021). omicron variants can develop and damage the immune system that is initially formed in the previous dose of vaccine over time (dolgin, 2021). as the pandemic spreads to lower-middle-income countries, there is growing concern about the risk of severe covid-19, including in indonesia (efendi et al., 2022). as of march 13, 2022, indonesia already ranks 16th in the world with the highest number of confirmed cases of 45,847,900, and a death rate of 151,414 (worldmeter, 2022). more than one year of the covid-19 pandemic, cases continue to fluctuate. in indonesia, the government has established several policies based on four critical components of surge capacity: staff, goods, structures, and systems (mahendradhata et al., 2021). currently, available medical staffs are insufficient to deal with the potentially increased demands due to the pandemic, putting a spotlight on human resources challenges faced by the healthcare system. in addition, the surge in patients requiring hospitalization led to a shortage of medical supplies. the existing health infrastructure is still inadequate to handle the increase in covid-19 cases (mailani et al., 2022). therefore, covid-19 booster vaccines are recommended to prevent the risk of more severe symptoms. https://doi.org/10.14710/nmjn.v12i3.xxxx https://crossmark.crossref.org/dialog/?doi=10.14710/nmjn.v13i1.47694&domain=pdf&date_stamp=2023-04-30 nurse media journal of nursing, 13(1), 2023, 122 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 however, the acceptance of covid-19 booster vaccination in indonesia is still low at 14,400,781 doses (7.01%). this condition is in line with the high number of cases of covid-19 infection (ministry of health the republic of indonesia [mohri], 2022). the acceptance of the covid-19 booster vaccination in indonesia has created a debate in the community about whether or not the booster vaccine needs amid efforts to spread the infection of the omicron variant (sihidi et al., 2022). post-vaccination death can occur because the immunity or protection forming in the body will decrease over time (jain et al., 2021). public perception of the new covid-19 variant concerns the safety, the effectiveness of the covid-19 booster vaccine, and the side effects of booster vaccination (lai et al., 2021). the perception of susceptibility related to covid-19 infection and barriers to vaccination affordability was high (85.4% and 88.5%, respectively), followed by the fear of contracting (56.3%), and the halal of vaccines (52.3%) (wong, alias et al., 2020). some reasons for people to refuse covid-19 booster vaccination in china are the safety of the booster vaccine, as many as 79.0%, and the concerns about the effectiveness of the booster vaccine protection as many as 75.9% (lai et al., 2021). according to the acceptance of the covid-19 vaccine in the community, further interventions are forming to increase public awareness about the benefits and safety of the covid-19 vaccine that can control the spread of the covid-19 virus (who, 2021). in connection with the public response to rejecting the covid-19 booster vaccine, it is assumed that there is concern over the uncertainty of the implications of the booster vaccine for the body’s immunity. in line with that, suspicions arise about the vaccine’s performance, the timing of immunity, and its usefulness to the body, causing factors affecting people who refuse the vaccine to maintain their arguments (sihidi et al., 2022). at the same time, vaccines are one of the last solutions to treat infectious diseases. therefore, utilizing hbm to identify people’s perceptions plays an important role in improving the acceptance of covid-19 booster vaccination. the health belief model (hbm) explains that there are perceptions about health, disease, and means in a person that can determine behavioral health that a person does to maintain his health, according to rosenstock (1874) in glanz et al. (2015). this concept gives the idea that a person will take action if they feel the adverse effects of the situation he experienced, hoping to improve his condition by believing in the success of an action. hbm emphasizes indicators of individual perception of a phenomenon that affects health (glanz et al., 2015). the framework includes constructs on perceived (susceptibility, severity, benefits, barriers) and cues to action (glanz et al., 2015; rodriguez et al., 2021; vebrielna, 2021). the purpose of the study is to build on the phenomenon that occurred. the researcher wanted to know the relationship between perceptions felt by the public based on the hbm with the acceptance of the covid-19 booster vaccination so that it could produce an output to determine the causes of perceptions that emerged in the community which affected the acceptance of the covid-19 booster vaccination. this study used the basic theory of hbm to measure perceptions about the covid-19 vaccination in the general public by including all five components of perception. the selection of this basis is because the concept of the hbm focuses on the basic problems of a disease related to means in a person, which can determine health behaviors that a person does to maintain health accordingly. to date, no known studies have been found on this topic in indonesia. more information about the relationship between public perception and future acceptance of the covid-19 booster vaccination in indonesia is needed. therefore, this study aimed to analyze the relationship between the perception of covid-19 vaccination based on the hbm and the acceptance of covid-19 booster vaccination. 2. methods 2.1 research design this study used an analytical observational design with a cross-sectional approach. this survey-based study collected the perceptions of covid-19 vaccination based on the health belief model (hbm) and the acceptance of covid-19 booster vaccination from the public community in the working area of a public health center in jember regency, indonesia. 2.2 setting and samples the study involved the public community in the working area of a public health center in jember regency, indonesia, and was conducted in may 2022. the inclusion criteria were people aged >18 who had received complete primary vaccination. in contrast, the exclusion criteria were nurse media journal of nursing, 13(1), 2023, 123 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 health workers, people with mental and cognitive disorders, and the respondents who withdrew during the research. a formula developed by lwanga and lemeshow for an unknown population was used to determine the number of samples in this study, with estimated proportions of the population at 0.05 (nursalam, 2020). the minimum sample was 385 respondents. adding 10%(39) of respondents was necessary to anticipate respondents who withdrew, resulting in a total of 424 respondents. after going through the dropout stage due to samples that did not meet the research criteria, such as two respondents under 18 years old and 46 respondents who had received the covid-19 booster dose vaccine, the number of samples that could be further analyzed was 387 respondents from 3 sub-districts in the specified area. 2.3 measurement and data collection the instrument used to collect the data in this study consisted of a questionnaire of participant’s characteristics, the perception of the covid-19 vaccination questionnaire based on hbm, and the acceptance of the covid-19 booster vaccination questionnaire. the first questionnaire consisted of 9 grouped items using nominal and ordinal scales, namely evidence of covid-19 vaccination, age, gender, marital status, education, occupation, monthly income, history of contracting covid-19, and comorbidities. the perception of covid-19 vaccination questionnaire based on the hbm had a total of 34 questions modified from previous studies by vebrielna (2021) and lai et al. (2021), which consisted of 5 subscales: perceived susceptibility (7 questions), perceived severity (7 questions), perceived benefits (7 questions), perceived barriers (7 questions), and cues to action (6 questions). modifications were made as there was no prior existing questionnaire found. this questionnaire measures respondents’ perceptions of positive and negative perceived covid-19 vaccinations using a likert response of 4 points from 1 to 4, indicating strongly disagree to strongly agree. the positive perception category was determined if the total score was ≥ 21, while negative perception was categorized if the total score was <21. this questionnaire had been tested for its validity dan reliability on 50 respondents in another area that had the same characteristics as the research area. the questionnaire met the construct validity test result for perceived susceptibility of 0.4560.737, perceived severity of 0.380-0.701, perceived benefits of 0.299-0.845, perceived barriers of 0.440-0.805, and action cues of 0.547-0.770, which indicated that the items on the scale were valid (r>0.279) at a significant level of 5%. moreover, cronbach alpha values of the questionnaire indicated good reliability, which included perceived susceptibility (α=0.749), perceived severity (α=0.682), perceived benefits (α=0.831), perceived barriers (α=0.798), and cues to action (α=0.754). the acceptance of the covid-19 booster vaccination questionnaire consisted of 6 question items about willingness, support, and confidence as a result of a modification from previous studies by vebrielna (2021) and lai et al. (2021). the minimum and maximum scores of this questionnaire were 0 and 6, respectively. this questionnaire was categorized as “accept” (score >3) and “do not accept” (score <3) to measure the acceptance of respondents who had received the covid-19 booster vaccination. a validity and reliability test had been conducted on the questionnaire on 50 respondents in another area that had the same characteristics as the research area. the validity test showed that all question items of the questionnaire were valid with r=0.728-0.994 at a significant level of 5%. the questionnaire also showed high internal consistency with a cronbach alpha of 0.931. data collection was carried out offline by meeting the respondents directly according to the research criteria and providing a questionnaire sheet that the respondents filled out. the research was carried out after permission from the related public health center was obtained. the health center then provided a travel document as proof of scientific data collection at the working area of the health center. the research team collected the data by spreading the questionnaires door to door using covid-19 health protocols, such as maintaining a distance between the research team and respondents, encouraging them to use the hand sanitizer that was provided by the research team, and encouraging them to use masks. 2.4 data analysis this study conducted analytical observations to describe the distribution of sample characteristics, the perception of the covid-19 vaccination based on the hbm, and the acceptance of the covid-19 booster vaccination. this study produced a statistical summary using nurse media journal of nursing, 13(1), 2023, 124 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 the frequency and proportion in categorizing each variable for descriptive analyses. the chisquare test was used to examine the relationship between the perception dimensions of the hbm and the acceptance of the covid-19 booster. a logistic regression analysis followed the unadjusted analysis to measure the most dominant association of the perceived hbm subscales on the acceptance of the covid-19 booster vaccination. 2.5 ethical considerations the ethics committee of the faculty of nursing, universitas jember, had approved this study, with the permit certificate number of 068/un25.1.14/kepk/2022. on the first page of the research questionnaire, an informed consent form informed the respondents regarding the research objectives. if the respondent was willing to participate in the study, it was necessary to provide a signature as consent. 3. results 3.1 characteristics of the participants table 1 presents the characteristics of the participants in the study. a total of 387 participants responded to the survey in this study. most respondents had a vaccination cards (77.8%) and were women (78.8%). less than half of the respondents were aged 36-45 years (25.6%), housewives (46.5%), and graduated from high school (37%). almost all respondents were married (85%), had an income of less than 2,400,000,idr (86.3%), had never contracted covid-19 (93.3%), and had no comorbidities (87.1%). table 1. characteristics of the participants (n=387) characteristics f % evidence of covid-19 vaccination vaccination certificate / vaccine card 301 77.8 peduli lindungi applications 86 22.2 age (years) 18-25 53 13.7 26-35 75 19.4 36-45 99 25.6 46-55 84 21.7 56-65 54 14.0 >65 22 5.6 gender male 82 21.2 female 305 78.8 maternal status married 329 85 never married 35 9.1 widow/widower 23 5.9 educational level no formal school 35 9 unfinished elementary school 24 6.2 elementary school 104 26.8 junior high school 56 14.5 senior high school 143 37 college 25 6.5 employment status unemployment 14 3.6 student 12 3.1 entrepreneur/trader 99 25.6 farmer 10 2.6 day laborer/driver/household assistant 21 5.4 government employees/army/police/state-owned enterprises 5 1.3 private employees 39 10.1 retired 7 1.8 housewife 180 46.5 nurse media journal of nursing, 13(1), 2023, 125 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 1. continued characteristics f % monthly income < 2,400,000,idr 334 86.3 ≥ 2,400,000,idr 53 13.7 history of contracting covid-19 yes 26 6.7 no 361 93.3 have comorbidities yes: hypertension diabetes mellitus asthma tbc cancer liver no 34 4 8 2 1 1 337 8.8 1 2 0.5 0.3 0.3 87.1 3.2 perceptions of covid-19 vaccination and the acceptance of covid-19 booster vaccination the results of covid-19 vaccination perceptions based on hbm are listed as positive and negative perceptions, as shown in table 2, while table 3 illustrates the acceptance of covid-19 booster vaccination. as seen in table 2, all subscales of the covid-19 vaccination showed more positive perceptions, namely perceived susceptibility (57.1%), perceived severity (65.9%), perceived benefits (61.0%), perceived barriers (54.8%), and cues to action (57.6%). table 3 also showed that most respondents accepted covid-19 booster vaccination (67.4%). table 2. perceptions of covid-19 vaccination based on hbm (n=387) no perception of covid-19 vaccination f % 1. perceived susceptibility negative perception 166 42.9 positive perception 221 57.1 2. perceived severity negative perception 132 34.1 positive perception 255 65.9 3. perceived benefits negative perception 151 39.0 positive perception 236 61.0 4. perceived barriers negative perception 175 45.2 positive perception 212 54.8 5. cues to action negative perception 264 42.4 positive perception 223 57.6 table 3. the acceptance of covid-19 booster vaccination (n=387) no the acceptance of covid-19 booster vaccination f % 1. do not accept 126 32.6 2. accept 261 67.4 total 387 100 3.2. correlations between the perception of covid-19 vaccination based on hbm and the acceptance of covid-19 booster vaccination the results of the analysis showed that there were significant relationships between all perception subscales of covid-19 vaccination and the acceptance of covid-19 booster nurse media journal of nursing, 13(1), 2023, 126 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 vaccination (p=0.001), as can be seen in table 4. table 4 indicates that most respondents with a positive perception of each subscale (perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action) chose to accept covid-19, which accounted for 77.8%, 76.9%, 80.1%, 85.4%, and 84.8% respectively. table 4. correlations between the perception of covid-19 vaccination based on hbm and the acceptance of covid-19 booster vaccination (n=387) perceptions’ subscales of covid-19 vaccination the acceptance of covid19 booster vaccination 95% ci p accept do not accept f % f % perceived susceptibility** negative 89 53.6 77 46.4 3.03 (1.95-4.71) 0.001a positive 172 77.8 49 22.2 perceived severity** negative 65 49.2 67 50.8 3.42 (2.18-5.36) 0.001a positive 196 76.9 59 23.1 perceived benefits** negative 72 47.7 79 52.3 4.41 (2.80-6.93) 0.001a positive 189 80.1 47 19.9 perceived barriers** negative 80 45.7 95 54.3 6.93 (4.27-11.24) 0.001a positive 181 85.4 31 14.6 cues to action** negative 72 43.9 92 56.1 7.103 (4.40-11.45) 0.001a positive 189 84.8 34 15.2 note. achi-square test; **reference for multivariate analysis 3.3. the most dominant subscales of perceptions relating to the acceptance of covid-19 booster vaccination table 5 illustrates the results of two steps of a multivariate analysis. from the step 1 analysis, it can be seen that perceived susceptibility and perceived severity should be removed as their pvalues were more than 0.05. step 2 analysis showed that perceived benefits, perceived barriers, and cues to action were significantly related to the acceptance of covid-19 booster vaccination. however, cues to action were the most dominant subscales of covid-19 vaccination perception relating to the acceptance of covid-19 booster vaccination (or=5.265; 95%ci=3.073-9.022; p<0.001). it means that respondents who had action cues were 5.265 times more likely to accept the covid-19 booster vaccination. table 5. the most dominant subscales of perceptions relating to the acceptance of covid-19 booster vaccination variable b se or (ci 95%) p step 1 perceived susceptibility 0.208 0.299 1.231 (0.686-2.211) 0.486* perceived severity 0.540 2.289 1.715 (0.974-3.201) 0.062* perceived benefits 1.093 2.275 2.984 (1.742-5.113) 0.001* perceived barriers 1.637 2.276 5.142 (2.991-8.838) 0.001* cues to action 1.590 2.292 4.904 (2.765-8.696) 0.001* step 2 perceived benefits 1.100 0.274 3.003 (1.754-5.145) 0.001* perceived barriers 1.636 0.276 5.135 (2.989-8.822) 0.001* cues to action 1.661 0.275 5.265 (3.073-9.022) 0.001* note. *backward lr method 4. discussion this study aimed to determine the relationship between the perception of covid-19 vaccination based on the health belief model (hbm) and the acceptance of the covid-19 booster vaccination in the community. the results found that most respondents accepted covid-19 booster vaccination, and they had positive perceptions of covid-19 vaccination in all subscales. there were significant relationships between all perception subscales of covid-19 vaccination and the acceptance of covid-19 booster vaccination, even though the action cues subscale was found to be the most dominant factor relating to the acceptance of covid-19 booster vaccination. nurse media journal of nursing, 13(1), 2023, 127 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 the finding showed that most respondents accepted covid-19 booster vaccination. this finding was similar to a study by lai et al. (2021), reporting that a relatively high covid-19 booster vaccination acceptance was obtained in china. this acceptance level was also in accordance with the presence of a new variant of covid-19 and a moderate resurgence of cases ongoing, emphasizing the importance of booster doses of the covid-19 vaccine and the durability of the effects of the covid-19 booster vaccine on the omicron variant. compared to the acceptance of covid-19 primary vaccination, the acceptance of covid-19 booster vaccination was lower in wang et al. (2020)’s study, although it was higher in vebrielna (2021)’s study. the higher level of acceptance of the covid-19 booster vaccination was influenced by high public expectations with the provision of the covid-19 booster vaccination during the transmission of the new covid-19 virus variant (lai et al., 2021). acceptance is a person's willingness to be aware of a phenomenon in the environment based on conditions of passive acceptance of a problem or situation (bloom et al., 1956, as cited in arumsari et al., 2021). the factors that influence the acceptance of the covid-19 booster vaccination can be affected by age, gender, marital status, education level, and sources of information, as well as other demographic factors (al-mohaithef & padhi, 2020; burke et al., 2021; lasmita, 2021; wang et al., 2020). adults show high vaccination acceptance. this is influenced by knowledge and maturity in thinking (wang et al., 2020). this study's result also confirmed the claim, reporting that most respondents were adults. in another study, women reported more associations with unexpected events with the covid-19 vaccine, but women were more proactive in accepting the covid-19 vaccine (mondal et al., 2021). this is in line with the result of this study which showed that the majority of the respondents were female. the level of education is one of the benchmarks for the community toward accepting covid-19 vaccination, where 16% of the reasons for respondents' refusal are lower levels of education (paul et al., 2021). the efficacy of communication and information technology is one of the vital needs for the community, which has a broad impact on the need for access to information in the community (zonneveld et al., 2020). based on the results of the study, the acceptance of covid-19 booster vaccination was related to all perception subscales of covid-19 vaccination based on the health belief model (hbm), namely perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action. this study reported that there was a significant relationship between perceived susceptibility and the acceptance of covid-19 booster vaccination. people with a positive perception of susceptibility would likely accept the booster vaccines. this result was supported by (wong, wong et al., 2020), stating that when there are concerns about the possibility of contracting covid-19, people will think that they are at high risk of contracting covid-19. this condition is characterized by feelings of being at risk or being vulnerable. according to rosenstock (1874) in glanz et al. (2015), perceived susceptibility occurs when persons believe that they are vulnerable or at risk of contracting a disease. the greater the risk of contracting the disease, the greater the preventive behavior to reduce the risk. when the risk of disease arises, more and more preventive behaviors are better carried out by people unless for those who are contracting covid19 and who have comorbidities that underlie risk conditions (lai et al., 2021). a previous study claims that perceived susceptibility refers to the chance that there is a high risk of contracting the disease (neumann et al., 2020). neumann et al. (2020) stated that a person’s exposure starts from the extent to which they believe that they have a chance of contracting covid-19. this statement was supported by wong, wong et al. (2020). the researchers point out that the vulnerability experienced by people depends on the extent to which they believe that they are at risk of contracting covid-19 if they receive the vaccine. however, this result was different from a previous study. the study reported that 35 respondents (72.9%) who were found to be vulnerable to contracting covid-19 did not accept the covid-19 vaccine. this is because the respondents who felt vulnerable to contracting covid-19 did not want to be vaccinated due to a lack of information related to covid-19 disease (liaumin et al., 2021). this study found that there was also a significant relationship between perceived severity and the acceptance of covid-19 booster vaccination. people with positive perceived severity tend to accept the covid-19 booster vaccination. in accordance with the hbm, which states that the more serious the impact caused by a disease, the greater the urge to take precautions. the perception of the severity of contracting covid-19 was related to the intention to accept the covid-19 booster vaccine (lai et al., 2021). a previous study found that a positive perceived severity was one of the factors that influenced the respondent's request to accept the covid-19 nurse media journal of nursing, 13(1), 2023, 128 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 vaccine (erawan et al., 2021). people have a solid vulnerability to the risks derived from the severity of contracting covid-19 when they are about to accept a covid-19 vaccination (zampetakis, 2021). perceived severity is an individual's subjective perception of how serious the consequences of the illness he suffers are. the more serious the threat of disease, the stronger a person's urge to take preventive action or avoid the danger (glanz et al., 2015) in addition to the result of this study, perceived benefits had a significant relationship with the acceptance of the covid-19 booster vaccination in individuals. this result was in line with studies by lin et al. (2020) and shmueli (2021), which reported that there was also a relationship between high perceptions of the benefits of covid-19 vaccination and increased acceptance of covid-19 vaccinations. people can understand the benefits of booster vaccination resulting in a positive perception that affects the intention to accept vaccination (lai et al., 2021). the perception of benefits or a person's belief that the preventive actions he takes provide benefits for his health condition can reduce the risk of developing a disease (glanz et al., 2015). the perceived barrier subscale in this study was significantly related to the acceptance of covid-19 booster vaccinations. this result is in line with a previous study which stated that respondents with perceived barriers doubted the effectiveness and safety of the covid-19 vaccine (wong, alias et al., 2020). barriers can be related to vaccination inconveniences such as access, cost, and time with negative results in accepting covid-19 vaccinations (burke et al., 2021). for someone who has a history of hypertension and diabetes, this condition will bring up more severe clinical manifestations, resulting in some obstacles to vaccination (liu et al., 2020). the hbm explains that someone with a high perception of barriers will have a lower tendency to take preventive action. in other words, if people have increased perceived barriers, they tend to commonly accept covid-19 vaccination (glanz et al., 2015). apart from the other subscales, cues to action subscales were not only significantly related to but also were the most dominant factor relating to the acceptance of covid-19 booster vaccination. people who had action cues were 5.265 times more likely to accept the covid-19 booster vaccination. this result is supported by a previous study reporting that the cue to act was a significant predictor of the acceptance of the covid-19 vaccine (shmueli, 2021). information aligns with good knowledge to affect the action (al-mohaithef et al., 2020). it is linked to the easiness of finding the correct information about the covid-19 booster vaccination through the mass media and health workers. providing the correct information to the public is focused on providing confidence about vaccine safety to achieve high vaccine acceptance (karlsson et al., 2021). the support provided is a form of encouragement to help individuals solve a problem or motivation to carry out specific actions (yazia et al., 2020). the action cues subscale in the hbm is influenced by perceived vulnerability and benefits. other factors can only potentiate in the form of environmental events that trigger actions (glanz et al., 2015). 5. implications and limitations this research has implications for nursing and health policies to maintain the health behavior of indonesian people during the covid-19 pandemic. primary prevention or prevention through education is one of the roles of nursing in improving public health status, which urgently needs to be intervened during the covid-19 pandemic. understanding the relationship between covid-19 vaccination perceptions based on the health belief model (hbm) in the community and the acceptance of covid-19 booster vaccination means that applying a multidisciplinary and multifaceted approach is very important. for example, the collaboration between clinical nursing and community nursing forms an interdisciplinary health team that provides health services that can provide a platform for education and vaccination service providers, using online and offline counseling platforms, and health screening, especially in vulnerable groups, before carrying out a covid-19 booster vaccination. there are some limitations of this study. first, the total primary dose of covid-19 vaccination recipients was mixed with vaccine recipients from various regions other than the health center where the study took place. second, the questionnaire used in this study had not been psychometrically tested as a qualified instrument, so it was likely to affect the results of the study. in addition, the hbm perception questionnaire could not measure the overall relationship to each component, so this study could only find the relationship between each subscale of the perception and the acceptance of the booster vaccination. nurse media journal of nursing, 13(1), 2023, 129 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 6. conclusion the findings concluded that public perceptions based on the hbm related to the acceptance of the covid-19 booster vaccination in the community. the five subscales of the covid-19 vaccination perceptions (perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action) showed positive results that related to the acceptance of the covid-19 booster vaccination. the most dominant factor related to the acceptance of covid19 booster vaccination was cues to action. this study recommends future research to look at the latest phenomena that have occurred because the conditions of the covid-19 outbreak along with the covid-19 vaccination program are currently still running and carry out a psychometric study for the instrument used in this study. for clinical practice, this research can be developed by surveying patients who have comorbidities. acknowledgment the researchers express their gratitude to all participants who were involved in the research and took their time. the team also would like to thank the community leaders, all the staff of patrang health centre, and all related sub-district officers who helped the team in searching for research participants and for assisting with research needs. a great gratitude was also conveyed to the academic educational institutions of the faculty of nursing, universitas jember, for their support. author contribution repakd: conceptualization, design analysis of data collection, interpretation of results, manuscript preparation. repa, jhs, and an: confirming the 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(2021). the health belief model predicts vaccination intentions against covid 19 : a survey experiment approach. international association of applied psychology, february, 1–16. https://doi.org/10.1111/aphw.12262 copyright © 2023 nmjn. this article is an open-access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). https://creativecommons.org/licenses/by-sa/4.0 nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://medianers.undip.ac.id 13(1):1-11, april 2023 https://doi.org/10.14710/nmjn.v13i1.49896 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 original research filipino nursing students’ health promoting behaviors during pandemic ma. prestige leudouel j. diana1, francesca g. cercado1, pearl zerrha t. chiu1, ma. pamela andrea d. de justo1, april rhose c. de silva1, ryan michael f. oducado1 1college of nursing, west visayas state university, philippines article info abstract article history: received: 29 october 2022 revised: 28 february 2023 accepted: 2 march 2023 online: 30 april 2023 keywords: lifestyle; nursing; pandemic; philippines; students corresponding author: ryan michael f. oducado college of nursing, west visayas state university, philippines email: rmoducado@wvsu.edu.ph background: research on health promoting behaviors can assist nursing students in identifying, maintaining, and improving health behaviors. the notable impact and changes in lifestyle behaviors during the pandemic necessitate a closer look into students’ health-promoting behaviors. however, there is a lacuna in the literature about health promoting activities of nursing students stuck at home and attending online learning during the pandemic. purpose: this study assessed the level and predictors of health promoting behaviors of nursing students in a philippine public university during a pandemic. methods: this study used a cross-sectional design with 363 out of 531 undergraduate nursing students of a public university in the philippines as study participants. data were gathered using an online survey last march 2022 employing the health promoting lifestyle profile (hplp) ii. significant predictors were identified using multiple linear regression analysis with the aid of spss version 26.0. results: results showed that nursing students had a high (m=2.80 out of 5) practice of health promoting behaviors. physical activity ranked the lowest among the six dimensions of health promotion behaviors. the variables that predicted the health promoting behaviors of nursing students were self-reported academic performance (β=2.110, p=.000), family income level (β=.055, p=.001), and academic year level (β=.057, p=.002). conclusion: nursing students should continue to maintain their good practice of health promoting behaviors. however, more attention should be given to engaging in physical activity to maintain holistic well-being. how to cite: diana, m. p. l. j, cercado, f. g., chiu, p. z. t., de justo, m. p. a. d., de silva, a. r. c., & oducado, r. m. f. (2023). filipino nursing students’ health promoting behaviors during pandemic. nurse media journal of nursing, 13(1), 1-11. https://doi.org/10.14710/nmjn.v12i3.49896 1. introduction healthy lifestyle promotion is an important factor of health status (almutairi et al., 2018; wei et al., 2012). health promotion combines educational, social, and environmental efforts to promote healthy lifestyles and habits (kim & kim, 2018). it is designed to aid people in achieving their full potential in terms of physical, mental, social, and spiritual health (kim & kim, 2018; shariferad et al., 2013). moreover, health promoting behaviors involves a positive living approach and a way of boosting well-being and increasing self-actualization (nassar & shaheen, 2014; wang et al., 2009). health promoting behavior is an ever-present factor in the lives of university students, many of whom have varying lifestyles and practices (al-momani, 2021; almutairi et al., 2018; ashgar, 2021). individuals can choose whether they want to improve their lifestyles and have several methods or means they can choose from (national institute of health, 2021). health promoting behaviors, especially those of students, have been researched many times throughout the years, and studies found that those with good health promoting behaviors have better healthy lifestyles (al-momani, 2021; hwang & oh, 2020). with the advent of the covid-19 pandemic, restrictions, and quarantine practices were implemented to control and prevent the spread of the covid-19 virus (mattioli et al., 2020). the pandemic has impacted all sectors, including nursing education (agu et al., 2021). as the crisis worsened, many governments shut down schools, colleges, and institutions to protect students, teachers, and their countries (schleicher, 2020). as a means of maintaining and safeguarding the overall health of students and teachers, traditional in-person classes, skills laboratories, and https://crossmark.crossref.org/dialog/?doi=10.14710/nmjn.v13i1.49896&domain=pdf&date_stamp=2023-04-30 nurse media journal of nursing, 13(1), 2023, 2 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 student clinical or hospital placement were either suspended or restricted when the pandemic broke out and education shifted to online mode (agu et al., 2021; oducado & soriano, 2021). meanwhile, multiple studies have already been conducted related to the health promoting behaviors of university students in pre-pandemic conditions (e.g., al-momani, 2021; alzahrani et al., 2019; ashgar, 2021; fashafsheh et al., 2021; hosseini et al., 2014; hwang & oh, 2020; polat et al., 2016), particularly nursing students, and the factors affecting it. mixed results were found with other studies reporting high (hosseini et al., 2014), while others disclosing only moderate levels (fashafsheh et al., 2021; farokhzadian et al., 2018; polat et al., 2016) of health promoting behaviors. however, to the researchers’ best knowledge, there is a lacuna in published literature touching on the health promoting behaviors of nursing students in the pandemic setting. covid-19 dramatically impacted lifestyle behavior (azzouzi et al., 2022). a closer look at the lifestyle of students is necessary as lifestyle is considered a key factor for the onset and course of diseases (van der werf et al., 2021). results of studies among the general population and university students conducted elsewhere indicated changes in the lifestyle during the pandemic, such as physical inactivity, faulty eating patterns, and increased mental stress (gadi et al., 2022; li et al., 2021; singh et al., 2021). online classes and restrictions related to quarantine inhibited students from practicing self-care and good health habits during the worldwide health crisis (cleofas, 2021). during this research, the students were still living within the pandemic context. previous studies have not touched on health promoting activities of nursing students stuck at home and attending online learning during the pandemic. it must be noted that while the survey was done towards the end of the pandemic and there was already some relaxation with covid19-related restrictions in other parts of the world, the conditions in which the study was conducted have not returned to its pre-pandemic state. also, students in this study have not yet returned to on-campus instruction. meanwhile, walker et al. (1987) identified six lifestyle behaviors that promote health. these include health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management. the health promotion model (walker et al., 1987) assumes that demographic or personal characteristics may influence health promoting behaviors. differentiation of behaviors that promote health by certain demographic constructs may help identify vulnerable student cohorts that may be targeted for health programs and interventions (muller et al., 2022). it is argued that university life of students can be a crucial time in promoting the good and changing the unhealthy lifestyle behaviors of students (cetinkaya & sert, 2021). given that the majority of lifelong good and ill lifestyle behaviors are formed throughout adolescence and continue to affect health even after early adulthood, it is critical to establish good health-related habits and disease prevention measures for teenagers and young adults (fish & nies, 1996; musavian et al., 2014). furthermore, the researchers recognized that it is vital to support students in developing and adopting behaviors that will maintain, improve and preserve their health and well-being and assist them in making sound health decisions (ross et al., 2017). nurses recognize the importance of a healthy balanced diet, stress management, adequate sleep, physical activity, and healthy relationships; this understanding, however, may not convert into self-care for nurses as they may not adhere to suggested physical activity and nutrition requirements (ross et al., 2017). the same can be said about nursing students, especially if they are overburdened with assignments and classes (chaabane et al., 2021). as healthcare professionals in the future, nursing students have a vital role in public health for others and their own well-being and fitness (hwang & oh, 2020). therefore, this study focused on how several factors involved in the lives of undergraduate nursing students affect their practice of health promoting behaviors, especially during the pandemic. the result of this study, based on student responses, could help inform university policymakers on ways to create healthier campuses, especially in nursing colleges. hence this research was conducted to assess the level of practice and significant predictors of the health promoting behaviors among undergraduate nursing students during a pandemic. 2. methods 2.1 research design this study was completed through the use of a descriptive cross-sectional research design. nurse media journal of nursing, 13(1), 2023, 3 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 2.2 setting and samples a complete or total enumeration was utilized in the study, wherein the acceptable response rate is 60% and above (bennett et al., 2011; fincham, 2008). all 531 undergraduate students from levels one to four of a public college of nursing in the philippines were invited to participate in the study. the college offers a four-year baccalaureate degree program and is the only public university within the province of iloilo. out of 531 students, 363 responses (68.36%) responded. a-priori sample size using g*power (kang, 2021) for multiple regression with eight and nine predictors, .80 desired statistical power, and .15 anticipated effect size only requires a minimum sample of 108 and 113, respectively. the subjects included in this study were officially enrolled students of the college in the second semester of 2022 and were willing to participate in the study. the five students who were part of the research team of this present investigation were excluded. 2.3 measurement and data collection data collection was done through a two-section questionnaire. the instrument was administered in the english language as the medium of instruction in philippine nursing schools is english. the first part included six socio-demographic questions (gender, academic year level, family income level, presence of medical condition, location of residence, and the number of people in the household) as well as the perceived academic performance of the student, covid19 infection history, and covid-19 vaccination status. the second part consisted of the health promoting lifestyle profile (hplp) ii questionnaire (walker et al., 1987). the researchers had permission to download and use the hplp ii for non-commercial data collection purposes. the hplp ii tool consists of 52 items categorized into six subscales: health responsibility (9 items), physical activity (8 items), nutrition (9 items), spiritual growth (9 items), interpersonal relations (9 items), and stress management (8 items). a likert-type scale was used to measure each behavior, with ranges of never (1), sometimes (2), often (3), and routinely (4). the following scale of means based on the work of beliran and legaspi (2014) was followed for the interpretation of this study: very low (1.00-1.50), low (1.51-2.50), high (2.51-3.50), and very high (3.51 4.00). hplp ii had a content validity index of 1.00 and a cronbach’s alpha result of .83 (tejada, 2019). in addition, the researchers have also tested the internal consistency of the instrument based on the actual data and revealed that the results of cronbach’s alpha were the following: .81 for health responsibility, .85 for physical activity, .71 for nutrition, .86 for spiritual growth, .80 for interpersonal relations, .78 for stress management and .94 for the entire scale. to gather data, the researchers secured permission and approval from the office of the dean and the respective division chairpersons per year level to conduct the study last march 2022. afterwards, the chairpersons of the student curriculum of each level were asked to contact the class chairpersons of each section through messenger or email. they were requested to post the link in their respective class facebook group chats or group pages. the students were encouraged to forward the link to their classmates through messaging or emailing apps to maximize the response rate. to ensure that only the study participants were given access to the survey link, the google forms were restricted to university users and were only distributed to college students included in the study. the link included the electronic informed consent. the participants had to click on the box that stated their voluntary participation. then they had to click “next” to be directed to the research survey questionnaire. when the expected response rate was reached, the participants’ responses were monitored, consolidated, and organized using google sheets. the data was then classified, tallied, interpreted, and processed. 2.4 data analysis statistical computations were calculated using ibm spss version 26. data were described using descriptive statistics. a test for normality of data distribution using the kolmogorov smirnov test was done. the t-test for independent samples and one-way anova were used to test the difference between categories of the independent variable. multiple regression analysis (step-wise) was employed to identify significant predictors. the significance level was set at .05 alpha. 2.5 ethical considerations the researchers submitted this study to the west visayas state university unified research ethics review committee (urerc), and it was approved with urerc protocol number nurse media journal of nursing, 13(1), 2023, 4 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 wvsu.urerc-2022.cons_001. electronic informed consent was used, and the participants were allowed to withdraw from the study without feeling obligated to continue. moreover, there were no repercussions for those who did not participate since this was not a mandatory survey. the consolidated data were only made accessible to the researchers. 3. results 3.1 profile of participants a total of 363 responses were included in this analysis. it can be gleaned from table 1 that the majority of the participants were female (71.6%), from the lower middle-income class (28.4%), had four (4) or less number of family members in the household (49.0%), residing in towns (52.9%), have average academic performance (81.0%), reported no medical condition (77.7%), and have not been infected with covid-19 (88.4%). almost all (99.2%) are fully vaccinated. there were nearly an equal number of students per year except for level iv (20.4%). table 1. profile of participants (n=363) profile f % gender male 103 28.4 female 260 71.6 year level level i 94 25.9 level ii 95 26.2 level iii 100 27.5 level iv 74 20.4 family income level poor to low-income 87 24.0 lower middle-income 103 28.4 middle middle-income 87 24.0 upper middle-income 47 12.9 upper-income to rich 39 10.7 number of family members in household currently not living with family members 21 5.8 4 or less 178 49.0 5 or more 164 45.2 medical condition no 282 77.7 yes 81 22.3 location of residence city 171 47.1 town 192 52.9 academic performance failing 3 .8 below average 47 12.9 average 294 81.0 above average 19 5.2 vaccination status fully vaccinated 360 99.2 partially vaccinated 2 .6 unvaccinated 1 .3 covid-19 status no 321 88.4 yes 42 11.6 3.2 level of health promoting behaviors table 2 shows that the majority (73.8%) had a high level of overall health promoting behaviors with a mean score of 2.80 (sd=.40). in terms of subscales, interpersonal relations (m=3.18, sd=.46) had the highest mean, followed by spiritual growth (m=3.11, sd=.53), stress nurse media journal of nursing, 13(1), 2023, 5 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 management (m=2.79, sd=.50), health responsibility (m=2.63, sd=.54), and nutrition (m=2.56, sd=.46). meanwhile, physical activity (m=2.47, sd=.65) had the lowest mean. table 2. level of health promoting behaviors of nursing students (n=363) level very low low high very high m sd f % f % f % f % overall hpb 2 .6 80 22 268 73.8 13 3.6 2.80 .40 interpersonal relations 1 .3 24 6.6 243 66.9 95 26.2 3.18 .46 spiritual growth 4 1.1 40 11.0 229 63.1 90 24.8 3.11 .53 stress management 5 1.4 109 30.0 228 62.8 21 5.8 2.79 .50 health responsibility 8 2.2 139 38.3 193 53.2 23 6.3 2.63 .54 nutrition 4 1.1 167 46.0 187 51.5 5 1.4 2.56 .46 physical activity 29 8.0 176 48.5 138 38.0 20 5.5 2.47 .65 3.3 differences in health promoting behaviors table 3 shows the differences in health promoting behaviors of nursing students using t-test for independent samples and anova. results of statistical analysis revealed that there was a significant difference in the overall health promoting behaviors of nursing students when grouped according to academic year level (f=3.817, p=.010), family income level (f=2.773, p=.027), and self-reported academic performance (f=12.473, p=.000). table 3. differences in health promoting behaviors of nursing students (n=363) profile m sd test statistics p-value gender -1.875 .062 male 2.86 .46 female 2.77 .38 year level 3.817 .010* level i 2.73 .41 level ii 2.76 .41 level iii 2.79 .39 level iv 2.93 .39 family income level 2.773 .027* poor to low-income 2.70 .41 lower middle-income 2.77 .39 middle middle-income 2.82 .43 upper middle-income 2.90 .38 upper-income to rich 2.88 .36 number of family members 1.801 .167 currently not living with family 2.94 .39 4 or less 2.77 .42 5 or more 2.81 .39 medical condition -.681 .496 no 2.79 .40 yes 2.82 .42 location of residence -.115 .909 city 2.79 .44 town 2.80 .37 academic performance 12.473 .000* failing to below average 2.56 .43 average 2.82 .39 above average 2.99 .33 covid-19 status -1.508 .132 no 2.78 .41 yes 2.88 .37 *p<.05 nurse media journal of nursing, 13(1), 2023, 6 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 4. predictors of health promoting behaviors table 4 shows that multiple regression analysis using step-wise method revealed that selfreported academic performance (β=2.110, p=.000), family income level (β=.055, p=.001), and academic year level (β=.057, p=.002) were significant predictors of nursing students’ health promoting behaviors accounting for 11.4% of the variance. table 4. regression analysis of health promoting behaviors (n=363) model β coefficients t p-value (constant) 2.110 20.336 .000* academic performance .213 4.827 .000* family income level .055 3.474 .001* year level .057 3.045 .002 gender .073 1.465 .144 number family members .000 .010 .992 medical condition .033 .658 .511 location of residence .052 1.028 .305 covid-19 status .038 .756 .450 note: r2 = .114; f = 15.370; p = .000 4. discussion this study assessed the level of practice and significant predictors of health promoting behaviors among undergraduate nursing students during a pandemic. this study demonstrated that self-reported academic performance, family income level, and academic year level significantly predicted nursing students’ health promoting behaviors. in this study, the majority of nursing students have not been diagnosed or experienced being infected with covid-19. this may be due to the students and community members’ strict implementation of safety precautions (tuppal et al., 2021). a study by rabacal et al. (2022) indicated that higher education students from western visayas region of the philippines generally had a high practice of covid-19 preventive measures. nursing students were concerned about their well-being and their families during the pandemic (barrett, 2022) and thus practiced covid-19 preventive measures to reduce the chances of acquiring the disease. the suspension of face-to-face teaching and learning and clinical experiences may also have benefited nursing students, reducing the chances of covid-19 transmission (agu et al., 2021; oducado & soriano, 2021). it is also significant to note that nursing students in this study had very high covid-19 vaccination rates. based on their background in nursing, nursing students could understand the necessity, effectiveness, and safety of the covid-19 vaccine, as evidenced by their willingness to get the vaccination (jiang et al., 2021). furthermore, the study of oducado et al. (2022) disclosed that nursing students highly intend to attend face-to-face classes. during data collection, only vaccinated students of higher education institutions were allowed to join limited face-to-face classes. in this study, while very high practice was deemed most desirable, the health promoting behaviors of student nurses were still found to be high. this result is similar to the study of hosseini et al. (2014), which showed that tehran-based nursing students’ health promoting behaviors scored high. on the contrary, studies conducted by fashafsheh et al. (2021) in palestine, polat et al. (2016) in turkey, and farokhzadian et al. (2018) in iran showed that nursing students had a moderate degree of health promotion. the variation with other related studies and this research may be due to how the mean was interpreted as the interpretation of a “moderate” corresponds to “high” in terms of this study’s scale of means. nevertheless, it is noteworthy that nursing students practice health promoting behaviors to a moderate to a great extent, although improvements can also still be made. moreover, in this study, the overall mean score was highest in the subscale of interpersonal relations. this could be due to the students spending most of their time with their classmates, who are also their friends, even on the online platform. also, the school and the college provide a range of extracurricular activities that could strengthen student camaraderie despite the virtual setup. the relationships among nursing students are recognized by them as being crucial to their nurse media journal of nursing, 13(1), 2023, 7 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 learning in clinical practice, as a forum for their feelings of safety and decreased anxiety while learning together. peer learning has shown positive experiences when the students support each other in knowledge development (holst et al., 2017; stenberg & carlson, 2015). in addition, spiritual growth was also rated high by the respondents. this could be attributed to the educational institution, which offers a wide range of spiritual formation activities such as regular masses and recollections, including the various religious organizations open to nursing students. this result is similar to the study by tejada (2019) in the philippines, which showed that among 118 regular nursing students, the highest means were spiritual growth and interpersonal relations. moreover, other studies by alzahrani et al. (2019) among medical students in saudi arabia, fashafsheh et al. (2021) among nursing students in palestine, polat et al. (2016) among nursing students in turkey, farokhzadian et al. (2018) among nursing and midwifery school in iran, hosseini et al. (2014) among nursing students in tehran, shaheen et al. (2015) among university students in jordan, and al-momani (2021) among medical students in saudi arabia revealed that the greatest mean in the spiritual growth dimension. on the other hand, physical activity had the lowest mean that was reported in this study. it is significant to note that 48.5% had low and 8.0% had very low physical activity. other studies conducted pre-pandemic by alzahrani et al. (2019), cetinkaya and sert (2021), farokhzadian et al. (2018), fashafsheh et al. (2021), hosseini et al. (2014), polat et al. (2016), and shaheen et al. (2015) showed that physical activity similarly had the lowest mean. fashafsheh et al. (2021) explained that regular exercise routines still need to be fully absorbed into daily life as leisure activities. during the pandemic, accessing sports equipment and facilities was challenging due to lockdowns and restrictions on physical mobility. also, with the advent of the pandemic and online classes, students spend most of their time in front of their computers and gadgets (oducado et al., 2021), further limiting their physical activity. other variables that may hinder physical activity include poor time management and a disregard for the negative effects of immobility (thivel et al., 2018). this study demonstrated that year level predicted the overall level of practice of health promoting of nursing students. post-hoc analysis revealed that level iv or senior students had significantly higher overall health promoting behaviors than level 1 or first-year (p=.008) and level 2 or second-year (p=.040) students. similarly, the study of polat et al. (2016) found that the mean total score of fourth-year students was significantly higher than the other year levels. a significant difference in health promoting behaviors based on the academic level was also noted in other studies conducted elsewhere (cetinkaya & sert, 2021; muller et al., 2022). and while some scholars pointed out that sedentary lifestyle tends to increase with age especially after early adolescence (tamanal & kim (2020), it may also be that students in higher academic year levels have acquired more valuable information about the importance of practicing healthy lifestyle and deleterious health outcome of sedentary behavior. college students’ drive to modify their lifestyle by gaining additional health knowledge while studying health-related courses may be one factor (mašina et al., 2017). these may help explain why higher academic levels have better health behaviors than those in the lower academic years. also, this study found that the practice of health promoting behaviors of nursing students was influenced by family income. post-hoc analysis revealed that the upper middle-income class had significantly higher overall health promoting behaviors than the poor to low-income class (p=.046). this finding is supported by the study of shaheen et al. (2015), whose findings indicated a statistically significant positive association between monthly family income and the average score on all subscales of health promoting behaviors among university students in jordan. socioeconomic variation in healthy lifestyle was also noted among university students in europe (cicchella et al., 2022). in addition, ashgar (2021) also found that among adults in saudi arabia, those with stable income were more likely to adopt one or more of the health promoting behaviors. the study of nacar et al. (2014) also noted that health promoting behaviors were higher for those with better economic situations among medical students in turkey. money directly influences health through the services and goods people purchase, either helping or harming their health. finally, this study demonstrated that perceived academic performance predicted the overall level of practice of health promoting behaviors of nursing students. results reveal that those with above-average academic performance (p=.000) and average academic performance (p=.000) had significantly higher overall health promoting behaviors than those with failing to below-average academic performance. this finding is supported by the studies of heidari et al. (2017) and nurse media journal of nursing, 13(1), 2023, 8 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 tamanal & kim (2020), wherein academic performance was positively related to a healthier lifestyle: the higher the academic achievement, the more the student practices a health promoting lifestyle. students with high academic performance have lifestyle habits that positively affect their health, including lessening their screen time, regular eating and sleeping schedules, and decreased social media use (dubuc et al., 2019). habits that promote the students’ academic performance could also promote their well-being. high academically performing students know how to plan effectively, pay attention to their schedules, set attainable goals, and know when they need activity and rest. 5. implications and limitations the study results provide several important implications concerning the practice of health promoting behaviors of nursing students. since health-related habits continue to affect health after early adulthood, establishing positive health behaviors among college-age students is crucial since altering behavioral patterns in early adulthood is easier. it is vital to identify the level and factors influencing health promoting behaviors to improve and encourage health promoting behaviors among college students. future healthcare practitioners, such as nursing students, will be crucial in educating patients on good lifestyle choices and serving as role models for healthy living. nursing students must maintain and promote their personal and professional health. the study findings will also be instrumental in designing and implementing strategies and programs to promote students' health and exploring modification of school policies and environments to help students maintain and encourage their practice of health behaviors. this study has limitations. the study only focused on the practices of health promoting behaviors reported by nursing students with respect to the six subscales of the hplp ii. the study was limited to undergraduate nursing students in one nursing college in the philippines. the conclusions drawn from this study cannot be extended to other nursing students who are not included in the sample. furthermore, because this study utilized a descriptive cross-sectional design, it could not infer causality between variables or follow changes over time. given the use of online survey questionnaires, self-report bias, subjectivity, and social desirability were also limitations of this study. this study only included selected predictors, and there may also be other factors that may influence health promoting behaviors not included in this study. 6. conclusion this study highlights that while nursing students frequently incorporate health promoting behaviors into their lifestyle, they still seldom engage in physical activities, and regular exercise routines are still not fully integrated into daily activities. also, this study underscores that certain personal characteristics, such as perceived academic performance, academic year level, and family income influence nursing students’ health-promoting behaviors. nursing students should continue to maintain their health-promoting behavior, and focus should be given to incorporating any form of physical activity into their daily schedule to keep active and maintain holistic wellbeing. acknowledgment we thank dr. rosana grace b. delariarte and dr. ben remor e. inventor for the financial help extended when we presented this study during the international conference of nurses. author contribution all authors contributed substantially to the study design, data collection, analysis, and interpretation of results. all authors drafted and revised the article, approved the published version, and agreed to be accountable for all aspects of the work. conflict of interest authors declare no conflict of interest. references agu, c. f., stewart, j., mcfarlane‐stewart, n., & rae, t. 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(2012). assessment of health-promoting lifestyle profile in japanese university students. environmental health and preventive medicine, 17, 222-227. https://doi.org/10.1007/s12199-011-0244-8 copyright © 2023 nmjn. this article is an open-access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). https://doi.org/10.1016/j.aorn.2016.12.018 https://creativecommons.org/licenses/by-sa/4.0 nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://medianers.undip.ac.id 12(3):452-465, december 2022 https://doi.org/10.14710/nmjn.v12i3.47082 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 review anatomical points of cupping therapy for musculoskeletal pain: a systematic review aris setyawan1, isma nur hikmah1, eka oktavianto1, i made moh. yanuar saifudin1 1nursing study program, stikes surya global, yogyakarta, indonesia article info abstract article history: received: 21 june 2022 revised: 20 december 2022 accepted: 22 december 2022 online: 28 december 2022 keywords: anatomical points; cupping therapy; musculoskeletal pain corresponding author: i made moh. yanuar saifudin nursing study program, stikes surya global, yogyakarta, indonesia email: yanuar.ikadek@stikessuryaglobal.ac.id background: the prevalence of musculoskeletal pain is rising and plays a substantial role in disease and disability worldwide. there have been several previous studies on cupping therapy’s effectiveness in reducing musculoskeletal pain. however, studies that specifically review the literature on cupping points to reduce musculoskeletal pain are lacking. purpose: this study aimed to identify the anatomical points of cupping therapy for musculoskeletal pain. methods: a systematic review was employed. pubmed, sciencedirect, and google scholar were used for the search process. the screening was performed based on inclusion and exclusion criteria. crowe critical appraisal tool (ccat) was used to measure the quality of the articles. standardized forms were used to extract essential characteristics from articles, including study design, participant and sample, and results. data were narratively analyzed for thematic synthesis. results: from a total of 1,045 articles acquired, eight articles were included in data synthesis. all articles were randomized control trials (rct) design. seven regions of cupping points were identified, including upper-middle-lower fibres of the trapezius muscles, the inter-scapular area around the 2-4th vertebrae torachalis, the sacrum area, between the lower vertebrae and the coccyx bone, the 1-5th vertebrae lumbalis, the 3-5th vertebrae lumbalis, knee joint, and lower border of the spinous process of the second lumbar vertebra (l2). conclusion: seven anatomical points of cupping therapy for musculoskeletal pain were identified by this systematic review based on studies. single research could not define the whole range of advantages of each point. to support the previously described theories regarding cupping and develop new ones, future novel scientific studies are also required. how to cite: setyawan, a., hikmah, i. n., oktavianto, e., & saifudin, i. m. m. y. (2022). anatomical points of cupping therapy for musculoskeletal pain: a systematic review. nurse media journal of nursing, 12(3), 452-465. https://doi.org/10.14710/nmjn.v12i3.47082 1. introduction musculoskeletal pain is extremely prevalent and contributes significantly to worldwide disability and disease, with most countries reporting neck and low back pain as the primary cause of disability. the treatment of musculoskeletal pain often consists of a combination of physical therapy, self-management, and short-term analgesic medicine to improve function and control pain (babatunde et al., 2017; vos et al., 2017). cupping therapy is currently one of the conventional treatments frequently taught and used in the medical field to reduce musculoskeletal pain (micozzi, 2014). the growing body of research demonstrating cupping’s efficacy as a therapeutic intervention has led to its widespread use in complementary medicine (siregar et al., 2021). practitioners of both conventional and complementary medicine have employed cupping therapy for ages. recent research indicates that it might help treat pain-related disorders (aboushanab & alsanad, 2018). a study by stephens et al. (2022) reported that health professionals in the usa perform cupping as a typical supplemental therapy. health professionals are reported to use cupping to treat muscular discomfort, myofascial trigger points, and musculoskeletal pain. cupping therapy is a traditional medical treatment that dates back centuries and has been used in many countries and regions worldwide. dry-cupping and wet-cupping are the two primary subsets that fall under the umbrella term “cupping therapy”. the process of dry cupping involves applying a vacuum to various parts of the body to collect blood from that area without making any incisions in the skin. the method of using a vacuum at different points on the body in conjunction https://ejournal.undip.ac.id/index.php/medianers https://crossmark.crossref.org/dialog/?doi=10.14710/nmjn.v12i3.47082&domain=pdf&date_stamp=2022-12-28 nurse media journal of nursing, 12(3), 2022, 453 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 with incisions (small, light scratches made using a razor) is called wet cupping (or hijama in arabic). this method removes previously referred to as “harmful blood”, which refers to accumulated blood just beneath the skin’s surface (aleyeidi et al., 2015; mahdavi et al., 2012). east asian countries have utilized cupping therapy as a conventional treatment for several diseases since ancient times. cupping therapy is said to have begun in egyptian civilization (1550 bc), then spread to chinese culture, greek culture, the middle east, and today all seven continents. cupping therapy was first performed with hollow animal horns, which evolved into bamboo cups, eventually replaced by glass or plastic cups. prophetic medicine refers to the health and disease remedy knowledge derived from the prophet muhammad’s (570 ce) teachings, recommendations, and sayings (hadiths) (qureshi et al., 2018). ancient societies such as the early greeks and egyptians acknowledged the therapeutic possibilities of cupping therapy. initially, it was employed to treat diseases and pain; however, clinical experience has expanded its application to a broad spectrum of chronic conditions (rauf, 2019). health promotion, prevention, and treatment are among the many purposes for which cupping therapy has been employed. this therapy involves the placement of a suction cup to an acupoint, a particular spot of the skin. even though the exact mechanism of action is unknown, cupping therapy is routinely utilized to alleviate chronic pain (khan, 2017). cupping therapy has been demonstrated to be beneficial for lower back pain, neck and shoulder pain, headaches and migraines, knee pain, facial paralysis, brachialgia, carpal tunnel syndrome, rheumatoid arthritis, hypertension, and asthma (al-bedah et al., 2019; darmawan et al., 2017; setyawan, sari, et al., 2020). according to research, cupping can help individuals with low back pain caused by blood vessel spasms and muscle spasms to relax. therefore, cupping is useful for reducing pain, particularly on minor pain scales (al-eidi et al., 2019; parawansa et al., 2020). the location of cupping therapy is determined by the problem being treated. the back is the most common application site, followed by the chest, abdomen, buttocks, and legs. cupping can also be used to treat other body parts, including the face. the majority of cupping points are located in the head and neck region, back, front chest, abdomen, anterior, posterior, and sides of trunk, front of upper arms, front, rear, and sides of both legs, and feet; nevertheless, the dorsal side of the body contains the most cupping points (qureshi et al., 2017). there have been several previous studies regarding cupping to reduce musculoskeletal pain. hanan and eman (2013) published the results of their research where hijama can reduce the incidence of disability and lower back pain; however, the study did not entirely mention the cupping points used. research results by abdulaziz et al. (2021) proved the effectiveness of cupping points in the waist area in reducing pelvic pain in women. arslan et al. (2015) published the results of research on cupping points to treat neck and upper shoulder pain. both of these studies are experimental research, not a literature review. mohamed et al. (2022) conducted a literature review regarding cupping therapy for musculoskeletal and sports rehabilitation, but it did not discuss the points of cupping. concerning the results of the literature search that the researchers have conducted, there has not been a study that reviews the literature specifically regarding cupping points to reduce musculoskeletal pain. therefore, it is essential and valuable to do a literature review research on cupping points to alleviate musculoskeletal pain. this study aimed to identify the anatomical points of cupping therapy for musculoskeletal pain. 2. methods 2.1 research design a systematic review method based on the joanna briggs institute manual of evidence synthesis was employed. this study developed and synthesized representative literature to establish new frameworks and views on the issue. the process included (1) defining the purpose, (2) defining inclusion criteria, (3) defining the strategy for searching, selecting, and extracting articles, (4) analyzing evidence, (5) presenting results, and (6) summarizing the evidence (peters et al., 2020). 2.2 search method this systematic review utilized three databases for its literature search: pubmed, science direct, and google scholar. researchers used boolean operators to widen or restrict the literature searches with the following term: “cupping therapy”, “cupping treatment”, “cupping therapy nurse media journal of nursing, 12(3), 2022, 454 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 points”, and “cupping treatment points”. the databases were searched by four authors (as, inh, immys, and eo). 2.3 inclusion and exclusion criteria the inclusion criteria of the studies were (1) the articles related explicitly to cupping therapy, (2) the articles that discuss the anatomical points of cupping therapy for musculoskeletal pain, (3) original research articles (4) publications published between 2018-2021, (5) english-language articles, and (6) full-text availability. in addition, the articles with no specific research methodology, including the protocol, editorial, and narrative review, were excluded. 2.4 screening of articles three reviewers (as, immys, and inh) independently assessed all titles and abstracts of the articles obtained from the search method to identify papers that met the inclusion and exclusion criteria. in the event of disagreement, a fourth independent reviewer was engaged (eo). when studies covered subjects unrelated to the anatomical regions where cupping therapy was used, they were excluded from the full-text review. based on the inclusion and exclusion criteria, the findings and analysis from databases such as pubmed, google scholar, and sciencedirect were retained. 2.5 data extraction after the initial screening, the full text was obtained for further assessment. all authors together simultaneously extracted the data. a standardized form was used to extract essential characteristics from the articles, which were then extended into structured points, such as study design, participant and sample, and results. the synthesis outcomes are presented in table 1 (see appendix 1). 2.6 quality appraisal before the data extraction process, the crowe critical appraisal tool (ccat) review of the article was conducted to determine the viability of the article’s contents. there were eight categories and 22 items in the form. a category could have a maximum score of 5 and a minimum score of 0. the score was given based on the presentation of item descriptors. the more item descriptions checked, the higher the score obtained. however, the assessment was not only based on the item descriptors but also looked at the importance of each item being assessed. the appraisal process was entirely up to the appraiser’s judgement. the methodological quality was evaluated separately by two reviewers (eo and immys). through discussion with two other reviewers (as and inh), the findings were validated, and the requirements’ completion was determined. the total ccat score can be calculated as a percentage by calculating the sum of the eight category scores multiplied by a maximum score of five and dividing by 40. in addition, the ccat evaluation is conducted by considering the points of each category to prevent the assessment of research publications with a high overall score but a very low category score. if the scores for each category are not assessed, poor performance in one or more areas will be masked by the overall result (crowe, 2013). 2.7 data analysis a narrative method, specifically thematic synthesis described by purssell and gould (2021) was used to analyze the data. the characteristics of the articles, including the study design, participant and sample, and results were all taken into consideration while describing the research findings. every study was assessed by three reviewers (eo, inh and immys) who also noted every aspect of the articles under investigation. reviewers looked more closely at each individual study to see if it used the same language to describe the same aspects or if it used a different one. through this approach, a set of fundamental components was produced. each specific cupping points was then assessed once more to see if it fell into one of the categories or not. a fourth reviewer (as), who was a lead author, double-checked the earlier procedures. nurse media journal of nursing, 12(3), 2022, 455 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 3. results 3.1 literature search a total of 1,045 articles were initially acquired, after conducting duplication screening and a management reference system employing endnotes, left as many as one 1,038 articles. based on the title and abstract, 1,014 items were omitted from the records during the screening step because they did not meet the inclusion criteria. eight included articles were produced as a result of fulltext screening. the results and the flow of the search process are illustrated in figure 1 based on the preferred reporting items for systematic reviews and meta-analyses (prisma) 2009 flow diagram (liberati et al., 2009; moher et al., 2015). figure 1. literature search flow based on prisma guideline 3.2 risk of bias for the included studies according to the ccat results table for the eight articles, the overall average scores for each assessment category were in the good category. three articles were obtained a score of 92.5% (abdulaziz et al., 2021; al-eidi et al., 2019; mardani-kivi 2018), two articles were obtained a score of 90% (chiu et al. 2020; yang et al., 2018), one article obtained a score of 87.5% (islam et al., 2021), one article obtained score 85% (moura et al., 2021), and one article obtained a score of 65% (silva et al., 2021). the results of the evaluation of the article’s quality are shown in table 2 (see appendix 2). 3.3 characteristics of the study eight articles were included in the screening process. the eight articles were randomized control trials (rcts) with as many as 30-198 samples made up of the participants and showed various recommendations for cupping duration, ranging between 3 minutes to 20 minutes per session period of every one week to two weeks. the eight articles explained the benefits of each cupping location, including neck and myofascial pain syndrome (chiu et al., 2020; yang et al., 2018), low back pain, pelvic pain, and physical disability (abdulaziz et al., 2021; al-eidi et al., 2019; mardani-kivi, 2018; moura et al., 2021; silva et al., 2021) and knee pain (islam et al., 2021). records identified from databases (n=1,045) pubmed (n=70) sciencedirect (n=136) google scholar (n=839) records removed before screening: duplicate records removed (n=7) records screened on the basis of title, keywords and abstract (n=1,038) records excluded did not met inclusion criteria (n=1,014) reports sought for retrieval (n=24) reports not retrieved (n=0) reports assessed for eligibility (n=24) reports excluded: irrelevant topic (n=13) irrelevant study design (n=3) studies included in the review (n=8) i d e n ti fi c a ti o n s c r e e n in g i n c lu d e d nurse media journal of nursing, 12(3), 2022, 456 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 two studies were carried out in china (chiu et al., 2020; yang et al., 2018), two studies in brazil (moura et al., 2021; silva et al., 2021), one study in iran (mardani-kivi, 2018), one study in india (islam et al., 2021), one study in egypt (abdulaziz et al., 2021) and one study in saudi arabia (al-eidi et al., 2019). both wet and dry cupping was demonstrated in eight included articles. wet cupping was demonstrated by mardani-kivi (2018), while dry cupping was explained by the remaining studies (abdulaziz et al., 2021; al-eidi et al., 2019; chiu et al., 2020; islam et al., 2021; moura et al., 2021; silva et al., 2021; yang et al., 2018). dry cupping is a painless skin bruising method involving lighting the bottom of a glass cup, placing it over the skin, and then rinsing the cup bottom with methylated spirits. on the other hand, wet cupping incorporates two different application techniques in prophetic medicine. the first is the cupping, puncturing and cupping (cpc) technique. the cpc process used six phases: skin demarcation, sterilization, cupping, puncturing, and cupping and sterilization. second, the puncturing and cupping (pc) technique consisted of four steps: skin demarcation, sterilization, puncturing, and cupping (aboushanab & alsanad, 2018). 3.4 anatomical points of cupping therapy eight included articles showed seven various locations of the cupping points to relieve musculoskeletal pain according to their benefits, which included one (1) cupping point for neck and myofascial pain syndrome, five (5) cupping points for non-specific and chronic low back pain, pelvic pain and physical disability, and one (1) cupping point for knee pain as shown in table 3. table 3. regions and benefits of cupping points no regions benefits cupping duration type of cupping 1. upper, middle, and lower fibres of the trapezius muscles neck and myofascial pain syndrome (chiu et al., 2020; yang et al., 2018) 15-20 minutes each time, twice a week, for four weeks dry cupping 2. the inter-scapular area around the vertebrae torachalis t2-t4 nonspesific low back pain (mardani-kivi, 2018) once a week and lasted about 20 minutes wet cupping 3. sacrum area, between the lower vertebrae and the coccyx bone nonspesific low back pain (mardani-kivi, 2018) five times and lasted about 20 minutes wet cupping 4. vertebrae lumbalis l1-l5 nonspesific low back pain (silva et al., 2021) 10 minutes once a week for eight weeks dry cupping 5. bilateral bladder meridian (bl) 23, spinal neurogenic acupoint located in 1.5 cun lateral to the lower border of the spinous process of the second lumbar vertebra (l2). pelvic pain (abdulaziz et al., 2021) 20 minutes each time, with no specific period dry cupping 6. knee joint (medially above, medially below, laterally above and laterally below the joint line) knee osteoarthritis (islam et al., 2021), 15 minutes every 2 days for a period of 20 days. dry cupping 7. the lower border of the spinous process of the second lumbar vertebra (l2), bilateral bladder meridian (bl) 23, bl 24, and bl 25. chronic low back pain and physical disability (moura et al., 2021; aleidi et al., 2019). 10 minutes each time, with no specific period dry cupping nurse media journal of nursing, 12(3), 2022, 457 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 3.4.1 cupping points for neck and myofascial pain syndrome the trapezius muscles’ upper, middle and lower fibers were cupping points to relieve neck and myofascial pain syndrome pain. it was done by dry cupping for 15 minutes twice a week for four weeks (chiu et al., 2020; yang et al., 2018). 3.4.2 cupping points for chronic low back pain, pelvic pain, and physical disability the interscapular area around the thoracic vertebrae t2-t4 and the sacrum area, between the lower vertebra and the coccyx bone, and lumbar vertebrae l1-l5 were cupping points for nonspecific low back pain. they were done both by wet cupping carried out five times, each of which lasted for about 20 minutes (mardani-kivi, 2018) and dry cupping for 10 minutes weekly for eight weeks (silva et al., 2021). bilateral bladder meridian (bl) 23, 24, 25, and the lower border of the spinous process of the second lumbar vertebra (l2) were cupping points to reduce pelvic pain, chronic low back pain, and physical disability (abdulaziz et al., 2021; al-eidi et al., 2019; moura et al., 2021). the dry cupping therapy was done on the two points lasting for about 10 -20 minutes for each session. 3.4.3 cupping points for knee joint pain the knee joint is a cupping point to relieve knee pain done by dry cupping for 15 minutes for a period of 20 days (islam et al., 2021). cupping was placed on the knee joint that was being treated, with the first cup placed medially above the joint line, the second cup below the joint line, the third cup above the joint line, and the fourth cup below the joint line. throughout the process, the cups’ maximum tolerable pressure was maintained. 4. discussion this study aimed to identify the anatomical points of cupping therapy for musculoskeletal pain. based on the results, eight articles were included, and seven regions of cupping points were identified. the cupping points can be classified into three categories, namely one cupping point for myofascial syndrome, and five cupping points for non-specific and chronic low back pain, pelvic pain and physical disability, and one cupping point for knee joint pain. 4. 1 cupping points for myofascial pain syndrome the review reported that anatomical points for myofascial pain syndrome were located on the upper, middle, and lower fibres of the trapezius muscles (figure 2). according to chiu et al. (2020), cupping therapy on the trapezius muscles’ top, middle, and lower fibres can boost functional recovery and maintain soft tissue health, and reduce myofascial pain. additionally, yang et al., (2018) reported the result from randomized controlled trial that cupping therapy in this site significantly reduced the neck pain severity in patients. the upper, middle, and lower fibres of the trapezius muscles are located close to the pain. these points are also employed in cupping techniques to lessen myofascial pain. by removing the metabolic wastes that generate pain, lactic acid, interstitial fluid, and the causative pathological substance (cps) mechanism, cupping therapy relieves pain (setyawan, budiyati, et al., 2020). according to the theories of diffuse nopsious inhibitory control theory, pain gate theory, and reflex zone theory, the vacuum effect at the point of cupping will affect the biomechanics of the skin. the first suction on the skin will excite the skin nerves, which will then travel through the delta and c nerves to the spinal cord and then towards the thalamus, where they will promote the release of endorphins. this endorphin is what will lessen the discomfort (yang, 2018). previous studies had shown that cupping might help improve local oxygen intake, blood microcirculation, hemodynamic activity, lower deoxyhemoglobin and boost oxyhemoglobin (chen et al., 2017). this effect may aid in the treatment of neck and myofascial pain syndrome and the facilitation of muscular function. previous research corroborated this conclusion, and it was reported that cupping therapy conducted during the recovery period from strenuous exercise could speed muscle fatigue recovery and retain superior exercise performance (chen et al., 2017; li et al., 2017). 4. 2 cupping point for nonspecific and chronic low back pain, pelvic pain and physical disability the review showed that the anatomical points for nonspecific low back pain included three areas: (1) on the interscapular area surrounding the t2–t4; (2) on the sacrum between the lower vertebrae and coccyx bone, and (3) on the vertebrae lumbalis l1 to l5 (figure 3a). mardani-kivi nurse media journal of nursing, 12(3), 2022, 458 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 (2018) pointed out that cupping therapy have a potential therapeutic effect on nonspecific neck and upper shoulder pain. the study also found that cupping therapy for persistent nonspecific low back pain (pnslbp) patients had an immediate response and was as effective as conventional treatment in pain intensity reduction. the points included the interscapular area surrounding the t2-t4 and the sacrum between the lower vertenbrae and coccyx bone. individuals with nonspecific low back pain have also been proven to benefit from cupping therapy (silva et al., 2021). the cups were positioned bilaterally on the lower back, parallel to the l1 to l5 vertebrae, with a 3-centimetre gap between them. figure 2. cupping points for neck and myofascial pain in addition to nonspecific low back pain, al-eidi et al. (2019) evaluated the effects of traditional cupping and asian cupping techniques in treating chronic low back pain patients. cupping points for chronic low back pain (clbp) included the bilateral bladder meridian (bl) 23, bl 24, and bl 25 points that were the most uncomfortable. this discomfort results from the location of more superficial nerves. bl 23 is at the level between the l2 and 3 processus spinosus, bl 24 is at the level between the l3 and 4 processus spinosus, and bl 25 is at the level between the l4 and 5 processus spinosus (figure 3b). additionally, moura et al. (2021) in their study showed that cupping therapy in the lower border of the spinous process of the second lumbar vertebra (l2) effectively treated chronic back pain and physical impairment. this point is effective because it is closer to the area of pain. when cupping therapy is carried out on the point, a mechanism will occur to release lactic acid and p substance for alleviating pain (setyawan, budiyati, et al., 2020). furthermore, abdulaziz et al. (2021) claim that cupping therapy can assist women with persistent pelvic pain in experiencing less pain. cupping on bladder meridian (bl23) spinal neurogenic acupoint was effective in reducing the effects of pelvic pain in women with chronic pelvic problems (cpp). dry cupping on this site reduces pain, promotes local blood and lymphatic circulation, activates the autonomous nerve system, stimulates the skin, and diminishes skin sensitivity. the mechanism of the referred visceral pain is thought to involve neurogenic inflammation and central sensitization of the spinal cord. acupoint sensitization stressed that pathological changes in the functional activity of internal organs can affect the size and function of neurogenic acupoints on the surface of the body. 4. 3 cupping point for knee joints knee pain is a problem for public health and one of the main sources of discomfort and functional impairment (hay et al., 2017). according to islam et al. (2021), dry cupping in the following points:(1) medially above the joint line, (2) medially below the joint line, (3) laterally above the joint line, and (4) laterally below the joint line, effectively reduces knee pain. hence, nurse media journal of nursing, 12(3), 2022, 459 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 regarding the quantity of suction, the duration of dry cupping treatment for people with knee pain is 15-20 minute application. furthermore, zhao et al. (2009) found that dry cupping application that lasts more than 30 minutes can lead to a complication, namely burn injuries. according to some studies, cupping therapy has a pain-relieving effect comparable to that of an analgesic. ischemia, which results in inflammation and pain mediators, occurs in low back pain. this mediator will activate the pain-related nerve fibres, resulting in pain. lactic acids are built up in the tissues more due to anaerobic metabolism when ischemia occurs. removing inflammatory and pain-causing mediators from the body by cupping therapy will lead to less activation of the pain nerve fibres. additionally, there is the release of the endorphin hormone, which aids in pain relief (setyawan, 2022; setyawan, budiyati, et al., 2020). (3a) (3b) figure 3. cupping points for low back pain, pelvic pain and physical disability unknown physiological processes may underlie the effects of cupping. cupping results may be divided into a series of categories, including neurological, hematological, immunological, and psychological consequences (silva et al., 2021). sites for cupping therapy are chosen according to the condition being treated. the most frequent areas for application are the back, chest, abdomen, buttocks, and legs. however, the cupping technique can also treat other areas, such as the face (yoo & tausk, 2004). in addition to being a robust, efficient, and effective therapy in and of itself, cupping therapy should be seen as a potent, curative, and potentiating treatment. although cupping therapy has specific indications, much like any other medical treatment methods, it is a valuable adjuvant preventative and therapeutic procedure in which blood and interstitial fluid are eliminated. there are significant variances in how the cupping point is determined, as seen by the multiple references to evidence. cupping therapy is effective when used as a treatment for musculoskeletal pain disorders. cupping treatment is one of the most efficient ways to cure various illnesses when performed alone or in conjunction with other therapeutic procedures (el sayed et al., 2013; el sayed et al., 2014). 5. implications and limitations according to the study’s findings, several cupping locations have been proven to lessen discomfort brought on by musculoskeletal issues. health professionals or cupping practitioners might utilize these findings when treating musculoskeletal pain as proof. the findings of this study can also be used as a foundation for further experimental studies on the effects of cupping on musculoskeletal pain issues. although substantial efforts were made, our review has significant limitations, including limited sources and bias of selective publishing and reporting, which must be considered that may influence both the quality and the quantity of research and limit the conclusiveness of this review. nurse media journal of nursing, 12(3), 2022, 460 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 6. conclusion this systematic review identified seven anatomical points of cupping therapy for musculoskeletal pain based on certain studies explaining its various benefits. no single research could explain the full spectrum of benefits of every point. the beneficial effects of cupping therapy need to be substantiated by large randomized clinical trials, systematic reviews and meta-analyses in future. basic scientific innovative research is also necessary to verify the discussed cupping theories and invent new ideas. acknowledgment the authors acknowledged the sekolah tinggi ilmu kesehatan (stikes) surya global yogyakarta for the support, including the faculty librarian providing the database access and arranging keywords. author contribution as and eo conceptualized, designed, drafted the initial draft and framework, authored the paper, and analyzed the data. the data were conceptualized and interpreted by immys and inh. all authors have read and approved the version of the manuscript that has been published. conflict of interest we have no conflicts of interest to disclose. references abdulaziz, k. s., mohamad, r. t., el-din mahmoud, l. s., ramzy, t. a. a., & osman, d. a. 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(2021). effects of ear acupuncture combined with cupping therapy on severity and threshold of chronic back pain and physical disability: a randomized clinical trial. journal of ttraditional and complementary medicine, 12(2), 152–161. https://doi.org/10.1016/j.jtcme.2021.07.008 parawansa, n., pertiwi, n. a., hasyati, f., quddusi, t. r., & septadina, i. s. (2020). the effect of cupping therapy on low back pain literature review. international journal of islamic and complementary medicine, 1(2), 71–76. https://doi.org/10.55116/ijicm.v1i2.10 peters, m. d. j., marnie, c., tricco, a. c., pollock, d., munn, z., alexander, l., mcinerney, p., godfrey, c. m., & khalil, h. (2020). updated methodological guidance for the conduct of scoping reviews. jbi evidence synthesis, 18(10), 2119–2126. https://doi.org/10.11124/jbies-20-00167 purssell, e., & gould, d. 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(2022). cupping for nursing: tinjauan syariyah dan ilmiah [cupping for nursing: syaria and scientific review] (1st ed.). cendekia muslim. setyawan, a., budiyati, g. a., & hardiyanti, w. o. s. (2020). the comparison of effectiveness and mechanisms of dry cupping therapy and wet cupping therapy in reducing neck pain symptom in hypertension. jurnal keperawatan respati yogyakarta, 7(3), 187-191. http://dx.doi.org/10.35842/jkry.v7i3.542 setyawan, a., sari, d. n. a., & budiyati, g. a. (2020). effectiveness and mechanism of wet cupping therapy in reducing mean arterial pressure value in hypertension patients. jurnal keperawatan, 12(4), 727–734. https://doi.org/10.32583/keperawatan.v12i4.987 silva, h. j. a., barbosa, g. m., scattone silva, r., saragiotto, b. t., oliveira, j. m. p., pinheiro, y. t., lins, c. a. a., & de souza, m. c. (2021). dry cupping therapy is not superior to sham cupping to improve clinical outcomes in people with nonspecific chronic low back pain: a randomised trial. journal of physiotherapy, 67(2), 132–139. https://doi.org/10.1016/j.jphys.2021.02.013 siregar, r., setyawan, a., & syahruramdhani, s. (2021). a model to standardize safety and quality of care for cupping therapy. journal of integrative medicine, 19(4), 327–332. https://doi.org/10.1016/j.joim.2021.01.011 stephens, s. l., dejong lempke, a. f., hertel, j., & saliba, s. (2022). clinical usage, application procedures, and perceived effectiveness of cupping therapy among healthcare professionals in the united states: a cross-sectional survey. complementary therapies in clinical practice, 48, 101610. https://doi.org/10.1016/j.ctcp.2022.101610 vos, t., abajobir, a. a., abate, k. h., abbafati, c., abbas, k. m., abd-allah, f., abdulkader, r. s., abdulle, a. m., abebo, t. a., abera, s. f., aboyans, v., abu-raddad, l. j., ackerman, i. n., adamu, a. a., adetokunboh, o., afarideh, m., afshin, a., agarwal, s. k., aggarwal, r., … murray, c. j. l. (2017). global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the global burden of disease study 2016. the lancet, 390(10100), 1211–1259. https://doi.org/10.1016/s0140-6736(17)32154-2 yang, y., ma, l., niu, t., wang, j., song, y., lu, y., yang, x., niu, x., & mohammadi, a. (2018). comparative pilot study on the effects of pulsating and static cupping on nonspecific neck pain and local skin blood perfusion. journal of traditional chinese medical sciences, 5(4), 400–410. https://doi.org/https://doi.org/10.1016/j.jtcms.2018.09.001 https://doi.org/10.1016/j.jtcme.2021.07.008 https://doi.org/10.11124/jbies-20-00167 https://doi.org/10.1016/s2095-4964(17)60339-x https://doi.org/10.9734/jocamr/2017/39269 https://doi.org/10.20959/wjpr20195-14759 http://dx.doi.org/10.35842/jkry.v7i3.542 https://doi.org/10.32583/keperawatan.v12i4.987 https://doi.org/10.1016/j.jphys.2021.02.013 https://doi.org/10.1016/j.joim.2021.01.011 https://doi.org/10.1016/j.ctcp.2022.101610 https://doi.org/https:/doi.org/10.1016/j.jtcms.2018.09.001 nurse media journal of nursing, 12(3), 2022, 463 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 yoo, s. s., & tausk, f. (2004). cupping: east meets west. international journal of dermatology, 43(9), 664–665. https://doi.org/10.1111/j.1365-4632.2004.02224.x zhao, x., tong, b., wang, x., & sun, g. (2009). effect of time and pressure factors on the cupping mark color. zhongguo zhen jiu = chinese acupuncture & moxibustion, 29(5), 385–388. copyright © 2022 nmjn. this article is an open access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). https://doi.org/10.1111/j.1365-4632.2004.02224.x https://creativecommons.org/licenses/by-sa/4.0 nurse media journal of nursing, 12(3), 2022, 464 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 appendix 1 table 1. the included studies characteristics author design participants & sample results chiu et al. (2020) experimental design 40 participants with myofascial pain shoulder and upper extremity function significantly improved. mardani-kivi (2018) a randomized clinical trial 180 individuals with nonspecific low back pain there was a significant reduction of nslbp among participants. al-eidi et al. (2019) a randomized clinical trial 70 participants with at least three months of chronic low back pain (clbp) there was a significant reduction of clbp immediately following the intervention, seven days later, and fourteen days later. there was no significant difference between the two groups on any of the outcome measures 14 days after the intervention. silva et al. (2021) randomized controlled trial 90 participants with nonspecific low back pain cupping was effective in relieving pain, physical function, mobility, quality of life, psychological symptoms, and medication use in patients with nonspecific chronic low back pain. moura et al. (2021) randomized, parallel-group controlled clinical trial 198 patients with chronic low back pain patients who received cupping therapy showed significant changes in pain relief, and physical impairment were observed during the follow-up session. yang et al. (2018) randomized controlled clinical trial 70 individuals with neck and nonspecific myofascial pain this study suggests that pulsating cupping may have greater analgesic effects on nonspecific myofascial pain than static cupping, possibly due to its greater effect on enhancing local skin blood perfusion. islam et al. (2021) randomized controlled clinical trial 40 patients with knee osteoarthritis significant changes in knee osteoarthritis pain reduction in intervention group. abdulaziz et al. (2021) a randomized controlled trial 30 patients, with 15 intervention group and 15 control group inflammation, pain perception and intensity, and the impact of pelvic pain on daily living were all considerably improved by cupping therapy in women with chronic pelvic pain (cpp). nurse media journal of nursing, 12(3), 2022, 465 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 2. the crowe critical appraisal tool (ccat) results no author and year result of ccat scoring categories and items total (/40) total (%) summary p re li m in a ri e s in tr o d u c ti o n d e si g n s a m p li n g d a ta c o ll e c ti o n e th ic a l m a tt e rs r e su lt s d is c u ss io n 1. chiu et al. (2020) 5 5 4 4 4 4 5 5 36 90 good 2. mardani-kivi (2018) 5 5 5 5 4 4 4 5 37 92.5 good 3. al-eidi et al. (2019) 5 5 4 5 4 4 5 5 37 92.5 good 4. silva et al. (2021) 4 3 3 3 4 3 3 3 26 65 fair 5. moura et al. (2021) 5 4 4 4 4 4 4 5 34 85 good 6. yang et al. (2018) 5 4 4 5 4 4 5 5 36 90 good 7 islam et al. (2021) 4 4 4 5 4 4 5 5 35 87.5 good 8 abdulaziz et al. (2021) 5 5 5 5 4 4 5 4 37 92.5 good nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://medianers.undip.ac.id 12(3):423-436, december 2022 https://doi.org/10.14710/nmjn.v12i3.46101 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 review the effect of music therapy on adult patients’ heart rate: a meta-analysis kamila alammar1,3, omar ghazi baker1,2, areej alotaiba1, anwar alkhunaizi1 1college of nursing, king saud university, riyadh, saudi arabia 2department of community, psychiatric and mental health, college of nursing, king saud university, riyadh, saudi arabia 3nursing department, anfas medical care, riyadh, saudi arabia article info abstract article history: received: 7 may 2022 revised: 22 november 2022 accepted: 24 november 2022 online: 28 december 2022 keywords: adult; heart rate; music therapy; patients corresponding author: kamila alammar department of community, psychiatric and mental health, college of nursing, king saud university, riyadh, saudi arabia email: kalammar89@gmail.com background: music can be used as a complementary intervention to bring about a positive effect on the quality of life. it has been widely employed in clinical practice as one of the earliest forms of treatment. despite the fact that music therapy is widely utilized and practiced in clinical and educational contexts, it has received little attention in formal medical settings. in addition, contradictory findings about the effect of music deserve further investigation. purpose: this meta-analysis is conducted to examine the effect of music therapy on heart rates among adult patients. methods: the medline, cinahl, psycinfo, cochrane library, and pubmed databases were used for searching the literature. the literature review was conducted by two independent researchers using the following medical subject headings terms: musicotherapy or music therapy, and heart rate or vital signs and clinical trials as the topic. standard mean difference (smd) with 95% confidence interval (ci) values was used to evaluate the effect of music therapy on heart rates. results: out of 194 studies, 12 studies were included with 1,118 patients. according to the results of the meta-analysis, the heart rates in the experimental groups in which music therapy was used with various diagnoses of adult patients were found to be significantly different in comparison with the control group (smd=-0.450, 95% ci=-8.86 to -0.31, p=0.04). conclusion: the results established that using music therapy for adult patients reduced their heart rates. however, the heterogeneity among the studies was high. therefore, it is recommended that high-quality trials are warranted to confirm the benefits of music therapy interventions among adult patients. how to cite: alammar, k., baker, o. g., alotaiba, a., & alkhunaizi, a. (2022). the effect of music therapy on adult patients’ heart rate: a meta-analysis. nurse media journal of nursing, 12(2), 423-436. https://doi.org/10.14710/nmjn.v12i3.46101 1. introduction music has an influence on cultures. it is one of the most delightful aspects of the human experience, as it influences the human body and mind. music is a universal language that breaks down barriers between different cultures. melody, harmony, rhythm, and dynamics are some aspects of music that make people feel a certain way. music can be a powerful tool for eliciting emotions and modifying physiological states (arjmand et al., 2017; liang et al., 2021). it has been widely employed in clinical practice as one of the earliest forms of treatment (ramalingam et al., 2022). pythagoras, a greek philosopher, was the first to propose music therapy (hole et al., 2015). in the 1940s, the united states formally recognized music therapy as an adjuvant therapy (taylor, 1981). music therapy is the practice of utilizing music to help people improve and maintain their overall well-being. it has been shown to be useful in reducing patients’ negative feelings, easing pain, and altering their physiological state (liang et al., 2021). the american music therapy association (2006) defined music therapy as “the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program”. many studies related to the benefits of music therapy have been conducted. most of them have focused on its use to relieve anxiety, stress, depression, pain, and insomnia (de witte et al., 2020; ding et al., 2021; erkkilä et al., 2021; liang et al., 2021). https://medianers.undip.ac.id/ https://crossmark.crossref.org/dialog/?doi=10.14710/nmjn.v12i3.46101&domain=pdf&date_stamp=2022-12-28 nurse media journal of nursing, 12(3), 2022, 424 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 music therapy has been shown to be effective in a variety of diseases, including dementia, multiple sclerosis, depression, and schizophrenia (abe et al., 2022; impellizzeri et al., 2020; geretsegger et al., 2017; leubner & hinterberger, 2017). according to fancourt and finn (2019), music can make a substantial contribution to health and well-being. finn and fancourt (2018) claimed that listening to music in both clinical and non-clinical settings lowered cortisol levels, which led to a lower level of stress and lower blood glucose levels. heart rate is one of the vital signs and it has important physiologic and prognostic significance. according to the american heart association, as cited in mason et al. (2007), the normal sinus heart rate is between 60 and 100 beats per minute. heart rate variability is influenced by the parasympathetic and sympathetic nervous systems. the parasympathetic nervous system suppresses the heart rate and restores the body to a restful state after stress by releasing acetylcholine. sympathetic stimulation increases heart rate by releasing norepinephrine (gordan et al., 2015). relaxation techniques stimulate parasympathetic nervous system effects and decrease cortisol, epinephrine, and norepinephrine levels as a result of regulating heart rate. using music in relaxation techniques has been shown to promote cognitive and emotional relaxation (bradt et al., 2015). several studies have examined the effect of music therapy on heart rate. a randomized controlled trial conducted by uggla et al. (2016) proved that music therapy dramatically reduced children’s heart rates following hematopoietic stem cell transplantation. another study conducted among pre-hypertensive young adults revealed that there was a significant reduction in heart rate after four weeks of music therapy sessions (mir et al., 2021). furthermore, chang et al. (2011) explored the effects of music on psychophysiological parameters among cardiac patients, but they found no significant effect of music therapy on heart rate. a systematic review conducted by loomba et al. (2012) concluded that music has the positive effect of decreasing heart rate. despite the fact that music therapy is widely utilized and practiced in clinical and educational contexts, it has received little attention in formal medical settings (loomba et al., 2012; pickard, 2022), particularly in arab countries where utilizing music therapy remains stagnant. additionally, it is difficult to determine the effect of music therapy on an individual’s quality of life, especially when compared to other health interventions. according to maldonado-resto (2021), contradictory findings about the effect of music deserve further investigation. since the effect of music therapy was inconsistent, examining the effect needs further verification (lu et al., 2021). this presents clear challenges to the national and international incorporation of music into health policies and care (bickerdike et al., 2017). formulation of more evidence-based music therapy prescriptions on heart rate promotes music therapy program development within hospital settings. therefore, this meta-analysis is conducted to examine the effect of music therapy on heart rate among adult patients. it sets the stage for further research into whether music therapy can help decrease heart rates. 2. methods 2.1 research design this meta-analysis was carried out in stages, starting with the formulation of the research question, followed by the identification of relevant research studies, assessment of study bias, summarization of the evidence, and interpretation of the findings. the preferred reporting items for systematic reviews and meta-analyses (prisma) procedure (moher et al., 2009) was used to extract available data linked to the effect of music therapy on heart rate. this protocol facilitated transparency in reporting meta-analytic research. 2.2 search method the primary research question was “what is the reported effects of music therapy on heart rate among adult patients?”. in this regard, the search included studies with (p) adult patients investigating the effect of (i) music therapy compared with a (c) control group on (o) heart rate in (s) randomized controlled trials (rcts). an extensive literature review was conducted using the electronic database searches of medline, cinahl, psycinfo, the cochrane library, and pubmed to retrieve studies from 2017 up to march 2022. each database was searched using the following medical subject headings (mesh) terms: “musicotherapy” or “music therapy” and “heart rate” or “vital signs” and “clinical trials” as the topic by the first author (ka). nurse media journal of nursing, 12(3), 2022, 425 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 2.3 inclusion and exclusion criteria the inclusion criteria of the studies were as follows: (1) randomized controlled trials (rcts); (2) available in full text, (3) published in english; (4) conducted among the adult patient population; (5) all the studies had to include mean or median scores; and (6) conducted in the last five years (2017-2022). according to the inclusion and exclusion criteria used during the search, qualitative studies, case studies, dissertations, conference abstracts, systematic reviews, symposiums, and studies on non-human subjects were excluded from this review. if studies compared music therapy with complementary and alternative medicine (cam), they were also excluded from the review. 2.4 screening of articles two research team members (ka and aa) independently screened the studies, and any disagreements were discussed between the two members. when no agreement was obtained, a third reviewer (ogb) was consulted. zotero software was utilized to import and manage the search results and reject duplicates. the two members then examined the titles and abstracts of the included rcts. when both members rejected a study, it would be eliminated from consideration. insufficient title or abstract information required a full article review based on the inclusion criteria. 2.5 data extraction after the final list of articles was identified, two investigators (ka and aa) used a microsoft excel spreadsheet (microsoft corporation, redmond, wa, usa) to extract the data from each article independently. each study included in the review had the following information extracted: first author and year of publication, sample size, quantitative data (mean ages, mean score, standard deviation), type and setting of procedure, duration of listening to music, and main findings. 2.6 quality appraisal the included studies were independently evaluated by independent reviewers from the research team (ka and aa) using the methodological quality assessment system in review manager (revman) version 5.4 (the nordic cochrane center, the cochrane collaboration, copenhagen, denmark, 2020). the risk of bias for each selected trial was assessed according to seven sources of bias that included selection bias, performance bias, detection bias, attrition bias, reporting bias, and other reported biases. all the items were classified as yes (“low risk of bias”), no (“high risk of bias”), or unclear (“moderate risk of bias”). when the risk of bias for each of the seven components was classified as “low risk of bias”, the total risk of bias for the trial was also characterized as “low”. similarly, when one or more of the seven components of bias were rated as high risk, the study was considered as high risk of bias (higgins et al., 2011). discrepancies in the evaluation were resolved by a third senior reviewer (ogb). missing information leads to rating the bias as an unclear risk, which leads to difficulty in assessing the limitations of the trials (viswanathan et al., 2012). 2.7 data analysis the meta-analysis was performed using revman software version 5.4 (the nordic cochrane center, the cochrane collaboration, copenhagen, denmark, 2020) for data synthesis. the means and standard deviation outcomes of the heart rate measurements were extracted from each study. one study provided the adjusted post-test mean (c.h. lee et al., 2017). the outcome measures of this meta-analysis were presented as the mean differences (mds) between the music and control groups, with the corresponding 95% confidence intervals (cis). random effects models were used to combine the effects from individual studies. heterogeneity was examined using cochran’s q test and i². the heterogeneity was considered high if the value of i² was greater than 50% (higgins, 2003). when there was significant heterogeneity, a random effects model was used for meta-analysis. a fixed effect meta-analysis was used when there was no significant heterogeneity. pooled analyses of data from all studies were conducted to determine various outcomes. nurse media journal of nursing, 12(3), 2022, 426 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 3. results 3.1 literature search one hundred and ninety-four articles were identified through database searching via the following search engines: cochrane library, ebsco, medline pubmed, and psycinfo. twentysix articles were removed due to duplication. the deleted records have the same title, author, and publication year. the remaining records (n=168) were exported to an excel file. the extensive screening by two independent reviewers (ka and aa) using the inclusion and exclusion criteria resulted in the elimination of 125 articles, leaving a total of 43 full-text articles that were downloaded for consideration. thirty-one articles were excluded for the following reasons: study conducted among healthy participants (n=7), comparison to another type of cam intervention (n=8), lack of appropriate statistical data (n=12), and non-rct (n=4). ultimately, 12 articles met all the inclusion criteria and were included in the qualitative synthesis (figure 1). figure 1. study selection methodology 3.2 risk of bias for the included studies according to the risk of bias that was evaluated using the cochrane collaboration’s software revman 5.4 (figure 2), in general, the methodology of the included trials was less than ideal, with significant flaws (figure 2a). figure 2b illustrates the risk of bias summary of each study. in terms of the randomization process, 11 studies described the process of randomization and were assessed as having a low risk of bias, and one study as high risk of bias (w. l. lee et al., 2017). the authors decided to include the high-risk study as including only the studies at low risk of bias may produce a result that is imprecise (boutron et al., 2019). four studies did not provide information about the allocation of concealment and were judged as having a high risk of bias (cakmak et al., 2017; lopez-yufera et al., 2020; w. l. lee et al., 2017; w. p. lee et al., 2017), and one study was assessed as unclear bias (hamidi & ozturk, 2017). in addition, seven studies failed to blind the participants and investigators (cakmak et al., 2017; lopez-yufera et al., 2020; mackintosh et al., 2018; tolunay et al., 2018; wazzan et al., 2022; w. l. lee et al., 2017; w. p. records identified from*: databases (n=194) pubmed (n=34) medline (n=72) cinhal (n=64) psych info (n=5) cochrane library (n=19) records removed before screening: duplicate records removed (n=26) records removed for other reasons (n=125) records screened (n=168) records excluded (n=125) reports assessed for eligibility (n=43) reports excluded (n=31) conducted among healthy participants (n=7) comparing to another type of pf cam intervention (n=8) lack of appropriate statistical data (n=12) non rct (n=4) reports of included studies (n=12) identification of studies via databases i d e n ti fi c a ti o n s c r e e n in g i n c lu d e d nurse media journal of nursing, 12(3), 2022, 427 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 lee et al., 2017). in terms of detection bias, five studies were considered as high risk (cakmak et al., 2017; mackintosh et al., 2018; tolunay et al., 2018; wazzan et al., 2022; w. l. lee et al., 2017), and the risk of bias was unclear for one study (wu et al., 2017). the remaining six studies were evaluated as low risk of bias. for attrition bias, most of the studies were rated as low risk of bias, except for four studies that were judged as high risk of bias (froutan et al., 2020; schaal et al., 2021; tolunay et al., 2018; w. l. lee et al., 2017). in terms of reporting bias, all of the studies were assessed as low risk, except for three studies for which the risk of bias was not clear (cakmak et al., 2017; hamidi & ozturk, 2017; w. l. lee et al., 2017). regarding the other bias, the studies by lee et al. (2017) and lopez-yufera et al. (2020) were deemed high-risk since the participants have not been able to select their preferred genre of music for the intervention. thus, it is possible that the effects of the music intervention were lessened. 3.3 characteristics of the study the total number of patients in all studies was 1,118, with sample sizes ranging from 38 to 200 for each study. a total of 554 patients were included in the music therapy groups, while 564 patients were enrolled in the control groups. the maximum mean age was 68.3 years, and the minimum mean age was 30 years. the study settings varied between inpatient and outpatient settings. two studies played music in an intensive care unit (icu) (froutan et al., 2020; c. h. lee et al., 2017), and three studies provided music in a preoperative room (lopez-yufera et al., 2020; schaal et al., 2021; wu et al., 2017). one study provided music in a cardiac ward (cakmak et al., 2017), one study in an interventional room in an outpatient clinic (hamidi & ozturk, 2017), one study in a dental clinic (wazzan et al., 2022), and one in a cast room (tolunay et al., 2018). there was one study in a radiology department that provided meditative music during tomography scans (w. l. lee et al., 2017). one study provided intraoperative music (mackintosh et al., 2018), and the final study provided music in a post-anesthesia care unit (pacu) (w. p. lee et al., 2017). the study by froutan et al. (2020) provided music during icu hospitalization until day 6. the duration of the music intervention ranged from 10 to 30 minutes. conversely, five studies (cakmak et al., 2017; hamidi & ozturk, 2017; mackintosh et al., 2018; tolunay et al., 2018; wazzan et al., 2022) reported that music was played throughout the procedure without specifying the total time of the procedure. various genres of music were played throughout the trials. c. h. lee et al. (2017) used western classical music, chinese classical music, music of natural sounds, and religious music based on the patients' preferences. six types of soothing music (such as nature, piano, harp, and jazz) were used among the patients, according to w. p. lee et al. (2017) and wu et al. (2017) studies. cakmak et al. (2017), hamidi & ozturk, (2017), and tolunay et al. (2018) played popular, classical, and slow music or turkish folk as the patients preferred. mediative music was used in the w. l. lee et al. (2017) study to enhance the relaxation feelings among patients who were waiting for positron emission tomography (pet) scans. relaxing music, as described by froutan et al. (2020) and lopez-yufera et al. (2020), was used among patients with potentially malignant oral disorders and icu patients. wazzan et al. (2022) used regular soft music tracks, while mackintosh et al. (2018) and schaal et al. (2021) did not specify the music type. four studies were carried out in taiwan (c. h. lee et al., 2017; wu et al., 2017; w. l. lee et al., 2017; w.p. lee et al., 2017), three studies in turkey (cakmak et al., 2017; hamidi & ozturk, 2017; tolunay et al., 2018), and one study in spain (lopez-yufera et al., 2020), iran (froutan et al., 2020), australia (mackintosh et al., 2018), germany (schaal et al., 2021), and the united arab emirates (wazzan et al., 2022) (table 1). 3.4 the effect of music intervention on heart rate in this analysis, data from various other subjective variables were pooled together using the standardized mean difference (smd) statistic. the music intervention showed a significant and small to medium effect in decreasing heart rate (n=1118, smd=-0.450, 95% ci=-8.86 to -0.31, p=0.04) when compared with the control group, with evidence of heterogeneity (p=0.00001, i2=98%) (figure 3). the heterogeneity was best resolved by excluding wu et al. (2017), c. h. lee et al. (2017), and froutan et al. (2020). the results favored music therapy after exclusion (n=941, smd=-1.56, 95% ci=-2.75 to -0.37, p=0.01), with p=0.68, and i2=0% (figure 4). nurse media journal of nursing, 12(3), 2022, 428 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 (2a) risk of bias graph (2b) risk of bias summary figure 2. risk of bias nurse media journal of nursing, 12(3), 2022, 429 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 3.5 the effect of music intervention on heart rate in this analysis, data from various other subjective variables were pooled together using the standardized mean difference (smd) statistic. the music intervention showed a significant and small to medium effect in decreasing heart rate (n=1118, smd=-0.450, 95% ci=-8.86 to -0.31, p=0.04) when compared with the control group, with evidence of heterogeneity (p=0.00001, i2=98%) (figure 3). the heterogeneity was best resolved by excluding wu et al. (2017), c. h. lee et al. (2017), and froutan et al. (2020). the results favored music therapy after exclusion (n=941, smd=-1.56, 95% ci=-2.75 to -0.37, p=0.01), with p=0.68, and i2=0% (figure 4). figure 3. mean difference in the effect of music on heart rates figure 4. mean difference after heterogeneity was resolved 4. discussion this meta-analysis of 1,118 participants in 12 rcts aims to examine the effect of music therapy on heart rate among adult patients. the results revealed that the heart rates of the patients assigned to the music therapy groups decreased significantly with small to medium effect (smd=0.450) compared to the control group patients. this reflects the significant effect of music therapy, although this result shows high heterogeneity. the heterogeneity may be raised due to differences in the participants’ diagnoses, characteristics, and perceptions of the populations based on their countries and study settings (inpatient or outpatient). two studies were in an icu setting, and three were in preoperative care units. there was one study in each of the following settings: an intraoperative setting, pacu, procedural room, dental clinic, cardiac unit, radiology department, and cast room. this conclusion regarding the effect of music therapy is consistent with what was reported previously by loomba et al. (2012) and de witte et al. (2020) in pooled analyses of 432 and 9,617 participants, respectively. music therapy is a complementary treatment for a wide range of medical disorders because its effects have the potential to promote whole-body coordination (mojtabavi et al., 2020). nurse media journal of nursing, 12(3), 2022, 430 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 listening to music enhances parasympathetic activities, as the parasympathetic system is the most active under restful conditions, which leads to a decrease in the heart rate (gordan et al., 2015). according to suhartini (2011), the human energy field receives oscillations produced by music, and numerous physiological reactions synchronize with or match the music’s oscillations. in this aspect, patients believe the music intervention to be more effective and enjoyable. the hospitalization process is a potential source of stress that may increase the risk of physiological complications. stressed patients with an activated sympathetic nervous system may be predisposed to increased epinephrine secretion, which influences physiological functioning, including elevating the heart rate (vaseghi & shivkumar, 2008). considering the individual studies, the greatest decrease in heart rate was obtained with 30 minutes of listening to music among patients undergoing awake craniotomy (-19.12 beats per minute in heart rate, 95% ci=24.62 to -13.38) (wu et al., 2017) followed by a study of frountan et al. (2020) with reduction of 17. 32 beats per minute, among patients with traumatic brain injury. a less pronounced reduction in heart rate was found among adult patients with potentially malignant oral disorders who listened to relaxing music with headphones (lopez-yufera et al., 2020) (-0.50 beats per minute in heart rate, 95% ci=-5.58 to 4.58). mir et al. (2021) used music among pre-hypertensive young adults and suggested that 30 minutes of music listening has a significant effect on reducing heart rates. this finding is in line with wu et al. (2017) findings that suggest the length of music therapy affects heart rate reduction. considering other outcomes, various meta-analyses have shown the positive effects of music therapy on pain, depression, anxiety, and sleep quality (li et al., 2022; lin et al., 2020; sorkpor et al., 2021). the overall results indicated that music therapy is an effective intervention that is relatively affordable, safe, and simple to administer. our findings support the use of music therapy as an empirically supported intervention for lowering heart rates among adult patients. the mechanism by which music affects heart rate is not clear. however, its use can be justified, as the music appears to have the ability to reduce physiological arousal, which is elevated during times of stress (de witte et al., 2020). reduced physiological arousal is associated with reductions in heart rate. music listening is a therapeutic strategy and relaxation technique that has the ability to modulate autonomic nervous system activity and decreases cortisol, adrenaline, and norepinephrine levels, hence regulating the heart rate (bradt et al., 2015; mccrary & altenmüller, 2021). ibn sina (avicenna) is one of the most significant physicians and philosophers of the islamic age indicates that listening to music is one of the most efficient medical treatment methods, which proves the value of music therapy in medical treatment (sidik et al., 2021). although, to the best of our knowledge, music therapy has been overlooked and ignored throughout the arab world, despite its numerous benefits. during our search and screening, only two studies were discovered that examined the effect of music therapy on patients undertaken by luis et al. (2019) in the aswan heart center in egypt and wazzan et al. (2022) in the urgent care dental department, the university of sharjah dental hospital in the united arab emirates. the reason for ignoring music therapy in the arab world can be justified as the disagreement and debate of being music permitted or prohibited (alamer, 2015). 5. implications and limitations this meta-analysis demonstrates that music therapy is an effective intervention that can improve people’s health, which opens the door for future research studies on the benefits of music therapy, particularly in the arab world. however, this study has some limitations. first, the search was limited to studies conducted among adult patients. including diverse populations, such as pediatric patients and healthy adults, might provide a more comprehensive view of the effects of music therapy on heart rates. second, studies with significant selection and performance biases were also included, which may have resulted in an overestimation of the results. finally, because the types and lengths of music therapy were so varied, how different music genres and durations affected patients’ heart rates could not be determined. 6. conclusion this meta-analysis revealed that music therapy has a beneficial effect on heart rate reduction in patients with a range of diagnoses in a variety of hospital settings. this study recommends that nurse media journal of nursing, 12(3), 2022, 431 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 additional high-quality clinical trials in a variety of settings are required to prove music therapy’s influence on heart rate. acknowledgment none author contribution ka participated in the investigation, methodology, project administration, and roles/writingoriginal draft, and independently reviewed trials for meeting the inclusion criteria and extracted data. ogb supervised in writing, reviewing, and editing. aal contributed to formal analysis, visualization, and software. aa independently reviewed trials for meeting inclusion criteria and extracted data. all authors discussed the results and contributed to the writing and editing of the manuscript. conflict of interest the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. references abe, m., tabei, k. i., & satoh, m. 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(2012). assessing the risk of bias of individual studies in systematic reviews of health care interventions. in: methods guide for effectiveness and comparative effectiveness reviews. agency for healthcare research and quality. https://www.ncbi.nlm.nih.gov/books/nbk91433/ wazzan, m., estaitia, m., habrawi, s., mansour, d., jalal, z., ahmed, h., hasan, h. a., & al kawas, s. (2022). the effect of music therapy in reducing dental anxiety and lowering physiological stressors. acta bio-medica: atenei parmensis, 92(6), e2021393. https://doi.org/10.23750/abm.v92i6.11668 wu, p. y., huang, m. l., lee, w. p., wang, c., & shih, w. m. (2017). effects of music listening on anxiety and physiological responses in patients undergoing awake craniotomy. complementary therapies in medicine, 32, 56–60. https://doi.org/10.1016/j.ctim.2017.03.007 copyright © 2022 nmjn. this article is an open access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). about:blank https://doi.org/10.1016/j.pcad.2008.01.003 about:blank https://doi.org/10.1016/j.ctim.2017.03.007 https://creativecommons.org/licenses/by-sa/4.0 nurse media journal of nursing, 12(3), 2022, 435 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 appendix 1 table 1. included studies characteristics author (publication year) country sample size per group mean age intervention duration of music listening hr outcome cakmak et al. (2017) turkey eg: 95 cg: 105 42.9 eg: listening to music during the shock wave lithotripsy session. cg: no music throughout the procedure hr was significantly higher in patients who did not listen to music (p=0.0001) froutan et al. (2020) iran eg: 28 cg: 28 eg: 42.46 cg: 40.32 eg: music therapy integrated with family recollection. cg: no music twice a day for 15 minutes for 6 consecutive days significant decrease in heart rate for the patients in the intervention group as compared to the patients in the control group (p<0.0001) hamidi et al. (2017) turkey eg: 50 cg: 50 eg: 46.5 cg: 48.1 eg: listening to music during the percutaneous nephrostomy tube placement. cg: no music throughout the procedure heart rates eg patients were significantly lower than cg patients (p=0.01) c. h. lee et al. (2017) taiwan eg: 41 cg: 44 eg: 59.46 cg: 59.52 eg: listening to music through headphones. cg: no music 30 minutes heart rates eg patients were significantly lower than cg patients (p<.001) w. l. lee et al. (2017) taiwan eg: 35 cg: 37 eg: 59.03 cg: 60.27 eg: listening to mediative music positron emission tomography (pet) scans. cg: no music 30 minutes significant decrease in heart rate for the patients in the intervention group as compared to the patients in the control group (p<0.001) w. p. lee et al. (2017) taiwan eg: 50 cg: 50 eg: 47.8 cg: 51.36 eg: patients listened to soothing music of their choice using mp3 player and over-ear headphones to reduce outside interference. cg: no music 30 minutes heart rate (t=2.61, p=0.012) decreased among intervention group lopez-yufera et al. (2020) spain eg: 40 cg: 40 68.3 eg: listening to relaxing music with headphones from an mp3 player and with access to the volume control. cg: resting in silence with headphones on but without music 10 minutes heart rates eg patients were significantly lower than cg patients (p<.001) nurse media journal of nursing, 12(3), 2022, 436 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 1. continued author (publication year) country sample size per group mean age intervention duration of music listening hr outcome mackintosh et al. (2018) australia eg: 30 cg: 30 eg: 65 cg: 68 eg: participants listened to the music via ear-bud headphones and the music was played during the entire duration of the pleural procedure and for an additional 10 minutes before and 10 minutes after the pleural procedure. cg: no music throughout the procedure and for an additional 10 minutes before and 10 minutes participants in the music group had reductions in heart rate (p=0.04). schaal et al. (2021) germany eg: 44 cg: 40 eg: 56.1 cg: 57.2 eg: participants listened to the music during port catheter placement. cg: no music throughout the procedure music group displayed a significant reduction in heart rate (p=0.035) tolunay et al. (2018) turkey eg: 100 cg: 99 eg: 52.50 cg: 51.85 eg: listened to music during cast room procedures on normal speaking level (40–50 db) with headsets covering the ear and minimizing noises from the environment. cg: no music throughout the procedure no statistically significant difference was identified for the hr among both groups (p=0.939) wazzan et al. (2022) united arab emirates eg: 23 cg: 23 30 eg: the group was exposed to the music throughout the entire endodontic procedure. cg: no music throughout the procedure no statistically significant difference was identified for the hr among both groups (p=0.74) wu et al. (2017) taiwan eg: 19 cg: 19 40 eg: patients were asked to choose their preference of music from 6 types of soothing music (close to heartbeat) while are lying on the operating table. cg: no music 30 minutes music group displayed a significant reduction in heart rate (p<.001) notes. eg: experimental group; cg: control group nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://medianers.undip.ac.id 13(1):95-108, april 2023 https://doi.org/10.14710/nmjn.v13i1.46399 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 review the prevalence of nurses’ emotional exhaustion during covid-19 pandemic: a systematic review and meta-analysis rana alaseeri1, omar ghazi baker2, maram banakhar3 1nursing college, king saud university, saudi arabia 2community, psychiatric & mental health nursing department, college of nursing, king saud university, saudi arabia 3public health nursing department, king abdulaziz university, saudi arabia article info abstract article history: received: 25 may 2022 revised: 14 april 2023 accepted: 19 april 2023 online: 30 april 2023 keywords: burnout; covid-19; emotional exhaustion; nurses corresponding author: rana alaseeri nursing college, king saud university, saudi arabia email: rana.alaseeri@gmail.com background: nurses in many countries face a high prevalence of psychological pressure while caring for covid-19 patients. several determinants of emotional exhaustion leading to occupational burnout risk were documented. however, a recent review examining nurses’ emotional exhaustion during the covid-19 pandemic is lacking in nursing literature. purpose: this review aimed to examine the prevalence of nurses’ emotional exhaustion during the covid-19 pandemic. this review also describes the organizational contributing factors to nurses’ emotional exhaustion. methods: a systematic review and meta-analysis of the literature following the prisma guidelines was conducted in march 2022. four databases, including pubmed, proquest platform, wiley, and google scholar, were searched from 1 january 2020 to 28 february 2022. the prevalence of nurses’ emotional exhaustion (ee) was pooled using random effect meta‐analyses. the quality appraisal of the studies was done using the joanna briggs institute (jbi) checklist. data analysis utilized a random effect model to evaluate the pooled effects of the studies due to the high heterogeneity between results. results: nine studies were included with a total number of 16,810 subjects surveyed, of whom, 8,150 (48.50%) met the criteria for emotional exhaustion. based on the standard effect model, the pooled estimate for ee prevalence was 48.9% (95% ci:48.1% to 49.6%). several organizational factors contributing to nurses’ emotional exhaustion included working in critical care units or isolation wards, longer working hours in covid-19 quarantine units, night shifts, working with confirmed or suspected co-workers, monthly salary income, and inadequate hospital resources. conclusion: this review found that nurses were suffering from high to moderate emotional exhaustion levels during the covid-19 pandemic. furthermore, several organizational factors influence this emotional exhaustion. these findings highlight the necessity for urgent interventions to decrease psychological impacts on frontline nurses. how to cite: alaseeri, r., baker, o. g, & banakhar, m. (2023). the prevalence of nurses’ emotional exhaustion during covid-19 pandemic: a systematic review and meta-analysis. nurse media journal of nursing, 13(1), 95108. https://doi.org/10.14710/nmjn.v13i1.46399 1. introduction globally, as of march 2022, over 462 million confirmed cases of the coronavirus disease (covid-19) have expanded into more than 60 countries (al-rabiaah et al., 2020; who, 2022). based on the global data reported to the world health organization (who), the pandemic has caused 6,056,725 deaths among the global population. moreover, who estimated up to 180,000 deaths occurred between january 2020 and may 2021 among healthcare professionals during the pandemic (who, 2021). healthcare professionals are at higher risk of being infected by the covid-19 virus than the general population (chen et al., 2020). unfortunately, a meta-analysis conducted during the first wave of the pandemic found that 25.3% of deaths from covid-19 among health care professionals were nurses (bandyopadhyay et al., 2020). based on the international council of nurses, an estimated 1,500 deaths among nurses were reported due to covid-19 in 44 countries as of october 2020 (international council of nurses, 2020). however, the burden of accurate mortality numbers is likely under-reports worldwide (who, 2021). mailto:rana.alaseeri@gmail.com https://crossmark.crossref.org/dialog/?doi=10.14710/nmjn.v13i1.46399&domain=pdf&date_stamp=2023-04-30 nurse media journal of nursing, 13(1), 2023, 96 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 nurses are frontline health care professionals who come close to covid-19 patients and undertake most direct tasks with inadequate protection from contamination (kang et al., 2020; liu et al., 2020; zhan et al., 2020). this fact threatens nurses’ safety and their family members, putting them under extreme and constant physical and psychological pressure (bao et al., 2020; hu et al., 2020; joo & liu, 2021). under these severe psychological and physical threats, nurses could experience burnout, emotional exhaustion, stress, fear, depression, and social prejudice, and then diminish professional productivity, errors in clinical care, and lower patient care outcomes (al maqbali et al., 2021; pappa et al., 2020). the current data report the startling levels of ee prevalence among nurses in various countries. several studies conducted during the covid-19 pandemic confirmed that nurses suffered from moderate to high levels of ee (clinton et al., 2022; hu et al., 2020; salari et al., 2020). according to the results of chen et al. (2020), moderate degrees of ee were reported by 6,051 chinese nurses, 48% of the total sample. similarly, wan et al. (2022) presented moderate to high degrees of ee among 200 chinese nurses, 22.6% of the total sample. in iran, kakemam et al. (2021) revealed that 703 nurses were suffering from moderate to high degrees of ee, which is 48.3% of the total sample. similar ee levels were reported by nurses from the united states, displaying that 61% of nurses experienced ee during the covid-19 pandemic (sagherian et al., 2020). these levels are like that found in bellanti et al. (2021), who confirmed that 76.5% of italian nurses had moderate to high scores in the ee dimension. jose et al. (2020) also reported that 54.16% of nurses working in the emergency department experienced severe ee, and 37% reported a moderate level in india. the international literature has shown a range of moderate to high ee levels among nurses, which call for further analysis and improvement strategies for the future development of nurses’ work, patients’ quality of care, and organizational outcomes (galanis et al., 2021). the consequences of ee can be examined from personal and organizational aspects. for instance, ee not only impacts nurses’ health and well-being but also leads to organizational malfunctioning (zhang et al., 2020). it may negatively affect patient care, nurse dissatisfaction, lack of quality sustainability in health care systems, reduced work commitment, and increased nurse turnover (aiken et al., 2012; lee et al., 2016). recognizing those factors and preventing ee that leading to occupational burnout can play a crucial role in improving nurses’ performance and well-being, thus enhancing the quality of healthcare services provided at hospitals (ahola et al., 2017). the emotional exhaustion dimension among nurses was reported to be higher and most affected in most of the previous studies during covid-19, while the other two dimensions of burnout presented with lower scores (hu et al., 2020; kakemam et al., 2021; sagherian et al., 2020; zhang et al., 2020). in addition, as far as our knowledge and search, there is no meta-analysis or systematic review that examined nurses’ ee prevalence during the covid-19 pandemic. therefore, it is vital to estimate the nurses’ ee during the crisis of covid19. such knowledge can be devised to protect and preserve frontline nurses and to increase future attention and support from organizations and policymakers. this study aims to analyze the prevalence of nurses’ emotional exhaustion and describe the influence of organizational factors during the covid-19 pandemic. the theoretical framework of this review is based on the maslach burnout theory. maslach’s theory describes burnout as an occupationally triggered condition, including emotional exhaustion, depersonalization, and decreased one’s feeling of personal accomplishment (dall’ora et al., 2020). ee is one of the three dimensions of burnout syndrome resulting from accumulating prolonged stressors in one’s working conditions (clinton et al., 2022). therefore, analyzing ee levels with antecedents from institutional factors and presenting a systematic review may help the global nurse community better understand nurse burnout during the covid-19 pandemic. 2. methods 2.1 research design a systematic review and meta-analysis of the literature was performed following the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines. 2.2 search method the search was conducted in march 2022. the search terms were ((“nurs* or “nursing”) and (“emotional exhaustion” or “burnout”) and (“coronavirus” or “covid-19”)) in english. nurse media journal of nursing, 13(1), 2023, 97 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 the authors conferred the following scientific databases: pubmed, proquest platform, wiley, and google scholar from 1 january 2020 to 28 february 2022, and removed duplicates. 2.3 inclusion and exclusion criteria the following inclusion criteria were considered for the search: (a) quantitative studies; (b) studies that assessed nurses’ occupational burnout; (c) studies that were conducted during the covid-19 period; (d) sample of nurses provided direct care to covid-19 patients; (e) english language papers; (f) studies utilized the maslach burnout inventory (mbi) involved in the metaanalysis. the authors excluded studies that examined the entire healthcare professional and did not focus on nurses. even preprints, mixed-methods, qualitative studies, protocols, editorials, book chapters, non-published papers, the abstracts of the conferences, and letters to editors, sample of nursing students or midwives, studies without adequate statistical information to perform meta-analysis estimations, and final studies (dissertations and thesis) were also excluded. 2.4 screening of articles the search strategy consisted of four steps according to the prisma guidelines of identification, screening, eligibility, and inclusion (moher et al., 2015). initially, the electronic databases searches identified 1,152 records, and 15 additional records were identified through an inverse search from the reference lists of the included studies or studies located from the included systematic reviews and a forward search of studies cited from the included studies. then, after removing the duplicates (n=469), screening was performed for each title and abstract of the document (n=698), followed by filtering the full texts to be included in the systematic review. in this phase, 638 records were excluded from the initial title and abstract screening. then, 60 full-text documents were screened. after that, another 51 records were excluded for not meeting the inclusion criteria as they utilized other scales to measure nurses’ burnout and not the mbi-emotional exhaustion subscale (n=25); studies used mbi but in non-english versions (n=3); studies did not measure nurses’ ee during covid-19 period (n=9) but was published in covid-19 period; studies with samples of nurses did not provide direct care to covid-19 patients (n=3); unable to reach full text of studies (n=4); studies with a mixed method design (n=2); a study used cohort design (n=1); a study with sample of nurses and midwives (n=1); a study with sample of nurses and nursing students (n=1); and preprint studies (n=2). finally, the documents were reduced to a final sample of nine studies utilized and measured the ee subscale of the mbi assessment tool (see figure 1). 2.5 data extraction a structured form was used to extract data from each study. the following data were considered for extraction: (a) authors; (b) year of publication; (c) country of the study; (d) sample size; (e) sampling method; (f) study design; (g) response rate; (h) data collection time; and (i) main results for the presence of nurse's ee and associated factors (table 1, appendix 1). 2.6 quality appraisal the study’s quality was evaluated using the joanna briggs institute (jbi) checklist to assess the risk of bias in each study. two reviewers (ra; mb) evaluated all the included studies in this systematic review to assess each article’ methodological quality and minimize errors. each article had a calculated score for selecting participants, study methods, and outcome assessment to determine the inclusion or exclusion of the study in the final sample. in addition, the joanna briggs institute (jbi) critical appraisal tools were used to assess the research quality of the quantitative designs (jbi, 2021). there were eight criteria for evaluating the quality of crosssectional studies. these criteria are specific to quantitative data and stipulated as a checklist. quality ratings of each study are considered if a study meets a predetermined set of questions (table 2). these questions were answered with a reviewer response of whether “yes,” “no,” “unclear,” or “not applicable” (jbi, 2021). nurse media journal of nursing, 13(1), 2023, 98 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 figure 1. prisma flow diagram 2.7 data analysis a random intercept logistic regression model was used to estimate the pooled prevalence of ee using data from the included studies in the current meta-analysis. heterogeneity was assessed using a maximum likelihood estimator for τ2 statistic calculation. the authors also calculated i2 and q statistics and evaluated between-study heterogeneity using the wald and likelihood ratio tests. the risk of publication bias was evaluated using a visual display of study estimates plotted against their precision and evaluating the expected inverted funnel plot. a formal assessment of publication bias was undertaken using duval & tweedie’s trim and fill procedure. the authors contrasted a pooled estimate using duval & tweedie’s trim and fill procedure with the observed pooled estimate. the authors did not perform a meta‐analysis for the organizational factors associated with nurses’ emotional exhaustion since the data were limited to different contexts and highly heterogeneous. 3. results 3.1 search outcomes the search was performed in march 2022. after applying the inclusion and exclusion criteria and critically appraising the studies, a total of nine studies were selected. all selected studies were cross-sectional with sample population of 16,810 nurses. four studies were published in 2020, two in 2021, and three in 2022. moreover, four studies were conducted in china (chen et al., 2020; wan et al., 2022; zhang et al., 2020; zhou et al., 2022), (1) study in the united states (sagherian et al., 2020), (1) study in italy (bellanti et al., 2021), (1) study in iran (kakemam et al., 2021), (1) study in indonesia (susila & laksmi, 2022), and (1) study in india (jose et al., 2020). most of the studies used a convenience sampling method (chen et al., 2020; sagherian et al., 2020; wan et al., 2022; zhang et al., 2020), while zhou et al. (2022) used both convenience and multistage-stratified sampling methods, and two studies used a simple random method records identified through database searching (1152) records excluded at first screening (title & abstract) (638) records screened for eligibility (60) records after duplicates removed (469) full-text articles included in the meta-analysis (9) full-text articles excluded for not meeting inclusion criteria (51) id e n ti fi c a ti o n s c re e n in g e li g ib il it y in c lu d e d additional records were identified through an inverse and a forward search from the included studies (15) nurse media journal of nursing, 13(1), 2023, 99 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 (jose et al., 2020; susila & laksmi, 2022). however, one study (bellanti et al., 2021) did not mention the sampling method. the response rate ranged from 65% to 100%. zhou et al. (2022) reported 65%, wan et al. (2022) reported 87.5%, bellanti et al. (2021) presented 71%, jose et al. (2020), and kakemam et al. (2021) reported a 100% response rate, while two studies did not indicate the response rates (chen et al., 2020; susila & laksmi, 2022). the overall prevalence of ee among nurses was 48.9%, and the accumulated percentage of moderate to high levels of ee ranged from 21.5%% to 76.5%% with a remarkably high heterogeneity between results. to emphasize, kakemam et al. (2021) reported a moderate degree of ee among 218 nurses (21.7%) and a high degree of ee among 485 nurses (48.3%) from the total sample. jose et al. (2020) reported a moderate degree of ee, 21.93%, and a high degree of ee 36.46%, among nurses from the total sample. sagherian et al. (2020) reported overall results of increased ee among 451 nurses, showing a degree of ee in 61% of nurses providing direct care to covid-19 patients. in addition, chen et al. (2020) reported that 45.14% of nurses experienced ee; of them, 26.58% (n=3342) showed a moderate degree of ee, and 21.55% (n=2709) with a high degree of ee. also, zhang et al. (2020) reported that ee was observed among 78.5% of the sample; 15.9% experienced moderate levels, and 6.6% experienced high levels. moreover, bellanti et al. (2021) reported moderate to high emotional exhaustion levels in 76.5% of the sample. zhou et al. (2022) presented that 25.41% of nurses experienced moderate levels of ee, and 26.30% reported a severe level. furthermore, susila & laksmi (2022) revealed that 20% of the nurses suffer from moderate levels of ee, while 7.1 % were at a severe level of ee. finally, wan et al. (2022) documented that 14.58% of the nurses (n=129) suffered from moderate levels of ee, and 8.02% of the nurses (n=71) were at a severe level. descriptive statistics for nurses’ emotional exhaustion according to the mbi tool in the studies included in this meta‐analysis are shown in table 1. 3.2 quality assessment results quality assessment of the included studies showed acceptable quality ranges (see table 2). however, considerable biases were found because some studies did not report the confounding factors and controlling strategies to eliminate them. another frequent bias was that the studies’ subjects or settings were not clearly defined in detail. 3.3 organizational factors associated with nurses’ emotional exhaustion organizational factors influenced nurses’ ee during the covid‐19 pandemic to a considerable extent. for instance, nurses that work in high‐risk work environments such as isolation departments, emergency departments, covid‐19-designated hospitals, a covid‐19 quarantine, or a critical care unit (bellanti et al., 2021; jose et al., 2020; sagherian et al., 2020; zhang et al., 2021) had a higher level of ee. in addition, increased workload, working three or more night shifts, and working more than 40 hours per week were associated with nurses’ ee (sagherian et al., 2020; wan et al., 2022; zhang et al., 2021; zhou et al., 2022). also, nurses who perceived inadequate workplace safety against covid-19 with insufficient personal protective equipment or worked in an unpleasant workplace environment while caring for covid‐19 patients experienced ee more frequently (bellanti et al., 2021; jose et al., 2020; kakemam et al., 2021; sagherian et al., 2020; susila & laksmi, 2022; zhang et al., 2021). other associated organizational factors were reported as living in a hospital dormitory, working with suspected or confirmed covid-19 medical staff (wan et al., 2022), skipping the 30-minute breaks (sagherian et al., 2020), lower monthly salaries (zhou et al., 2022), and current or previous direct contact with patients having infectious diseases (bellanti et al., 2021; kakemam et al., 2021; sagherian et al., 2020; susila & laksmi, 2022). measures of organizational support were reported to reduce ee, such as support from team leaders (zhang et al., 2021), emotional support, and social relationship (bellanti et al., 2021). table 3 presents the organizational factors associated with nurses’ ee in each study. 3.4 the analytical findings the prevalence of nurses’ emotional exhaustion was measured by the standardized and valid questionnaires of the mbi in all nine studies indicating high homogeneity. however, it is nurse media journal of nursing, 13(1), 2023, 100 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 worth mentioning that numerous studies in the nursing literature have measured the prevalence of total burnout dimensions with different instruments, which may provoke counterintuitive results in this meta‐analysis model. thus, it was decided to include studies using the maslach burnout inventory only to calculate the prevalence of nurses’ emotional exhaustion to improve the comprehensiveness and clarity of the results. table 3. organizational factors associated with nurses’ emotional exhaustion study organizational factors associated with nurses’ emotional exhaustion chen et al. (2020) working in a covid-19-designated hospital, working in critical care units, and departments related to covid-19. wan et al. (2022) living in a hospital dormitory, working for three or more night shifts weekly, and having confirmed or suspected medical staff around. zhang et al. (2020) longer working time in the covid-19 frontline quarantine areas. support measures were reported to reduce ee, such as support from team leaders and sufficient material supply. kakemam et al. (2021) close interpersonal interaction with patients in complicated practice environments. sagherian et al. (2020) work status (full time or part-time), hours worked per week, the unit of practice, shift length (extended shifts ≥10 hours or traditional shifts 8–9 hours), and shift types (fixed or rotating). nurses who skipped 30-minute breaks, worked more than 40 hours per week, and provided care for a patient with covid-19 had higher scores of ee. jose et al. (2020) inadequate workplace safety against covid-19, inadequate ppe, and working in the emergency department. bellanti et al. (2021) working in covid-19 units and emergency departments, workload, and direct contact with infected patients. measures of organizational support, emotional support, social relationship, and availability of ppe. zhou et al. (2022) working at night shifts, working more than 40 hours per week, and lower monthly salaries. susila & laksmi (2022) inadequate hospital resources and facilities, current or previous providing care for patients with infectious diseases. figure 2 shows the forest plot for the effects of individual studies included in the metaanalysis and the pooled overall ee prevalence effect size. the total number of subjects surveyed was 16,810), of whom, 8,150 (48.50%) met the criteria for emotional exhaustion. the pooled estimate for ee prevalence of moderate to high levels of ee experienced by nurses was 48.9% (95% ci: 48.1% to 49.6%) based on the common effect model. however, based on the random effects model, the pooled estimate for the prevalence of ee would be 47.8% (95% ci: 34.5% to 61.4%). the random-effects analysis also determined the accepted variance weight of the individual study with a small sample size. figure 2. the pooled overall ee prevalence effect size nurse media journal of nursing, 13(1), 2023, 101 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 regarding between-study heterogeneity, the estimate for τ2 was 69.1% (indicative of substantial between-study heterogeneity). for the i2 estimate, it was 98.5% (95% ci: 98% to 98.9%); therefore, the random effects modeling would be more appropriate for the current dataset, given the high heterogeneity, h statistic = 8.23 [95% ci: 7.14 to 9.49]. this indicates a massive difference between fixed and random effects variability estimates. more formal testing of between-study heterogeneity was conducted using the q statistic, which was 542.41 (8 degrees of freedom) and indicated statistically significant between-study heterogeneity (p<0.0001) (table 4). table 4. the formal test of between-study heterogeneity q statistic degrees of freedom p-value test type 542.41 8 <0.0001 wald-type 623.52 8 <0.0001 likelihood-ratio in terms of assessment of publication bias, we adopted a visual examination of the studies’ findings based on a funnel plot and trim-and-fill procedure. notably, we could not find strong evidence for publication bias based on duval & tweedie’s trim and fill procedure. the effect size for ee prevalence imputed by the trim-and-fill procedure was 47.9% which was close to the observed effect size. due to the small number of studies used in this meta-analysis, it was not feasible to run a full egger’s test for the assessment of the symmetry of the funnel plot. see figure 3 for a visual display of the funnel plot. figure 3. funnel plot for the standard errors of estimates derived from individual studies plotted against their effect estimates. the finding is interpretable as an overall ee prevalence of 47.8% among nursing staff; however, between-study heterogeneity was quite high, indicating substantial variability in ee estimates across different settings. there was little evidence to support publication bias among the chosen studies in this meta-analysis. 4. discussion this review aimed to examine the prevalence of nurses’ emotional exhaustion during the covid-19 pandemic and describe the organizational contributing factors to nurses’ emotional exhaustion. this review found a significant prevalence of nurses’ burnout during the covid‐19 pandemic, according to the mbi. as expected, significant differences were noted between ee levels across the nine included studies from different countries. the prevalence of moderate to high levels of ee experienced by nurses was 48.9%. in comparison with another meta-analysis, nurse media journal of nursing, 13(1), 2023, 102 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 it was found that the prevalence of ee was 34.1% in galanis et al. (2021), conducted in the first year of the pandemic in 2020, with a total of 18,935 nurses, which is lower than the current study result. a possible explanation for the current high prevalence of the pooled mean of ee is that the current meta-analysis included studies from 2020 to 2022, which means that during the start of the covid-19 pandemic crisis and all the sudden changes in healthcare systems, as well as high rate of infected cases and dealing with a new pandemic is increasing (bellanti et al., 2021; jose et al., 2020). these results indicate that overall ee estimates in nurses have to be considered alarming and demand solutions to improve nurses’ work conditions. according to this review, ee is a work-related syndrome resulting from working in a highly stressful environment such as emergency departments, critical care units, covid-19 departments units, and isolation wards. for example, nurses working in emergency departments experienced moderate to high levels of ee (bellanti et al., 2021; jose et al., 2020; kakemam et al., 2021; sagherian et al., 2020). perhaps, the reasons may be due to uncertainty about safety, the fear of becoming infected, the urgent need for covid-19 patient care organization across the department, and insufficient personal protective equipment (ppe) in the initial wave of the covid-19 could be the major sources of anxiety and ee in the emergency department (ahorsu et al., 2021). also, burnout and ee increased among nurses working in the critical care units during the pandemic (bellanti et al., 2021; chen et al., 2020; kakemam et al., 2021; sagherian et al., 2020). a possible reason could be because of the poor patient prognosis, especially for the elderly patients who have another respiratory problem, the increased mortality rate among confirmed covid-19 patients, and the lack of family presence. another possible reason is that hospitals increased the critical care bed capacity, which required transferring more nurses from general wards to the critical care units. this may contribute to nurses feeling unpreparedness or lack of competence in providing care to severely ill patients leading to ee (bellanti et al., 2021). working in covid-19 department units (chen et al., 2020) and isolation wards (wan et al., 2022) increased nurses’ stress, ee, and feelings of isolation. in addition, nurses working in quarantine environments have to possess higher proficiency in facing greater challenges to the specifics of covid-19 patient care and disease prevention. as a result, those nurses may be more vulnerable to stress and more likely developed to ee (zhang et al., 2020). also, higher job demands, workload, and direct contact with covid‐19 patients increase work‐related stress leading to ee (bellanti et al., 2021; sagherian et al., 2020; zhang et al., 2020). moreover, extended working hours, three or more night shifts per week, working with other healthcare professionals who have confirmed or suspected covid-19 results (wan et al., 2022), lack of emotional support (bellanti et al., 2021), inadequate hospital resources (susila & laksmi, 2022) were found as negative organizational factors leading to ee (wan et al., 2022). therefore, future interventional studies on workload, stressful environments, and higher workplace demands during a crisis should focus on effective actions and strategies to prevent and reduce ee and burnout symptoms. notably, decreased self‐confidence in self‐protection, lack of specialized training, and lack of working safety were further influences associated with increased ee among the nurses (jose, 2020; zhang et al., 2020). this indicates the significant need for regular training and professional development for infection prevention and control strategies among nurses (al maqbali et al., 2021; bellanti et al., 2021). these results suggest that ee levels among nurses could vary significantly between different departments and be influenced by several organizational factors. the results of this review align with the maslach theory of burnout. most previous results consider that significant associated factors within the workplace can contribute to nurses’ ee. the present review synthesized and described the character and the sources of work-related antecedents that can result in nurses experiencing ee. 5. implications and limitations nurses working on the frontline play a crucial role in health care services, especially during crises. nurse managers should pay attention to their demands, occupational development, and personal well-being and make additional efforts. establishing psychological consultation clinics should be prioritized to enhance nurses’ mental health status. then, a structured reward system, including improving nurses’ salaries, nurse recognition, and appreciation, is highly mandated. nurse media journal of nursing, 13(1), 2023, 103 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 providing career development plans and learning opportunities would empower nurses and increase their readiness to face challenging circumstances. this systematic review faced some limitations. the first limitation is the limited number of included studies, so meta‐regression analysis to assess further nurses’ characteristics as the independent variables on ee cannot be performed. furthermore, diverse samples in the included studies with insufficient information about the sample inclusion criteria restricted the author from understanding and analyzing the direct relationship between the dependent and independent variables. moreover, most of the included studies were conducted in asia, reducing the generalization of the results. in addition, there is a possibility that other studies from different databases were not included in this systematic review, although this review used several mesh terms and four databases. finally, all included studies were cross-sectional design, which reduced the analysis options to signify the effect of the organizational factors on nurses’ ee. 6. conclusion as far as our knowledge, this is the first systematic review and meta-analysis to estimate the pooled prevalence of ee among nurses during the covid-19 period. the findings confirmed that nurses have been struggling with high to moderate ee levels since the beginning of the pandemic till the current year. furthermore, several organizational factors influence this ee level. these findings highlight the necessity for urgent interventions that can decrease psychological impacts on frontline nurses. acknowledgment the authors would like to appreciate the efforts of all nurses in dealing with covid-19. author contribution ra, og, and mb: plan and design the systematic review and meta-analysis. ra: search and data extraction. ra: paper writing. ra and mb: articles appraisal and data analysis. og and mb: a paper review. all authors are responsible for the study report and provide approval of the manuscript submission. conflict of interest the authors declare no personal or financial conflict of interest in this study. references ahola, k., toppinen-tanner, s., & seppänen, j. 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(2022). factors associated with burnout among chinese nurses during covid-19 epidemic: a cross-sectional study. bmc nursing, 21(1). https://doi.org/10.1186/s12912-022-00831-3 who. (2022). who covid-19 dashboard. world health organization. https://covid19.who.int/ world health organization: who. (2021, october 20). health and care worker deaths during covid-19. who.int; world health organization: who. https://www.who.int/news/item/20-10-2021-health-and-care-worker-deaths-duringcovid-19 zhan, y., ma, s., jian, x., cao, y., & zhan, x. (2020). the current situation and influencing factors of job stress among frontline nurses assisting in wuhan in fighting covid-19. frontiers in public health, 8, 579866. https://doi.org/10.3389/fpubh.2020.579866 zhang, l., chai, l., zhao, y., wang, l., sun, w., lu, l., lu, h., & zhang, j. (2021). burnout in nurses during the covid-19 pandemic in china: new challenges for public health. bioscience trends, 15(2), 129–131. https://doi.org/10.5582/bst.2021.01099 zhang, x., song, y., jiang, t., ding, n., & shi, t. (2020). interventions to reduce burnout of physicians and nurses. medicine, 99(26), e20992. https://doi.org/10.1097/md.0000000000020992 zhou, l.-l., zhang, s.-e., liu, j., wang, h.-n., liu, l., zhou, j.-j., bu, z.-h., gao, y.-f., sun, t., & liu, b. (2022). demographic factors and job characteristics associated with burnout in chinese female nurses during controlled covid-19 period: a cross-sectional study. frontiers in public health, 9, 757113. https://doi.org/10.3389/fpubh.2021.757113 copyright © 2023 nmjn. this article is an open-access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). https://doi.org/10.37363/bnr.2022.3169 https://doi.org/10.1097/md.0000000000020992 https://creativecommons.org/licenses/by-sa/4.0 nurse media journal of nursing, 13(1), 2023, 106 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 appendix 1. table 1. data extraction of the included studies authors country study design sample size & method data collection time results database chen et al. 2020 china large-scale cross-sectional study. 12,596 nurses convince sample. response rate not mentioned april 2020 moderate degrees of ee among 6051 nurses, 48% of the total sample. influential factors relating to ee were being a woman, working in a covid-19-designated hospital, working in critical care units, and departments related to covid-19. pubmed wan et al. 2022 china cross-sectional 885 nurses convince sample 87.5% response rate. february 2020 moderate to high degrees of ee among 200 nurses, 22.6% of the total sample. nurses with longer than five years of work experience had higher ee. working in isolation wards, three or more-night shifts per week, living in hotels, and being surrounded by confirmed\ suspected medical staff were all negative factors that influenced nurse's ee. pubmed zhang et al. 2020 china a crosssectional survey 107 nurses convince sampling. 97% response rate. march 2020 ee was observed among 78.5% of the nurses. moderate to severe ee among 23 nurses 21.5% of the total sample. participants with longer working hours in covid-19 quarantine units. ee increased with younger age and decreased with increasing working experience years pubmed kakemam et al. 2021 iran a crosssectional study 1,004 nurses convenience sample. response rate not mentioned. september november 2020. a moderate degree of ee was found for 218 nurses (21.7%), and a high degree among 485 nurses (48.3%) from the total sample. ee is related to low patient care quality and adverse events. wiley sagherian et al. 2020 united states cross-sectional study. 587 nurses convenience sample. 100% response rate. may-june 2020 the ee among 275 nurses 61% of the total sample. ee related to worked hours per week and participants who skipped 30-min breaks. pubmed nurse media journal of nursing, 13(1), 2023, 107 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 1. continued authors country study design sample size & method data collection time results database jose et al. 2020 india cross-sectional design 120 nurses simple random sampling. 100% response rate. august 2020 56 nurses working in the emergency experienced a severe level of ee of 36.46% and a moderate level of 21.93% among nurses from the total sample. ee was higher among nurses who had a fear of infecting family members, had confidence in self-protection, and had felt poor safety in the workplace. pubmed bellanti et al. 2021 italy a crosssectional study 293 nurses the sampling method is not indicated. 71.8% response rate. juneseptember 2020 a moderate to high ee 224 of nurses 76.5%. ee score was higher in females, nurses with at least one chronic disease, and nurse working for more than 20 years as compared to those working 1–5 years. pubmed zhou et al. 2022 china multisite crosssectional online survey 1133 nurses multistage, stratified sampling & convenient. 65% response rate. septemberoctober 2020 586 nurses reported ee 51.72%. female nurses had higher ee, stage of covid-19 outbreak, job tenure, monthly salary income, and night shift associated with ee. pubmed susila & laksmi 2022 indonesia cross-sectional study 85 nurses simple random. response rate not mentioned june 2021 most of the respondents (72.9%) were in mild ee, 20% moderate, and 7.1 % were at a severe level of ee. hospital resources, have comorbidities, and previous experience of treating patients with infectious diseases were associated with nurses ee. pubmed nurse media journal of nursing, 13(1), 2023, 108 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 2. quality of the included cross-sectional studies item\study chen et al. (2020) wan et al. (2022) zhang et al. (2020) kakemam et al. (2021) sagherian et al. (2020) jose et al. (2020) bellanti et al. (2021) zhou et al. (2022) susila & laksmi (2022) 1. were the criteria for inclusion in the sample clearly defined?  unclear     unclear   2. were the study subjects and the setting described in detail?    unclear unclear     3. was the exposure measured in a valid and reliable way?          4. were objective, standard criteria used for measurement of the condition?          5. were confounding factors identified?  no  no  no no no no 6. were strategies to deal with confounding factors stated?  no  no  no no no no 7. were the outcomes measured in a valid and reliable way?          8. was appropriate statistical analysis used?          copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 nurse media journal of nursing, 10(3), 2020, 260-274 available online at http://ejournal.undip.ac.id/index.php/medianers doi: 10.14710/nmjn.v10i3.31302 critical care nurses’ experiences of end-of-life care: a qualitative study reni sulung utami1, ahmat pujianto2, dody setyawan1, elsa naviati1, nana rochana1 1department of nursing, faculty of medicine, universitas diponegoro, semarang, indonesia, 2department of nursing, faculty of health sciences, universitas borneo tarakan, indonesia corresponding author: reni sulung utami (reni.sulung@fk.undip.ac.id) received: 30 june 2020 revised: 7 november 2020 accepted: 1 december 2020 abstract background: patients admitted to the intensive care unit (icu) may face terminal illness situations, which may lead to death. in this case, the role of critical care nurses shifts from life-sustaining to end-of-life care (eolc). nurses’ involvement in eolc varies between countries, even in one country due to differences in religion, culture, organization, laws, cases and patient quality. in indonesia, research on eolc in icu has not been carried out. purpose: this study aimed to explore the experiences of critical care nurses in providing eolc. methods: a qualitative study with a phenomenological approach was conducted. ten critical care nurses having the experiences of caring for dying patients were recruited through a purposive sampling technique for in-depth interviews. manual content analysis was used to identify themes. results: the results of the study found five themes, including the challenge of communication with the family, support for the family, support for the patient, discussion and decision making, and nurses’ emotions. conclusion: most of eolc provided by critical care nurses was focused on the family. they had some challenges in communication and decision making. nurses need to get training and education about how to care for patients towards the end of life. keywords: critical care nurse; end of life care; experience; intensive care unit how to cite: utami, r. s., pujianto, a., setyawan, d., naviati, e., & rochana, n. (2020). critical care nurses’ experiences of end-of-life care: a qualitative study. nurse media journal of nursing, 10(3), 260-274. doi:10.14710/nmjn.v10i3.31302 permalink/doi: https://doi.org/10.14710/nmjn.v10i3.31302 background death is a common occurrence in the intensive care unit (icu) due to the patient’s poor condition. traditionally, the mortality rate of critically ill patients in the icu is the highest compared to the mortality rate in any other wards of a hospital. a study showed the average icu mortality rates worldwide were 16.2% (vincent et al., 2014). these deaths occur either anticipated and unexpected. in this situation, the role of critical care nurse shifts from providing actions to maintain life to end-of-life care (eolc) (espinosa, http://ejournal.undip.ac.id/index.php/medianers nurse media journal of nursing, 10(3), 2020, 261 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 young, symes, haile, & walsh, 2010). thus, knowledge of end-of-life care is highly recommended for health care providers in icu. according to world health organization (who), eolc aims to improve the quality of life of patients and families by helping them to overcome various physical, psychological, social and spiritual problems. implementation of quality eolc in the intensive care unit (icu) can be very challenging considering the focus of service in the icu is to maintain life (griffiths, 2019). the other studies also address some challenges in implementing eolc in the icu, such as inadequate experience and knowledge to provide eolc, situational conflict to determine the best treatment of eolc (kim et al., 2019), difficulties in communication and decision making, and unrealistic family expectation (brooks, manias, & nicholson, 2017). the practice of eolc in the icu varies significantly between countries. variability is also found within countries and between intensivists within hospitals. differences in religion, law, culture, organization, severity of illness, and complexity of cases, as well as the patient’s prognosis and quality of life, are believed to play a role in creating this variability (decato et al., 2013; muni, engelberg, treece, dotolo, & randall, 2011; ranse, yates, & coyer, 2016a). it is supported by kim et al. (2019)’s study claiming that hospital policy and environmental constraints have become some hindrances in the practice of eolc in korea. meanwhile, brooks et al. (2017) point out that culture, collaboration, and communication are important to yield safe and high quality eolc in australia. the latter researchers also recommend to develop eol care leader and patient support coordinators with nursing and/or medical background. nurses have an important position in providing quality eolc (zomorodi & lynn, 2010). nurses can be a resource and support for patients and families. nurses provide guidance for them confronting difficult decisions and adapting to painful realities. king and thomas (2013) state that nurses accept the reality of death and show a strong commitment to making death as comfortable as possible, more peaceful and dignified. however, providing the best care at the end-of-life is a challenge for them (coombs, addingtonhall, & long-sutehall, 2012; griffiths, 2019). eolc processes expose nurses to human suffering and miserable situations, thus creating anxiety and uncertainty (peters et al., 2013) as well as physical and emotional exhaustion (ozga, woźniak, & gurowiec, 2020; ryan & seymour, 2013). nurses’ education and experiences related to eolc will have an impact on the application of end-of-life practices. a study mentioned the importance of nurses’ experiences in gaining knowledge to handle end-of-life situations (ranse, yates, & coyer, 2016b). this knowledge helps them in professional activities for handling difficult situations when caring for dying patients. however, lacking of experience and knowledge of nurses in dealing with eolc results in negative expressed feelings like sorrow, guilt, regret, and even numbness (kim et al., 2019). research on eolc has been carried out in many countries and has been identified as a research priority in an international delphi study (blackwood, albarran, & latour, 2011). however, up to now, this topic is still rarely carried out in indonesia. several studies have nurse media journal of nursing, 10(3), 2020, 262 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 been done (fitriyani, juniarto, & utami, 2018; rochmawati, wiechula, & cameron, 2018; wessner, 2018), yet the focus is more on the family and religion in palliative care. only one study was found to explore nurse’s experience in carrying out eolc in west java (safitri, trisyani, & iskandar, 2017) though its results remain inadequate to describe indonesian critical nurses’ experiences providing eolc within broad literature. enriching literature to get comprehensive understanding of indonesian critical nurses’ experience related to eolc is necessarily needed by conducting more studies in this area. therefore, studies on different cultures within indonesian context should be done. purpose this study aimed to explore the experiences of critical care nurses in providing eolc. methods research design and setting the present research was a qualitative study with a phenomenological descriptive design. phenomenology was considered ideal for this study because it enables researchers to understand the lived experiences of the human being in the context of their world (polit & beck, 2017). the phenomenon explored in this study was the critical nurses’ lived experience in performing eolc. this research was carried out in the icu and pediatric intensive care unit (picu) of two public hospitals in the province of central java, indonesia, at the end of 2018. in order to uncover the phenomenon, after the research design was conveyed and the research setting was described, the researchers then conducted some systematic steps, such as participant recruitment, data collection and their storage, data analysis, and ensuring trustworthiness (polit & beck, 2017). participants and sampling a purposive sampling technique was used to recruit ten nurses from icu/ picu who met the inclusion and exclusion criteria. criteria for inclusion of participants in this study were nurses working in icu/picu for at least one year, permanent employees and had experiences in caring for patients with end-of-life conditions. the recruitment of participants was done after ethical clearance and research permits from two hospitals were obtained. the researchers approached and delivered information to the head nurses at the research location about the objectives and the research procedures. the researchers asked them for help to obtain data on nurses in their units to identify potential participants. together with the head nurses, the researchers identified potential nurses as participants based on established inclusion and exclusion criteria. involving the head nurses was done as they in nature had a good view and consideration about the duty and working experience of their nurses according to the inclusion and exclusion criteria. after obtaining the names of the potential participants and their contact numbers, only ten participants from the list were approached and contacted for further interviews. this process did not involve the head nurses to maintain participants’ privacy. data collection in-depth interviews using semi-structured question sheets were used as data collection methods in this study. the interview questions were developed from the literature review nurse media journal of nursing, 10(3), 2020, 263 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 and consulted with clinical experts. participants were invited to take part in interviews by phone. after they agreed to participate in the interview, both parties made a contract on where and when the interviews were carried out at the participant’s convenience. this semi-structured interview was conducted for approximately 40-50 minutes in a quiet, comfortable, and closed room and was recorded using a digital recorder. each participant was interviewed more than once. the interview began with the introduction, signing informed consents, and some general questions. some open-ended questions were then asked to gain their experiences, like “could you tell me your experience in looking after the end-of-life patients and their families in this unit?” and “what do you feel when you deal with the patients in their end-of-life and their families?”. some probing questions were asked to clarify or to seek more information about participants’ responses, such as “what do you mean by difficulty here?” and “could you tell me more about this emotion?”. observational field notes/ memos were written throughout the interview process. after all questions were asked, the researchers thanked the participants and asked for their oral consent for a follow-up interview. each interview record was then labeled in the form of a participant identification number, interview time, and sequence of interviews and field notes during the interview. furthermore, the recording was transferred to three duplicate audio files stored on a computer, external hard disk (flash disk) and cd before being transcribed verbatim. the stored files on the computer and flash disk were locked for confidentiality and security and only the reseachers knew the password. the interview and participant recruitment were stopped after 10 interviews to the point of data saturation. data analysis data collected in this study were analyzed using manual content analysis which was divided into four stages (polit & beck, 2017). the first stage was the process of verbatim recording transcripts and the elimination of the participant’s self-identity. the second stage was the process of reading transcripts accompanied by listening to recordings repeatedly to get general conclusions. this process was important to get holistic sense (the gestalt) and overall understanding of the participant’s information. the third stage was the process of identifying keywords to produce categories before combining them into sub-themes and themes and looking for relationships between data using maps and diagrams. the fourth stage was the process of integration and interpretation of themes and sub-themes into meaningful descriptions of the phenomena under study. data quality ensuring validity and trustworthiness was maintained throughout this study. validity in term of maintaining the objectivity of the researchers was done through bracketing from the literature review process to the data analysis. bracketing prevented the researchers’ personal views and preconceptions from interfering the unique descriptions of the phenomenon. it also prevented the researchers’ interpretation during data analysis. prior knowledge and interpretation were bracketed and written down on memos. furthermore, the trustworthiness of this study was ensured by conducting triangulation with the theory and secondary data (documents, field notes), member checking, peer debriefing, and audit trail. member checking was carried out by having follow-up interviews for clarification and further discussion. however, only four out of ten participants had done the member checking due to time constraints. peer debriefing was done through researcher team’s nurse media journal of nursing, 10(3), 2020, 264 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 meetings to review and discuss the transcripts, keywords, categories, and themes while audit trail was conducted by collecting and documenting the data systematically so that the data could be reviewed externally. ethical consideration this research had obtained an ethical clearance prior to the data collection from the health research ethics committee (kepk) of the faculty of medicine, universitas diponegoro (no. 250/ec/fk_rsdk/iv/2018), and permissions from two hospitals where this study was taken place. a statement letter explaining the research and an informed consent letter as a participant was given to participants before interviews to respect the dignity and the freedom of the participants and to avoid being coerced into participating in this research. participants who agreed to be involved in the study were asked to sign an informed consent form. privacy and confidentiality of participants were also maintained in this study. the use of pseudonyms to identify the participants was done to keep the confidentiality. results characteristics of participants as presented in table 1, this study involved ten nurses working in the icu/picu. a majority of them were females, aged 41 to 50 years old, graduated from bachelor and nursing professional degree and had working experiences of two to ten years. table 1 characteristics of participants characteristics f(%) gender male female 2 (20) 8 (80) age (years) 21-30 31-40 41-50 1 (10) 3 (30) 6 (60) icu experience (years) 2-10 11-20 >20 6 (60) 2 (20) 2 (20) level of education diii div s1 + ners 4 (40) 1 (10) 5 (50) the results of the thematic analysis of nurses’ experiences in providing eolc to patients in the icu revealed five main themes namely the challenges of communication with family, support for the family, support for the patients, discussion and decision making, and nurses’ emotions. each of these themes is presented and illustrated using verbatim quotes from interviews. nurse media journal of nursing, 10(3), 2020, 265 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 theme 1: the challenges of communication with the family participants stated that communicating with families with end-of-life conditions has its own challenges and difficulties. the communication difficulties faced by nurses primarily are communicating with families who have high expectations, families are still in the denial stage, and smart-assed families. higher and lower education does not always guarantee the ease of communication. the participants’ statements are quoted below: “the challenge is the family, ... sometimes the family has been informed, but the family has not been able to accept the patient’s condition ...” (p7) “i thought that communicating with the family with higher education will be easy; but it is not; they even need more details... for family who had low education…, giving knowledge is also difficult. it turns out that education also determines the standpoint of the other side... so, the family’s response must be meticulous too. it was also difficult to provide education to people who work in health field as similar with us…” (p6) “... the family still hopes that the patient is be able to return; it is difficult to tell the family that this is hopeless, and they also have difficulty in understanding the medical terms...” (p9) “it’s difficult to handle family who acts know it all...; family with a high-income and higher education... they can understand when they are given explanation, but there are also some families who are pretentious to understand... they did not fully understand... however, there are also some families that are highly educated but it is difficult to talk to them. it’s just difficult to explain to them…” (p2) one participant said that nurses’ ability to communicate significantly determines the relationship of nurses, both with colleagues and family. level of education of family affects the communication techniques that nurses applied. “...our ability to communicate determines both partners and family... the level of education of family varies, so the language we choose determines whether or not he can accept it. we have to adjust to their level of education so that they can understand if we use a common imagery. maybe our techniques for conveying need different ways…” (p10) the existence of a case conference that decides an agreement between the health team regarding what the family will convey is perceived to be very helpful for the participants in communicating with the family. this was stated by the participants as below: “so, nurses and physicians convey their feelings and voices related to patient care in the case conference and then a decision will be made... we talk to the family based on the script that we agreed upon, for example a to a or b to b. this conference is very helpful for us…” (p2) theme 2: support for families this theme emphasizes the form of support provided by nurses to families of patients with end of life care plans. this support included giving encouragement, trying to always nurse media journal of nursing, 10(3), 2020, 266 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 be there for the family, and inviting families to chat and pray together. this was stated by the participants as below: “so, we can only give encouragement to his family..., and providing understanding to his family in order to accept the reality... the most important thing for me to support him is being close to him, accompanying him, and inviting him to discuss about his son problems so he can accept any circumstances related to his son... basically, communication is the key to being close with him... do not leave him alone...; invite him to prayer together as well...” (p8) “...we give understanding that the patient cannot be helped and we have tried to help patient optimally..., but the patient did not want to be helped anymore... we explain it to both parents even though it was in sad situation... at least, we encourage them to talk to reduce their grief rather than only said to them that their child is dead and we are busy taking care the deceased... it looks like we left them alone... if we ask them to talk, they will not feel sad alone.” (p9) another form of support provided by nurses is to provide opportunities for families to always be close to patients. families are allowed to be near the patient even outside the visiting hours, but this applies only to the nuclear family, for example the patient’s parents. “… two family members are allowed to wait in the bedside of a dying patient… we gave them the opportunity even though it was out of visiting hours…” (p3) “...those conditions sometimes trigger our social spirit. we allow the caregiver sit near the patient’s bed even though it was not the visiting hours. all curtains were closed. we also often accompany them so that patients can be accompanied continuously.” (p5) “he was allowed to pray together with his family’s member or his religious leader... he is permitted to approach his child to pray until his child death.” (p8) theme 3: support to patients support is given to patients as an effort to raise comfort to patients such as avoiding actions that cause pain, providing pain medication and providing personal hygiene care. almost all participants gave spiritual support to patients, either directly or indirectly, for example, listening to spiritual texts (e.g., the holy quran recitation), guiding prayers, and facilitating spiritual guidance by calling religious leader as needed. “…improve the quality of life of patients by providing a sense of comfort, for example by reducing pain ...” (p7) “... if it has been stated end-of-life, we are more focus on patient comfort, for example, performing personal hygiene, positioning, and persuading the physician to avoid taking unnecessary blood samples... that’s the focus of nursing care...” (p9) “...we give analgesic to make the patient feel comfortable, perform maximal wound care, nutrition is also maximized. we support family in order to continue in providing support for patient” (p6) nurse media journal of nursing, 10(3), 2020, 267 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 “for moslem patients, usually while bathing, they recite al fatihah or healing prayers. if the patients are still conscious, we encourage them to recite al fatihah... when i give injection, i ask them to pray... hopefully later, through this drug, the god can give the cure” (p2) “for spiritual care, it’s rather difficult if the patient is not fully conscious...; at least by playing al quran recitation.” (p6) “...for patients and families... so we offer it to the family ... do they need spiritual support/guidance?... in our hospital there are islamic and christian spiritual facilities ... if necessary we will facilitate ...” (p1) theme 4: discussion and decision making majority of participants stated that decisions related to care provided to patients were made based on the results of the discussion between family and the multidisciplinary team; yet the role of physicians is dominant compared to that of nurses. nurses tend to follow the doctor’s instructions. “...for cases of long-stay patient, we usually have discussions with family and team such as anesthetist, neurologist, pulmonologist, and others. we sit and discuss together then we made a decision...” (p5) “...if patients stay for more than 10 days or more than 2 weeks... we always carry out case conferences... the result will be informed to the family for further followup... for long stay patients or patients with complicated diagnosis.” (p2) “the nurse is the first one who knows for sure... we share it first to the doctor... later the doctor will educate the family... even though we can do it, but we always share with the doctor... we didn't make decisions... it is because in the informed consent, the doctor is the one who gives the signature... but the doctor knew the issue from the nurse...” (p2) “if the patient has been declared dying, we will wait until the time is up... then what the advice of the doctor? if for example, he has bradycardia/ asystole...., there is no hope anymore and then the doctor says it is finished... yeah it means finished.” (p8) however, there were some participants who have a courage to argue with doctors regarding patient care. that happen if they had a strong justification. “...actually, i disagree, but this is a team... so i give help too... we had an argument... our last strategy was calling the family...” (p9) “... actually, it doesn't make any difference, even though it is end of life... we still support the respiration, their nutrition and others..., but these supports depend on the physician... but we can propose, for example giving analgesia... we can propose it to the doctor because it’s his area, not ours. but still we can propose it with a note if there is a reason.” (p10) theme 5: nurses’ emotions participants said that caring patients of end-of-life reminded them of death. participants conveyed sympathy and empathy to both patients and families. participants could feel the sorrow of the family who lost their member and even cried. nurse media journal of nursing, 10(3), 2020, 268 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 “... if saw the patient is still productive and the disease is not too complicated, there is such a pity feeling... why not helping up to the maximum first... once there was a family that is given up; it might be because of the cost or something. we always explain that this patient can be improved... why did not withhold?... but, if the patient is on end stage…for example cancer stage 4, elderly with stroke..., we just remember about dies; we will also experience death someday….” (p2) “the most imprint is when they have a son...; to have a son is already difficult or has many times but miscarriage, and this is the only child he has... it continues to imprint in our heart...feel a pity... extraordinary empathy... because we are also a human and a woman can feel how she has a difficulty in having child but god does not grant it” (p8) “... sometimes, when the family has been told that their child is dying... i am emotionally crying too...” (p10) one participant said the death rate in her ward was quite high and this caused fears on her that it will reduce her empathy due to seeing patients die so often. “… i am afraid that my heart will harden… i am afraid that i am less sensitive to people’s sadness because i often see people die… when the patient dies, the family cries and we can still laugh…” (p4) discussion this study aimed to explore the nurses’ experiences in providing eolc in the icu. the findings showed that nurses had several challenges in providing the care. moreover, most of eolc provided by nurses was focused on family. some studies state that eolc in the icu is challenging (kisorio & langley, 2016; ozga et al., 2020). ozga et al (2020) identified three categories of potential barriers in providing eolc, namely (1) barriers attributable to the hospital, (2) barriers related to the patient’s family, and (3) barriers related to the icu personnel providing direct eolc. in this study, participants reported some challenges and difficulties when communicating with the family of dying patients. these results are consistent with the results of previous studies (aslakson et al., 2012; crump, schaffer, & schulte, 2010; muni et al., 2011; ozga et al., 2020). there are several factors that can create challenges and have an impact on the quality and quantity of communication between doctors, patients, and families at the end-of-life in the icu. these factors include communication skills of doctors and nurses, lack of time of doctors/nurses, the ability of families to understand the information delivered, cultural disparities and the emotional condition of the family (aslakson et al., 2012; jin, 2013; levin, moreno, silvester, & kissane, 2010). all these factors were stated by participants in this study. nurses in this study convey difficulties when communicating with families who are still in the denial phase. denial is a common coping mechanism for those facing a terminal illness. in this stage, families start to deny bad news that is given. they believed that the information is wrong and there must have been a mistake. in dealing with this situation, nurses must respect the family’s essentially protective nature of it. nurses need to seek first to understand and validate before attempting to change anything. this will produce far more therapeutic benefits than trying to change or override such defenses. encouraging positive aspects of the family and building them as strengths nurse media journal of nursing, 10(3), 2020, 269 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 may be more beneficial than confrontation and criticism. nurses need to master these skills. the complexity of information, family’s lack of capacity in understanding information, and the uncertainty of critical patient conditions can make family members feel depressed and frustrated (carlson, spain, muhtadie, mcdade-montez, & macia, 2015). this emotional disturbance can interfere with cognitive processes and affect the ability of families to understand, remember, and search for complex information about the condition and prognosis of their loved ones (morgado & cerqueira, 2018; sandi, 2013). in 2015, mathew, azariah, george, and grewal reported that 71% of families have a poor understanding of the diagnosis, treatment, and prognosis of patients. family’s understanding will get worse when the family only interacts with the healthcare staff for less than 10 minutes. nurses spent the most amount of their time with patients and families compared to other health care professionals; thus, it gave nurses a great opportunity to build trust and give comfort care. nevertheless, they still feel they are not sufficiently prepared to care for dying patients and their families (espinosa et al., 2010). nurses who are inexperienced and not ready to provide care can experience doubts about what should be done and, in the end, do nothing (kisorio & langley, 2016). in this study, the inexperienced nurses sought for help from their senior experienced nurses. families feel the presence of nurses as comforting hugs that sustain them before, during and after the death of the patient (williams, lewis, burgio, & goode, 2012). in this study, some participants provide time for families to accompany them and listen to their feelings and thoughts even though it was not always possible. being present allow nurses to experience the families’ lives, sensing their milieu and their situation. as a result, it could enhance their empathy and compassionate behavior to others. indeed, for some nurses, this practice is not easy task for them because they do not feel confident from their lack of knowledge and experience. in indonesia, training and nursing curriculum related to end of life care is likely to be inadequate. this issue also found in other settings (cavaye & watts, 2010). to ensure patient comfort in the dying process, nurses provide spiritual care and basic nursing care. in this study, nurses encouraged and guided patients and their families to pray and facilitated them in inviting a religious leader. nurses also allowed them to bring their own spiritual leader. spiritual care plays a vital role in preparing for a peaceful death and is an important aspect of holistic nursing care (witt sherman & free, 2015). spiritual care is not only important for family, but also for family member and medical staff. the positive effects of spiritual care have been reported (chen, lin, yan, wu, & hu, 2018; willemse et al., 2020; zhang, nilsson, & prigerson, 2013). a recent ethnographic study in indonesia found that spirituality/religiosity is very important in the daily lives of patients, family members and healthcare staff (rochmawati et al., 2018). even though spiritual care is viewed as an important dimension of end-of-life care, its implementation is still inadequate (balboni et al., 2013). this phenomenon may be caused by the lack of training and education. nurse media journal of nursing, 10(3), 2020, 270 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 end-of-life decision making is a growing need in the icu, covering a continuum of treatment possibilities. it has been perceived as complex, difficult and stressful (pereira, fradique, & hernandez-marrero, 2018). this study reveals that families are involved in the decision-making process. in indonesian culture context, the role of family is strong and important in patient care. moreover, discussion involving family is essential because patient in high vulnerability condition and generally unconscious. in line with previous research (flannery, peters, & ramjan, 2020; griffiths, 2019; kisorio & langley, 2016), the role of nurses in making decisions regarding the end-of-life in this study is still lacking. they still have a tendency to follow doctor’s instructions. this could happen because end-of-life decision is a medical decision and becomes the responsibility of physicians. on the other hand, nurses often feel inadequately prepared (griffiths, 2019). interprofessional education and collaboration between physician and nurse can improve future decision-making processes (flannery et al., 2020). nurses are frequently exposed to the care of death and dying patients. this experience made them aware of their own death (peters et al., 2013). this is as stated by participants in this study. peters et al (2013) reveals that exposure to death often causes anxiety in nurses. senior nurses with more experiences tended to have more positive attitudes toward death and caring for dying patients, whereas nurses without this experiences had more negative attitudes (abu hasheesh, abozeid, el-said, & alhujaili, 2013). hinderer (2012) stated that understanding nurses’ emotions to patient death can help to improve the quality of care they provided to dying patients and to meet the needs of the nurses who care for them. the reactions of participants in this study conveyed sympathy and empathy to both patient and family. sympathy was described as a superficial acknowledgment of suffering, generating a compassionate response that fails to adequately acknowledge the person who is suffering. in contrast, empathy is an affective response that recognizes and tries to understand individual suffering through emotional resonance (sinclair et al., 2017). empathy has a positive meaning and more welcomed and valued by patient and families. this study reveals that caring for the dying patients was challenging emotionally and psychologically for nurses. these challenges must be addressed. nurses need to enhance their communication skills and more actively involved in facilitating the end-of-life decision making process. education and training about eolc are imperative for providing the best quality of eolc. in addition, a course in palliative care is suggested to be mandatory in nursing education. a few limitations of this study should be acknowledged. some participants were interviewed at the icu because they could not leave the ward and refused to meet after working hours. as a result, the interview process is sometimes interrupted by the activities of other nurses in the room. member checking was not carried out to all participants due to time constraints resulting in possible researchers’ bias though bracketing and peer debriefing had been done. conclusion nurse media journal of nursing, 10(3), 2020, 271 copyright © 2020, nmjn, p-issn 2087-7811, e-issn 2406-8799 this study showed five themes, namely the challenges of communication with family, support to the family, support to the patients, discussion and decision making, and nurses’ emotions. nurses had several challenges and difficulties in communicating with the family of dying patients. moreover, eolc provided by nurses was more focused on family involvement. nurses were still not optimal in providing care for patients in endoflife condition. nurses need to get training and education about how to care for patients towards the end-of-life. further research needs to be carried out to explore nurses’ communication experiences related to eolc. acknowledgment we gratefully thank the faculty of medicine, universitas diponegoro for financial support. conflict of interest the authors declare that they have no conflict of interests references abu hasheesh, m. o., abozeid, s. a. s., el-said, s. g., & alhujaili, a. d. 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(2010). critical care nurses’ values and behaviors with end-of-life care: perceptions and challenges. journal of hospice & palliative nursing, 12(2), 89–96. doi:10.1097/njh.0b013e3181cf7cf6 nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://medianers.undip.ac.id 13(1):56-67, april 2023 https://doi.org/10.14710/nmjn.v13i1.50633 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 original research parents’ experiences of caring for children with congenital rubella syndrome (crs) in remote and rural areas of indonesia petrus kanisius siga tage1, herliana monika azi djogo1, erna febriyanti1, yulia martiningsih karmila letor1, maria yoanita bina1, maria yasintha goa goa1, angela muryanti gatum1 1departement of nursing, health sciences faculty, universitas citra bangsa, east nusa tenggara, indonesia article info abstract article history: received: 2 december 2022 revised: 27 april 2023 accepted: 28 april 2023 online: 30 april 2023 keywords: caring; congenital; parents; remote; rubella syndrome corresponding author: petrus kanisius siga tage departement of nursing, health sciences faculty, universitas citra bangsa, east nusa tenggara, indonesia email: petruskanisiussigatage@ucb.ac.id background: parents of children with congenital rubella syndrome (crs) in rural areas face limited access to medical care and specialised services, financial difficulties, social isolation, and stigma. research on their experiences is limited. purpose: this study explores parents’ experiences of caring for their children with crs in rural areas of indonesia. methods: the research used a descriptive phenomenological approach, purposive sampling to collect parents of children with crs from the shelter, and snowball sampling for other participants. inclusion criteria included parents who cared for crs children over than two years old, could express their experiences, and spoke indonesian. twenty-five parents participated in an in-depth semi-structured interview. the data were analysed using the colaizzi method. results: this research found that parents caring for sick children in rural areas experienced life-altering situations that affected their mental health. in addition, caring for sick children also caused emotional disturbances and tension in family life. other challenges included getting proper treatment for their child, especially in remote rural areas, and difficulty to reach health services. therefore, proper mental health treatment and support were essential for parents who cared for sick children in rural areas. conclusion: this study describes complexities of parents’ experiences of caring for children with crs, such as difficulty to accept the child's condition and feeling burdened by their child’s case. further studies are needed to understand cultural influences and expand the study area. how to cite: tage, p. k. s., djogo, h. m. a., febriyanti, e., letor, y. m. k., bina, m. y., goa, m. y. g., & gatum, a. m. (2023). parents’ experiences of caring for children with congenital rubella syndrome (crs) in remote and rural areas of indonesia. nurse media journal of nursing, 13(1), 56-67. https://doi.org/10.14710/nmjn.v13i1.50633 1. introduction congenital rubella syndrome (crs) is an infant disease caused by infection with the rubella virus in the mother during pregnancy (lanzieri et al., 2020). globally, based on the world health organization’s report in 2020, the number of crs cases was 603; in southeast asia, it was 248. in indonesia, it was 110 cases, which made indonesia the country with the most significant number of crs cases in southeast asia (world health organization, 2021). the existing crs case data shows that this problem can significantly pressure children and families regarding symptom management, emotional burden, and treatment costs. early recognition of crs cases is significant for patients. however, identifying cases of crs is difficult because clinical symptoms such as sensory disturbances, endocrinopathy, and thyroid often appear later (wondimeneh et al., 2018). in addition, the characteristics of crs, such as cataracts, congenital heart disease, hearing loss, and developmental delays, can lead to worsening chronic disease (nahar et al., 2020). parents’ burden while caring for a child with a crs hurts their emotional, social, financial, physical, and spiritual functioning. a study in the philippines explains that the average health cost for children with crs in the 16-14 months age is us$ 7.45; most of the costs come from treating heart complications, with the highest average being us$ 2.12 to us$ 15.5 (tan & leon, 2023). reports from ethiopia show that parents who care for children with congenital abnormalities due to crs experience high emotional stress (taye, 2021). studies in america show that parents who care for children with crs who experience high caregiver stress have a poorer overall quality of life (armstrong, 2015). studies of parents’ experiences of caring for crs children show that they https://crossmark.crossref.org/dialog/?doi=10.14710/nmjn.v13i1.50633&domain=pdf&date_stamp=2023-04-30 nurse media journal of nursing, 13(1), 2023, 57 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 experience emotional stress, need family support, lack knowledge, and try various ways to help their children (leon et al., 2018). the problems faced by parents when caring for children with crs in the indonesian context are increasingly complex, considering that currently, indonesia still has remote areas (left behind =left behind, leading/farthest=remote, and outermost=frontier/outermost) consisting of 9 provinces (out of 34 regions) defined by government regulations (ministry of national development planning of indonesia, 2020). these underdeveloped areas need more resources for health workers; only a portion of the population has received national health insurance services (wenang et al., 2021). therefore, it is difficult for parents to bring their children to health facilities and get proper treatment. in addition, due to limited facilities, this study shows the disparity of health facilities in indonesia, where adults living in urban areas tend to use hospital outpatient facilities 1,246 times higher than adults living in remote areas. furthermore, the possibility of simultaneously using outpatient and inpatient facilities for adults living in urban areas is 1.134 times higher than in rural areas (wulandari et al., 2022). crs has various clinical patterns and treatment modalities, and early recognition of cases of crs is significant for patients. in rural areas, the problem of crs is complex because of the need for more detection tools, human resources to provide long-term care, and surveillance funds so that early detection of cases is not optimal (brown et al., 2020). parents’ various complex problems in raising children with crs require a comprehensive study to provide appropriate psychological assistance so parents can take good care of their children. little information is available from previous studies about the experiences of parents caring for children with crs, especially in remote areas that require access to health resources. therefore, this study explores parents’ experiences of caring for their children with crs in underdeveloped regions of indonesia. 2. methods 2.1 research design this study used a descriptive phenomenological method that systematically describes the structure of a phenomenon reflected in the participants’ life experiences by using language that reflects the transformation of the participants’ natural expressions (bartholomew et al., 2021). 2.2 setting and participants the study was conducted in january-june 2022. determination of participants in this study was done using the purposive sampling technique. the researcher collected parents with crs children from the shelter where the patients lived during their child’s referral care in jakarta. in addition, the researchers used a snowball sampling technique to recruit one participant to another based on the inclusion and exclusion criteria of the study to track participants through associations of parents with children suffering from crs. the participants of this study were parents with crs children from the provinces of east java, south kalimantan, east kalimantan, east nusa tenggara, papua, southeast sulawesi, and west sumatra. participants included in this study were parents who (1) cared for a child with crs for more than two years, (2) could reveal their life experiences, and (3) could speak indonesian. this study used a sample of 25 participants aged 30-40 years who were recruited in different numbers from seven regions according to the availability of participants and the fulfillment of inclusion criteria to increase the variety of participants’ demographic backgrounds, broaden research subjects from the various areas, and allow the birth of diverse experiences. 2.3 measurement and data collection the interview process in this study was conducted face-to-face and via video conference through the zoom application conducted by three researchers. the researcher visited the participants for face-to-face interviews and contacted the interviewees via the zoom application before the interview to ensure that the participants met the inclusion criteria. the researcher also conducted a preliminary assessment, explained the research, and provided an interview time contract. interviews were conducted with 25 participants. data saturation was reached in the 23rd participant when the participants’ answers during the interview remained consistent. the researcher used questions from the interview guide to help focus on the interview. the method used in this research was in-depth interviews with semi-structured interview techniques where the questions were not asked in a specific order but were asked based on the conversation nurse media journal of nursing, 13(1), 2023, 58 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 that appeared, and each statement was explored in detail to get the meaning according to the research objectives. two researchers conducted the interview process for 45-60 minutes separately for each participant. the participants submitted a recording permit to record voices during face-to-face interviews in jakarta in february 2022. video recording was recorded during interviews via the zoom application in march-may 2022. the researcher used open-ended questions and tried to understand the phenomenon from the participants’ perspectives without giving opinions, criticisms, and evaluations during the interview. some of the questions in the interview included (a) how do you feel about trying to care for a child with crs?, (b) what obstacles are experienced when caring for a child with crs?, (c) what treatment efforts have been made so far?, (d) what support is received from the closest people, the government, and the surrounding community?, (e) what are the expectations regarding the childcare process in the future?. 2.4 data analysis the pre-recorded data was transcribed verbatim. next, the researcher listened to the recordings to improve the accuracy and reliability of the data. data were analysed using the colaizzi method (sanders, 2014). in the first stage of the analysis, seven researchers (pkst, hmad, ef, ymkl, myb, myg, amg) reread the transcribed data, focusing on the context of the data and participants’ responses and selecting significant statements. then, similar words were grouped into the same category, followed by theme extraction by similar grouping categories based on factual statements. five researchers collected and analysed data simultaneously (pkst, hmad, ef, ymkl, myb). in this study, the interviews were conducted until saturation was reached so no new content emerged in the discussions, and the same concepts and themes appeared in the data analysis. 2.5 trustworthiness the data validity in this study is maintained based on cypress’s (2017) following steps; (1) dependability, seven researchers conducted the research by discussing the appropriate method related to the study approach, data analysis, and data interpretation. three researchers with previous qualitative study experience focused on developing appropriate methods. three researchers extracted significant ideas from participants about their specific experiences when interpreting the data. in contrast, four researchers were explicitly tasked with reviewing the transcribed material to validate themes and appropriate descriptions. if the identified theme is different, it is agreed not to use it. (2) credibility was fulfilled using prolonged involvement of researchers and persistent observations to study the context of existing phenomena and minimise distortions that might infiltrate the data. to achieve this, the two researchers spent six months with the participants to build trust and rapport with them, participants, throughout the data collection process. the same questions were asked in different forms to allow for repeated identification during interviews and analysis. peer debriefing was conducted through meetings and discussions among the seven researchers to find deficiencies in research activities. in addition, a source triangulation process was carried out from previous studies to ensure the correctness of the data. (3) confirmability is carried out by member checking with participants to ensure the data is complete, representative, and written without the researcher’s bias. in addition, authors with different academic and clinical backgrounds and interests read and discussed each other’s interpretation of the data each week, which helps identify implicit concepts. (4) transferability to measure whether or to what extent study results can be applied in other contexts, circumstances, and settings. it was done by expanding study locations, increasing the diversity of participant demographic status, and using a purposive sampling technique. moreover, the recorded data was carefully transcribed by five researchers. during the analysis phase, all aspects of the analysis were documented. analysis refers to the categorisation and organisation of information in such a way as to understand the data and to write a true and accurate final report. 2.6 ethical consideration ethical clearance and research permission were obtained from universitas citra bangsa with a reference number of 5/ucb.fik/01.01/2022. each recruited participant had received an explanation of the purpose and benefits of the research and signed a research consent letter. nurse media journal of nursing, 13(1), 2023, 59 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 3. results 3.1 demographic data of participants table 1 shows that the majority of participants were aged 20-30 (76%), females (64%), senior high school graduates (52%), homemakers (64%), and muslim (68%). participants mostly came from east java, with a presentation of 32%. the majority of illness duration is 2-10 years (64%), and the diagnosis of most children’s diseases is congenital heart defects (52%). table 1. characteristics of participants characteristics n (%) age (year) 20-30 19 (76) 30-40 6 (24) gender female 16 (64) male 9 (36) education elementary school 5 (20) junior high school 5 (20) high school 12 (48) college 3 (12) profession homemakers 16 (64) farmer 2 (8) civil servant 2 (8) driver 2 (8) domestic workers 3 (12) religion islam 17 (68) protestant 5 (20) catholic 3 (12) origin of participants east java 8 (32) south kalimantan 2 (8) east kalimantan 2 (8) east nusa tenggara 3 (12) papua 1 (4) southeast sulawesi 4 (16) west sumatera 5 (20) child’s disease duration (years) 2-10 16 (64) 11-20 9 (36) diagnosing children’s diseases congenital heart abnormalities 13 (52) eye anomaly 4 (16) sensorineural hearing loss 4 (16) bone defects 4 (16) this study produced four themes which can be seen in figure 1. 3.2 theme 1: life-changing situations parents finally accept their child's congenital disabilities caused by crs. this situation changed their lives due to their difficulty caring for them and the social stigma. there are four sub-themes in this theme: it is hard to accept the reality, overwhelmed by new situations, learning to understand children's conditions, avoiding bad stigma. nurse media journal of nursing, 13(1), 2023, 60 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 figure 1. summary of themes and subthemes 3.2.1 it is hard to accept reality parents have high hopes for their child before birth but have difficulty accepting it at birth with crs. participants expressed the following statements: i rejected my child’s condition and considered it normal, like other children, for six months (p4); my husband and i thought our son was normal for some time (p7). 3.2.2 overwhelmed by new situations the birth of a child with crs is new for some parents who feel overwhelmed by their child’s complex problems. participants expressed the following statements: the first child is normal, and i feel overwhelmed caring for the second child with crs (p13); my son’s diagnosis is very complex so i am confused about how to treat it (p16). 3.2.3 learning to understand children’s conditions parents often do not understand their child’s condition when they are under pressure due to change but learn quickly to help overcome their child’s problems. two participants stated: learning about childhood illnesses and how to deal with them is important and must be done quickly (p21); children get sick easily, i learned to measure body temperature and give warm compresses when they have a fever (p15). 3.2.4 avoiding bad stigma conditions experienced by children, such as mental disorders, make children get a bad stigma from the community; parents’ efforts to protect their children limit themselves from social activities for fear of getting wrong statements from the community. participant expressed the following statements: i avoid activities where there are many people; i am not active in neighbourhood meetings because of society's statements that call my child a stupid monkey (p7); i have never featured my child on social media or brought him to church for worship; i have heard someone say my child has no future (p11). 3.3 theme 2: emotional disturbance various emotional problems are expressed by parents when dealing with child’s condition. it makes parents stuck with a variety of emotional issues. this theme has three subthemes: daily anxiety of losing a child, confrontation with sadness, and dealing with uncertainty. •it is hard to accept the reality •overwhelmed by new situations •learning to understand children's conditions •avoiding bad stigma life-changing situations •the daily anxiety of losing a child •confrontation with sadness •dealing with uncertainty emotional disturbance •barriers to family relationships •loss of family income source •the increased family debt burden •divorce tension in family life •difficult access •lack of resources •wrong regional political policy •using shaman the challenge of getting treatment nurse media journal of nursing, 13(1), 2023, 61 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 3.3.1 the daily anxiety of losing a child when a child is seriously ill, parents worry about the possibility of the child dying. lifethreatening illness raises the harsh reality parents face about possibly losing a child. two participants stated: when my child suffers from a severe decline in physical condition, i realise that, at any time, due to the development of the disease, or a crisis, it may result in me losing my child (p1); we are part of a parent group with a child with crs, when a fellow parent reported that their child had died, i was worried that this would happen to my child (p17). 3.3.2 confrontation with sadness despite the imminent threat of losing a child, parents must always deal with the loss and sadness associated with their child’s physical weakness. they must constantly adapt their own lives to fulfill their nurturing role. participants expressed the following statements: it can be tough when your child is sick and can't attend school, eat alone, or communicate. it can be difficult even if you try to escape the situation (p20); due to breathing difficulties and hospitalisation, he could not celebrate his birthday with his friends. sometimes i feel sad, but i hope he can heal from the burden he's been under (p23). 3.3.3 dealing with uncertainty parents often face the unpredictable course of their child’s illness and even the inevitable death. unclear information about a child’s development or physical changes can also lead to feelings of uncertainty and lack of control in parents. two participants stated: when dealing with children’s conditions, everything that happens to us is uncertain. sometimes he is healthy, but sometimes sick; everything happens so fast (p8); with my son’s condition, sometimes i feel optimistic about his physical development, but i also sometimes doubt whether he can live well in the future like my other children (p23). 3.4 tension in family life caring for a child with crs affects parents’ time, relationships, work, and finances, leading to disruptions in family life and even divorce. this theme consists of four sub-themes: barriers to family relationships, loss of family income source, the increased family debt burden, divorce. 3.4.1 barriers to family relationships parents devote much time caring for crs children, giving them almost no time to interact with their families. when their attention is reduced to family, they are disliked and considered to have no respect for the extended family. participants expressed the following statements: my husband's family considers me a bad wife because, in every activity, my family is less actively involved; my time is spent taking care of children (p19); when my in-laws died, my husband and i cared for the children in the hospital and did not attend the funeral. my extended family forced my husband to divorce me because he was not filial to his parents (p6). 3.4.2 loss of family income source time spent caring for children makes parents have to leave or neglect their jobs, making them lose much income and get fired from work. participants stated: i cannot travel; my trip can only be one day. all my activities are scheduled around the house. if i go out, i must return as soon as possible. i lost much income (p8); i used to work in a company, but because i often got permission to care for my children, i was finally fired; now i stay at home; our family income is decreasing, and we only depend on my husband (p13). 3.4.3 increased family debt burden one of the biggest challenges in caring for children with crs who have complex diseases is the high cost of treatment, especially for the medical procedures that the national health insurance does not cover. participants expressed the following: my wife and i now have a fairly large loan at the bank due to heart surgery and cochlear implants; the costs are very high and are not covered by health insurance (p19); i was forced to sell our farmland to pay my child's medical bills and our living expenses during treatment in jakarta (p5). nurse media journal of nursing, 13(1), 2023, 62 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 3.4.4 divorce crs child-rearing pressures, such as lack of acceptance of the child’s condition, relationship problems with family, loss of income, and increased debt burden, can cause high stress for families and lead to a quick divorce. participants stated: since my child was born and diagnosed with a spinal disorder, my husband divorced me; he accused me of being a cursed woman for giving birth to a disabled child (p23); i just got divorced last month; my husband's family forced him to divorce me because he ignored them. after all, he was busy taking care of the children (p21). 3.5 theme 4: the challenge of getting treatment children with crs with complex health problems need adequate care; however, it is not easy in remote areas of indonesia. participants experience severe barriers to accessing services. even if they reach them, the benefits are often not quality or effective. there are four sub-themes: difficult access, lack of resources, wrong regional political policy, using shaman. 3.5.1 difficult access parents of children with crs face difficulties in accessing adequate health services. factors influencing access include remote location, quality of healthcare facilities and providers, and physician practices. some families must travel long distances to get the special care their children need. participants stated: we need help accessing the pediatrician because we must go to the district town, which takes 2-4 hours away, depending on weather conditions (p10); my son has a spinal cord disorder; on our island, there is no neurologist, so we took a boat to the provincial capital; the trip could take a full day (p5). 3.5.2 lack of resources parents of crs children must travel long distances to seek emergency medical care because local hospitals do not have the necessary resources. they also feel frustrated that medical staff do not understand the impact of chronic illness. two participants expressed the following: our son was sent home from the hospital's emergency department despite his complex condition and officers focusing on only one symptom (p14); my child with a poor respiratory condition requires continuous evaluation, but no chest x-rays are available for a year because they are damaged and have not been repaired (p11). 3.5.3 wrong regional political policy the governance of health services depends on political policies, especially in remote areas, which affect financing and referral systems in health services. poor parents with crs children need local health insurance and appropriate referral channels when bringing their children to health care facilities. participants stated: since the change of regent in our district, my health insurance card has yet to be recognised by the hospital; according to them, the new government no longer allocates a budget for it (p1); as a health insurance policy, we must follow the primary to secondary health services referral path. however, the government's secondary health services are far from where we live, so transportation costs are expensive (p7). 3.5.4 using shaman scarcity of access to resources, lack of funds, and parents’ distrust of health workers make parents use traditional birth attendants to care for their children. in addition, solid cultural factors make parents prefer shamanic practices to care for their children. a participant stated: i do not have money to take care of my child, so i choose to use a traditional birth attendant to treat my child with traditional medicine, and so far, i am doing well (p1). furthermore, one participant expressed the following: in addition to using health services at the hospital, i took my child to a traditional healer for treatment; i was certain spirits and angry ancestral spirits had possessed my child. i need a shaman to eliminate spirits and make peace with ancestral spirits. (p23) nurse media journal of nursing, 13(1), 2023, 63 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 4. discussion this study explored parents’ experiences of caring for children with crs in underdeveloped areas in indonesia. four themes were revealed: (1) life-changing situations, (2) emotional disturbance, (3) tension in family life, and (4) the challenge of getting treatment. 4.1 life-changing situations parenting a crs child can change a parent’s life. some find accepting their child’s condition complex because of the difference between expectations and reality. parents need time to get their child’s condition and focus on their health efforts because they are the primary source of joy, hope, meaning, and purpose in life (yin et al., 2018). caring for a child with crs can be a new experience for parents. studies show that parents view parenting with severe health problems as a new experience (nayeri et al., 2021). this experience can have positive consequences if parents accept it well, but it will result in tremendous emotional pressure if parents refuse (spinelli et al., 2020). parents try to learn simple actions to help their sick children. parents who understand and learn about their child's illness will feel better and happier (källquist & salzmann-erikson, 2019). parents reported social stigma in the neighbourhood. support for overcoming stigma can be provided through positive adaptation, spirituality, and encouragement to love self (de los santos, 2022). 4.2 emotional disturbance parents in this study felt emotional disturbances because they experienced anxiety about losing their child due to the child’s declining physical condition. previous studies have indicated that parents caring for sick or disabled children experience significant psychological and emotional impacts, such as post-traumatic stress and feelings of isolation (wray et al., 2018). this feeling of anxiety needs to be considered because it will lead to the development of acute stress disorder (asd) and post-traumatic disorder (ptsd) in parents and interfere with their efforts to care for their children (nayeri et al., 2021). parents of children with complex health conditions may find themselves facing constant grief. however, they are still trying to fight for their son’s recovery. this is in line with previous studies, which show that parents tend to give up on their child's illness but still try to make their child recover (hubert & aujoulat, 2018). this study concluded that parents’ uncertainty regarding the disease’s condition and the child’s future often arises. a previous study also showed that parents of children with chronic epilepsy feel diagnostic, asymptomatic, and future uncertainty for their child (webster, 2019). therefore, it is necessary to carry out discussions and improvements to overcome the fate of parents and children with such complex conditions. counselling is used to reinforce hope. the higher the expectations of parents with chronic illnesses, the more confident and passionate they will be in caring for their children (bell et al., 2019). 4.3 tension in family life pediatric chronic diseases have physical, psychological, social, economic, and behavioural effects on patients and their families that cause a decrease in function and quality of life (toledano-toledano & domínguez-guedea, 2019). parents in this study reported that caring for a child with a chronic illness interfered with extended family relationships. similarly, previous research has shown that caring for children with chronic diseases can damage personal relationships, reduce psychosocial functioning, and cause sleep disturbances (lian et al., 2022). loss of income sources is a common problem in caring for children with crs because it takes up many parents’ time (hatzmann et al., 2014). parents whose marriages are intact and have high socioeconomic status tend not to feel the adverse effects of loss of income, while single parents are more vulnerable (brewer, 2018). in addition, the more complex the disease the child suffers from, the more significant the decrease in parental income is because time is devoted to their child (roddy, 2022). financial support is urgently needed for low-income families with crs children, especially in indonesia, with well-directed and well-controlled financial assistance. health subsidy programs such as the healthy indonesia card (kis) can help with childcare. in contrast, social services such as the family hope program (pkh), the prosperous rice program (rastra), and village funds can help build community health centres and overcome shortages of medical personnel and equipment (booth et al., 2019). declining income and high maintenance costs have nurse media journal of nursing, 13(1), 2023, 64 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 left parents in debt, forcing them to sell their assets. another study shows that caring for a child diagnosed with a chronic illness can hurt the socioeconomic situation of parents (roser et al., 2019). further efforts are needed to systematically implement an assessment of parents’ financial difficulties with crs children as part of care services. parental tension with crs children often leads to divorce. separated parents have broad implications for increased depression, decreased economic status, and reduced family quality of life (tosi & albertini, 2019). in the indonesian context, divorce has a worse impact, especially for women, where there is a harmful cultural construction for divorced women. they get a terrible stigma from society (saraswati, 2019). single mothers who take care of children with crs will certainly become a serious problem when they have to be burdened by their children’s condition and the bad stigma of divorce from society. special assistance is needed for single mothers with children with crs to suppress the adverse effects of severe psychological disorders. 4.4 the challenge of getting treatment crs childcare efforts in remote areas always need help accessing treatment, such as long distances that make it difficult for parents to take their children to health facilities. financial constraints and expensive public transport also exacerbate this situation (coombes et al., 2018). barriers to access to health facilities in underdeveloped areas of indonesia were also reported by another study, where the failure of tb treatment in papua was related to the distance or cost of travel to health facilities (ruru et al., 2018). loss of treatment for mental disorders in east java is also associated with the problem of accessibility to health facilities (tristiana et al., 2018). in addition to difficult access to services, parents also have difficulty caring for children with crs due to a lack of health resources. previous studies have shown that the low capacity of health workers, such as paediatricians, is an obstacle in treating children with chronic illnesses (altman et al., 2018). in the indonesian context, it has been reported that limited support from the health system, such as poor staff management and coordination and lack of medical equipment and supplies, are significant barriers to health care (robbers et al., 2021). also, security instability resulting from political and armed conflicts, such as in papua, further impacts service delivery (rizkianti et al., 2021). healthcare efforts are closely related to political policies, especially in health insurance decisions to support universal health coverage (uhc) (rizvi et al., 2020). the problem in this study is the certainty of health insurance and unclear referral mechanisms for parents. by previous reports, local governments still need help managing the health budget, including unevenly distributed health services and financing that could be more optimal, especially in regional health insurance for low-income and poor people (kharisma, 2020). serious efforts are needed from the government to manage the health insurance system to access health services for children with crs can be more accessible. when access to an adequate financing system is difficult, parents tend to turn to shamanic practices to care for their children, supported by strong cultural influences. studies show that dissatisfaction with health services due to high costs, incompetent staff, and difficult access are factors causing indonesians to choose shamanism as an alternative treatment (an et al., 2020). a people’s culture supports shamanism in indonesia, passed down through oral traditions and shared models of behaviour, which have historically been important for creating a collective faithbased social peace of mind. this is believed to strengthen the effect of non-medical efforts on the quality of human physical endurance (sukmawan & sahiruddin, 2021). setting aside the results of the benefits received by children conveyed by parents and respect for local wisdom is necessary for this treatment to be seen as a complementary method that cannot replace services in health facilities. 5. implications and limitations this study provides some implications. since rubella in children has complex implications for parents, including high psychological distress, nurses should consider psychological interventions to reduce the risk of depression in parents. the care team can coordinate to provide long-term care. the government must increase health insurance and social assistance financing to overcome parents' economic problems. we recognise that this report has limitations regarding the number of participants and the geographical area of the study. in addition, the short research time, mostly through online nurse media journal of nursing, 13(1), 2023, 65 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 interviews without observation, could affect the depth of reports regarding the psychological conditions experienced, which might affect the physical condition of parents. 6. conclusion the results of this study show the complexity of parents’ experiences in raising children with crs. they face difficulties accepting their child’s condition and feel overwhelmed by their child’s case. in addition, social stigma, emotional distress, and problems accessing health services exacerbate the family’s situation. constraints such as lack of equipment and human resources and changes in political policies also affect access to health services. further studies are needed to understand the influence of culture in each area and expand the study scope. acknowledgment the authors would like to thank all participants involved in this study. author contribution pkst, hmad, ef, ymkl, myb, myg, amg: study design. pkst, hmad: data collection. pkst, hmad, ef, ymkl, myb, myg: data analysis. pkst, hmad, ef, ymkl, amg: drafting and revision of the manuscript. conflict of interest contributing authors declare no conflicts of interest. references altman, l., zurynski, y., breen, c., hoffmann, t., & 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(2018). an investigation of physical and mental health consequences among chinese parents who lost their only child. bmc psychiatry, 18(1), 1–6. https://doi.org/https://doi.org/10.1186/s12888-018-1621-2 copyright © 2023 nmjn. this article is an open-access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). https://creativecommons.org/licenses/by-sa/4.0 nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://ejournal.undip.ac.id/index.php/medianers 12(1):75-87, april 2022 https://doi.org/10.14710/nmjn.v12i1.44336 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 review discovering elements and developing strategies to implement the tailored care education for patients with diabetes through a systematic review satriya pranata1, shu-fang vivienne wu2, tsae-jyy tiffany wang2, shu-yuan liang2, yeu-hui chuang3, kuo-cheng lu4,5, khoiriyah khoiriyah1 ¹department of nursing, faculty of nursing and health sciences, universitas muhammadiyah semarang, semarang, indonesia 2school of nursing, national taipei university of nursing and health sciences, taipei city, taiwan 3college of nursing, school of nursing, taipei medical university, taipei, taiwan 4department of medical research, taipei tzu chi hospital, buddhist tzu chi medical foundation 5 fu-jen catholic university hospital, school of medicine, fu-jen catholic university, taipei, taiwan article info abstract article history: received: 23 january 2022 revised: 2 april 2022 accepted: 7 april 2022 online: 27 april 2022 keywords: diabetes; diabetes complications; diabetes education; tailored care education corresponding author: satriya pranata department of nursing, faculty of nursing and health sciences, universitas muhammadiyah semarang, semarang, indonesia email: satriya.pranata@unimus.ac.id background: the popular intervention in avoiding diabetes complications in several countries is health education. however, a tailored care education approach based on the phenotyping of patients’ abilities, preferences, cultural orientation is still unclear. purpose: to discover elements and develop strategies to implement tailored care education for patients with diabetes through a systematic review. methods: this two-stage systematic review was conducted. the first stage was primary search and assessed the quality of articles followed by discovering elements and developing strategies of tailored care education for patients with diabetes in the second stage. results: this review included 44 out of 1421 articles that were published in english and focused to discuss on tailored care education for patients with diabetes. selfmanagement, patient preferences, patient value, interprofessional collaboration, tailored support, glycemic control, and patient centre were among the elements. these factors were utilized to develop seven step strategies for providing diabetes patients with tailored care education. conclusion: traditional clinical intervention, decision-making, and future research trends are predicted to be transformed into a personalized care approach. establishing the effectiveness of tailored care education programs in reducing the risk of diabetes complications among diabetic patients is needed. how to cite: pranata, s., wu, s.-f.v., wang, t.-j.t., liang, s.-y., chuang, y.-h., lu, k.-c., & khoiriyah, k (2022). discovering elements and developing strategies to implement the tailored care education for patients with diabetes through a systematic review. nurse media journal of nursing, 12(1), 75-87. https://doi.org/10.14710/nmjn.v12i1.44336 1. introduction compared to other people, diabetics have a higher risk of developing numerous complications. every 30 seconds, people with diabetes are two to three times more likely to develop cardiovascular disease, and ten times to get end-stage renal disease, as well as a lower limb amputation (who, 2016). the international diabetes federation (idf) estimates that total healthcare expenditure for diabetics aged 20 to 79 years is usd 966 billion in 2021; it will become usd 1.03 trillion by 2030 and usd 1.05 trillion by 2045 (idf, 2021). in numerous nations, health education is a popular intervention for preventing diabetes complications. however, a standardized approach to health education does not serve all patients equally (hertroijs et al., 2018a). the education have to tailor-made to the specific patient’s needs (social–cognitive determinants, intention, and behavior) (pranata et al., 2021). furthermore, people have the right and obligation to participate in the planning and delivery of their health care (pranata, shing, et al., 2021). patient-centered is related with better levels of patient satisfaction and more effective patient education (sassen, 2018). clinical guideline recommendations that require more specific identification based on demands and treatment goals are now being https://ejournal.undip.ac.id/index.php/medianers https://crossmark.crossref.org/dialog/?doi=10.14710/nmjn.v12i1.44336&domain=pdf&date_stamp=2022-04-27 nurse media journal of nursing, 12(1), 2022, 76 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 hampered by the availability of health data relevant to diabetic patients in particular (pranata, wu, et al., 2021). the term “tailored care education” has been used to describe those research approach. the vedas, india’s ancient books, first described tailored care 4000 years ago (dekkers & hertroijs, 2018). it was originally known as ayurvedic medicine, and its goal was to adapt therapy to each individual in order to keep the body, mind, and spirit in harmony. the goal of tailored care education currently is to improve patients’ health goals by incorporating the specific requirements and preferences into the plan of treatment (dekkers & hertroijs, 2018; hertroijs et al., 2018a). education-based on phenotype is considered. such considerations are able to group patients by their care needs and preferences for achieving personalized goals (dekkers & hertroijs, 2018; hertroijs et al., 2018a; lutes et al., 2020; osborn et al., 2010). modifying the program for patients with diabetes which includes a tailored care education can help reduce the number of complications (cimo et al., 2020). patient centre, preference, and cultural orientation refer to tailored care education (cimo et al., 2020; dekkers & hertroijs, 2018; hertroijs et al., 2018b; lutes et al., 2020; osborn et al., 2010; solano et al., 2020). education approaches by using flexibility in teaching to match personal needs, and empowering clients in self-management are examples of tailored care education implementations (cimo & dewa, 2019). although there have been many studies on tailored care interventions in diabetic patients, the strategy for implementing tailored care education is still unclear. one study mentions strategies for implementing tailored care education (van de velde et al., 2016), but another study also mentions other strategies with different way (van de velde et al., 2016; wensing et al., 2014). the various implementation strategies are closely related to the unclear elements that involved the concept of tailored care education. the aim of this study was to discover elements and develop strategies to implement tailored care education for patients with diabetes through a systematic review. 2. methods 2.1 research design this study qualifies as a systematic review because of the discovery, selection, assessment, and synthesis of high-quality research material relevant to the research issue. a systematic review entails the identification, selection, evaluation, and synthesis of high-quality research evidence (bettany-saltikov, 2012). moreover, systematic review is undertaken in answer to a specific research issue using a rigorous research technique (polit, 2017). 2.2 search methods we combined the keywords: tailored care, tailored care education for diabetes using the boolean logic operators “and” and “or”. ebsco host engine search included medline complete, medline with full text, academic search complete, computers & applied sciences complete, education research complete, sportdiscus with full text, professional development collection, omnifile full text select (h.w. wilson), newspaper source, and apa psycarticles were databases searched in this study. 2.3 inclusion and exclusion criteria we discovered studies in the literature that were clearly focused on tailored care education for diabetes and published in english from january 2016 to december 2021. on the other hand, articles not aligned with tailored care, incomplete, participants not having diabetes, and unrelated with tailored care education concepts were exclusion criteria of this study. 2.4 screening of articles as many as 1421 relevant papers about tailored care education for diabetes were found. members of the study team (sp, sfvw, and kk) reviewed the title and abstract, then excluded articles based on the following criteria: duplication (n = 678), article not aligned with tailored care (n = 406), incomplete (n = 87), participants not having diabetes (n = 121), and unrelated with tailored care education concepts (n = 77). following the exclusion criteria, the number of articles excluded were (n = 1369). the full texts of all 44 articles that matched the inclusion criteria were obtained, reviewed for the level of evidence and quality before study extraction (figure 1). nurse media journal of nursing, 12(1), 2022, 77 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 2.5 data extraction in this stage, we assessed the tailored care education elements after summarizing the derived literature search findings in table 1, further developed clinical strategies to implement tailored care education for patients with diabetes in table 3. every paragraph that referenced tailored care education was highlighted, split, and suggestions were generally marked by punctuation. we also created coding roles and coding sheets based on the study protocol, which comprised a list of mutually exclusive and exhaustive ideas (e.g., patient centre, and phenotype). the two specialists (sfvw and tjtw) coded, extracted, and combined the data separately, and then established a final consensus following discussion. 2.6 quality appraisal researchers (sfvw, tjtw, syl, yhc, and kcl) used the joanna briggs institute validity scale 2011 to review level of evidence and assessed the quality of articles (higgins & deeks, 2011). the result is presented in table 1. table 1. extraction of the elements, level of evidence and quality of articles no method population level of evidence summary of appraisal sm pp pv ic ts gc pc 1. (berkowitz et al., 2020) qs diabetes 6 fair ✓ ✓ 2. (benavides-vaello et al., 2017) qs diabetes 6 fair ✓ 3. (berkowitz, terranova, et al., 2019) rc diabetes 4 good 4. (hedderson et al., 2018) rct diabetes 2 good ✓ 5. (lake et al., 2018) mm diabetes 2 good ✓ ✓ 6. (kassavou et al., 2020) rct diabetes 2 good ✓ 7. (hu et al., 2016) rct diabetes 2 good 8. (solano et al., 2020) rct diabetes 2 good ✓ 9. (tervaskanto-mäentausta et al., 2017) cs diabetes 7 fair ✓ 10. (goodfellow et al., 2016) rct diabetes 2 good ✓ 11. (campmans-kuijpers et al., 2015) rct diabetes 2 good ✓ ✓ 12. (huang et al., 2019) rct diabetes 2 good ✓ 13. (choi et al., 2017) cs diabetes 7 fair ✓ 14. (brown et al., 2015) cs diabetes 7 fair ✓ 15. (de sequeira et al., 2019) qs diabetes 6 fair ✓ 16. (navodia et al., 2019) sr diabetes 1 good ✓ 17. (nelson et al., 2016) cs diabetes 7 good ✓ ✓ ✓ nurse media journal of nursing, 12(1), 2022, 78 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 1. continued no method population level of evidence summary of appraisal sm pp pv ic ts gc pc 18. (krishna & provenzano, 2019) qs diabetes 6 good ✓ ✓ ✓ 19. (lake et al., 2020) rct diabetes 2 good ✓ 20. (caro-bautista et al., 2021) sr diabetes 1 good ✓ ✓ 21. (patel et al., 2017) qe diabetes 4 fair ✓ ✓ 22. (nelson et al., 2021) rct diabetes 2 good ✓ ✓ 23. (joo & liu, 2021) sr diabetes 1 good ✓ ✓ ✓ 24. (berkowitz, terranova, et al., 2019) rct diabetes 2 good ✓ 25. (ballotari et al., 2017) sr diabetes 1 good ✓ ✓ 26. (nijpels et al., 2019) lr diabetes 5 fair ✓ 27. (camacho et al., 2015) cs diabetes 7 fair ✓ ✓ 28. (alamer et al., 2020) qe diabetes 4 fair ✓ ✓ ✓ 29. (lim et al., 2016) rct diabetes 2 good ✓ ✓ 30. (piombo et al., 2020) mm diabetes 2 good ✓ ✓ 31. (d. f.l. hertroijs et al., 2018) mm diabetes 2 good ✓ ✓ ✓ 32. (liddy et al., 2016) qs diabetes 6 fair ✓ 33. (o’neil et al., 2016) rct diabetes 2 good ✓ 34. (cummings et al., 2019) rct diabetes 2 good ✓ 35. (dorijn f.l. hertroijs et al., 2018) sr diabetes 1 good ✓ ✓ 36. (keramat, 2018) qs diabetes 6 fair ✓ ✓ ✓ 37. (gold et al., 2019) mm diabetes 2 good ✓ ✓ 38. (holmen et al., 2017) sr diabetes 1 good ✓ 39. (dekkers & hertroijs, 2018) lr diabetes 5 fair ✓ 40. (iovane et al., 2017) qe diabetes 4 fair ✓ ✓ ✓ 41. (kasteleyn et al., 2016) rct diabetes 2 good ✓ 42. (munsour et al., 2020) rct diabetes 2 good ✓ ✓ 43. (afandi et al., 2020) lr diabetes 5 fair ✓ ✓ 44. (jeon et al., 2016) cs diabetes 7 fair ✓ note: sm: self-management; pp: patient preferences; pv: patient value; ic: interprofessional collaboration; ts: tailored support; gc: glycemic control; pc: patient centre; sr: systematic review; rct: randomized controlled trial; mm: mix method; qe: quasi experiment; rc: retrospective cohort; cs: case study; qs: qualitative study; lr: literature review. nurse media journal of nursing, 12(1), 2022, 79 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 2.7 data analysis this review could not perform a meta-analysis due to heterogeneity in the methods and statistical values of the outcomes. therefore, a thematic analysis was conducted (nowell, 2017). the elements of tailored care education were discovered. these findings are illustrated under the themed headings in table 2. 3. results figure 1. flowchart of screening articles on tailored care education for diabetes 3.1 discovery elements of tailored care education and concept description we outlined the tailored care education elements for patients with diabetes were selfmanagement, patient preferences, patient value, interprofessional collaboration, tailored support, glycemic control, and patient centre. by extracting data from each article and comparing definitions, we were able to identify the concepts and then combine the results. as a result, after medline complete (n ＝ 460 articles) medline with full text (n = 457 articles) academic search complete (n ＝ 405 articles) computers & applied sciences complete (n ＝36 articles) education research complete (n ＝ 22 article) sportdiscus with full text (n ＝ 12 articles) professional development collection (n＝11 articles) omnifile full text select (h.w. wilson) (n = 9 articles) newspaper source (n = 7 articles) apa psycarticles (n = 2 articles) f il te r in c lu d e d total number of articles (n =1,421) articles excluded for being unsuitable or irrelevant after filtering (n = 1369) 1. duplication (n = 678) 2. article not aligned with tailored care (n = 406) 3. incomplete (n =87) 4. participants not having diabetes (n = 121) 5. unrelated with tailored care education concepts (n = 77) full-text articles were excluded because they were not related to tailored care education for diabetes (n = 8) articles included in the analysis (n = 44) full-text articles included in systematic review (n = 52) q u a li fi e d s e a rc h nurse media journal of nursing, 12(1), 2022, 80 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 consulting with the research team, we reached to a final decision. table 2 shows the concept descriptions for each element, which are detailed below. 3.2 definition of tailored care education for patient with diabetes related with tailored care education elements, tailored care education definition was an approach in interdisciplinary collaboration among health professionals, patients, and families in which patients became the center of service through personalized consideration of patient preferences, values, ethnicities in the achievement of personalized goals in self-management and glycemic control (caro-bautista et al., 2021; choi et al., 2017; cimo & dewa, 2019; cummings et al., 2019; iovane et al., 2017; prato et al., 2010; van de velde et al., 2016). table 2. the concept description of tailored care education elements no elements concept description 1. self-management reflecting the cognitive, emotive, and behavioural areas within the context of the culture. 2. patient preferences phenotyping and biopsychosocial characteristics were consideration to identify various health-care needs of patients 3. patient value diabetes patient impressed with medically adjusted meals, emphasizing the value of culturally acceptable food 4. interprofessional collaboration through culturally targeted diabetes education, health providers primarily offered information and used knowledge reinforcement to induce behavioral change 5. tailored support the community will benefit from the support of an interdisciplinary team as well as family members in achieving optimal metabolic control 6. glycaemic control effects on diabetes control (e.g., haemoglobin a1c) and patient lifestyles should be evaluated in longer-term evaluation 7. patient centre several professional recommendations divide individuals with diabetes into three risk groups: very high/high, moderate, and low. this classification was based primarily on the kind of disease, metabolic control level, and therapy type, with the presence of other comorbidities and situational factors being adjusted. 3.3 strategies of tailored care for patients with diabetes broadly, the main strategy in applying tailored care education is to make various efforts, such as 1). brief deducting teaching; 2). assessment of patients' self-management levels and characteristics; 3). writing a list of patients' needs, glycemic control and difficulties; 4). rank a personal priority; 5). setting a goal and drafting an action plan using brainstorming and a support group to archive patients' unique objective behaviors; 6). follow-up; and 7). goals-attempted report (afandi et al., 2020; ballotari et al., 2017; campmans-kuijpers et al., 2015; caro-bautista et al., 2021; choi et al., 2017; hertroijs et al., 2018b; iovane et al., 2017; joo & liu, 2021; navodia et al., 2019; nelson et al., 2021; nijpels et al., 2019; patel et al., 2017; van de velde et al., 2016; wensing et al., 2014). the development of strategies adopted from the elements of tailored care education can be read in table 3. table 3. developed clinical strategies of tailored care education based on elements no elements clinical strategies 1. self-management within the scope of the culture, self-management reflected cognitive, emotional, and behavioral aspects (benavides-vaello et al., 2017; krishna & provenzano, 2019; lake et al., 2018; nelson et al., 2016, 2021). 2. patient preferences phenotyping of a patient's biopsychosocial characteristics can help health professionals to identify patients with various health-care needs (berkowitz et al., 2020; berkowitz, terranova, et al., 2019; caro-bautista et al., 2021; nelson et al., 2016). 3. patient value diabetes patient pleased with medically adjusted meals, emphasizing the value of culturally acceptable food (choi et al., 2017; de sequeira et al., 2019). nurse media journal of nursing, 12(1), 2022, 81 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 3. continued no elements clinical strategies 4. interprofessional collaboration through culturally targeted diabetes education, health providers primarily offered information and used knowledge reinforcement to induce behavioral change (goodfellow et al., 2016; krishna & provenzano, 2019; tervaskanto-mäentausta et al., 2017). 5. tailored support the community will benefit from the support of an interdisciplinary team as well as family members in achieving optimal metabolic control (alamer et al., 2020; joo & liu, 2021; nelson et al., 2016). 6. glycaemic control glycaemic control referes to hba1c level and patient’s lifestyles (alamer et al., 2020; ballotari et al., 2017; solano et al., 2020). 7. patient centre several professional recommendations divide individuals with diabetes based on the kind of disease, metabolic control status, therapy type, and the existence of other comorbidities and contextual factors, as well as continued follow-up and reporting of each patient's personalized goals into three risk groups were very high/high, moderate, and low (campmans-kuijpers et al., 2015; nijpels et al., 2019). 4. discussion the main purpose of this study was to discover tailored care education elements and developed strategies to implement tailored care education for patients with diabetes. seven elements of tailored care education for patients with diabetes has its own meaning to translate the overall tailored care education concept. these elements serve as a foundation for evolving sevenstep strategies for facilitating the implementation of tailored care education for patients with diabetes. self-management solutions that were culturally relevant and addressed cognitive, emotional, and behavioral aspects in control desire to eat, advice in diet adjustment (benavides-vaello et al., 2017). more specific and realistic instruction is essential in self-management (benavides-vaello et al., 2017). in addition, grasp of which phenotype in the identification of patients with various health-care needs related with patient preferences. only by taking into account the care preferences of patients, the health professionals can an efficient in tailored care education implementation (hertroijs et al., 2018b). patients’ biopsychosocial characteristics are utilized to identify their care needs, abilities, and preferences for customizing solutions using a tailored care education approach (dekkers & hertroijs, 2018). diabetes patients impressed with medically adjusted meals, emphasizing the value of culturally acceptable food, refer to patient values. a transcultural intervention based on clinical and socio-cultural factors and tailored to the patients’ lifestyles improves adherence to dietary restriction (piombo et al., 2020). through interprofessional collaboration, health professionals can provide group didactic teaching. patients were given individual clarification at the end of an education session in order to create their own management plan. through culturally tailored diabetes education, health providers primarily offered information and employed knowledge reinforcement to facilitate behavioral change (choi et al., 2017). the consultations, emotional support, and technique of lifestyle teaching are the most significant factors of diabetes care (hertroijs et al., 2018b). resource center, motivator, and outside perspective are crucial roles of health professionals. clinical information systems, decision support tools, flow sheets, and delivery system design are the examples of these advances (community resources) (liddy et al., 2016). moreover, community health centre will benefit from tailored support from an interdisciplinary team, including training and technical assistance, to enable patients’ action, which will give timely recommendations to primary care providers (gold et al., 2019). the tailored support intervention improves health status and well-being, which are both promising (kasteleyn et al., 2016). in addition, the help of their family members can be supporting system among diabetic patient to achieve their adequate metabolic and glycemic control (iovane et al., 2017). glycemic control included hba1c should be evaluated in longer-term evaluation (berkowitz, delahanty, et al., 2019). the effects will be greater if medically adjusted meals are accompanied with diabetes self-management education or lifestyle changes (berkowitz et al., 2020). medically customized meals improved dietary pattern then decreased hypoglycemia. a transcultural nurse media journal of nursing, 12(1), 2022, 82 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 intervention based on clinical and socio-cultural factors and tailored to the patients’ lifestyles improves adherence to dietary restriction (piombo et al., 2020). for tailored care education, several professional recommendations are divided diabetic patients into extremely high/high, moderate, or low risk groups. it is referred to patients centre. the classification of patients centre is based on metabolic control level, and therapeutic type. taking into account the hours of fasting during the day, weather, resources, personal eating, sleeping, and activity patterns, prior fasting experience, and patient preferences are example of tailored diabetes management in ramadhan fasting context. encourage clinicians to think outside the box when deciding whether or not to fast and how to change treatment regimens efficiently if fasting is deemed safe (afandi et al., 2020). in the early phases of implementing a tailored care education plan, brief deducting instruction is required. the application of brief deduction instruction is based on two key components. self-management and interprofessional collaboration are two of these elements (benavides-vaello et al., 2017; choi et al., 2017; hertroijs et al., 2018a; liddy et al., 2016). sharing information through health seminars between health professionals together with diabetic patients might be used to provide brief deducting instruction (choi et al., 2017). health education, such as brief deducting teaching, will help patients with diabetes manage their health at home. as we have discovered, one of the crucial element of diabetes education was self-management (benavidesvaello et al., 2017). self-management entails emphasizing a specific treatment plan for patients (ballotari et al., 2017; liddy et al., 2016; navodia et al., 2019; solano et al., 2020). furthermore, patients with diabetes should practice self-management due to stresses precise problem solving and reduces the need of unnecessary treatments (liddy et al., 2016). for health literacy, it is critical to confirm and clarify this understanding. it is vital to validate and explain this understanding in the context of health literacy. in a nutshell, medical experts, nurses, nurse specialists, and dietitians should all build multidisciplinary communication platforms and collaboration models (benavides-vaello et al., 2017). health care professionals must disseminate patient information. it would help patients better comprehend the plans while they were at home (e.g., test, medicine, procedure, behavior modification). other processes in assessing patients’ self-management level and characteristics include guiding the construct lists of their requirements, prioritize, personalized purpose, and personalized plans to achieve their objective (holmen et al., 2017; liddy et al., 2016; o’neil et al., 2016; piombo et al., 2020). this process can provide diabetic patients with specialized care and allow for the creation of a treatment plan based on more accurate diagnosis and care, resulting in improved treatment and care efficacy (de sequeira et al., 2019). a patient center that takes into account not only medical care but also glycemic monitoring, preferences, and values (berkowitz, delahanty, et al., 2019; berkowitz, terranova, et al., 2019; dekkers & hertroijs, 2018; hertroijs et al., 2018a; piombo et al., 2020). the agreement between health providers and patients on tailored glycemic control goals is based on tailored care education (benavides-vaello et al., 2017). the aim for individualization was set based on the risk of hypoglycemia episodes among patients. patient-centered tailored care education solutions for diabetic patients in clinical practice must include dynamic personalized glycaemic control and strategies produced by a care team (berkowitz, delahanty, et al., 2019; piombo et al., 2020). the patient and health care team’s goals can help to lessen an error in intervention, foster collaboration among health professionals with patients, improve patient goals, quality of life, and evade pointless medical treatments as well as lowering the medical burden (berkowitz et al., 2020; berkowitz, delahanty, et al., 2019; berkowitz, terranova, et al., 2019; piombo et al., 2020; purwadi et al., 2021). strategies to rank the priorities of each patient, create goals, and write action can be accommodated by brainstorming and support groups to achieve glycaemic control and specific target behavior (berkowitz, delahanty, et al., 2019; piombo et al., 2020). this strategy is known as personalized support based on patient value and desire (dekkers & hertroijs, 2018; gold et al., 2019; hertroijs et al., 2018a; iovane et al., 2017; kasteleyn et al., 2016; piombo et al., 2020). through brainstorming, patients able to learn each other and work together to solve individual health problems. the capacity to solve problems is thought vital for patients because it can assist them in making the best decisions, which are methodical, rational, and take into account diverse perspectives as a patient-centered approach (afandi et al., 2020). furthermore, brainstorming makes it easier for patients to communicate also obtain information they require, particularly nurse media journal of nursing, 12(1), 2022, 83 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 when it comes to establishing glycemic control and specific target behavior (afandi et al., 2020; choi et al., 2017; hertroijs et al., 2018a; liddy et al., 2016; piombo et al., 2020). 5. implications and limitations tailored care education is a new approach in the clinical setting and potentially improves self-management and reduce the risk of complications among patients with diabetes. however, the impact on patient outcomes is still debatable, as several studies in this analysis had design flaws that made it difficult to make conclusions. as a result, before presence evaluated on a large sample using the randomized controlled trial (rct) approach, this strategy must first be examined on a small sample using a pilot study to identify impediments to implementation. 6. conclusion elements to develop strategies for implementing tailored care education for diabetes are needed. tailored care education strategies are an approach that emphasizes consideration of patient preferences, values and phenotypes. intervention considerations based on the patient personal goals followed by a collaboration between health professionals and patients through tailored care education might be expected to minimize conflict recommendations of health professionals. acknowledgment the researchers are grateful to the national taipei university of nursing and health sciences’ (ntunhs) research centre and ministry of education (moe) taiwan for their financial support. author contribution sp conceptualized, designed, wrote the first draft and framework as well as evaluated the data. sfvw conceptualized, interpreted the data and supervised. tjtw, syl, yhc, kcl, kk conceptualized and interpreted the data. the published version of the manuscript has been read and approved by all authors. conflict of interest the authors have reported no conflicts of interest. references afandi, b. o., beshyah, s. a., hassanein, m. m., jabbar, a., & khalil, a. b. 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(accessed, 2018 october 14). copyright © 2022 nmjn. this article is an open access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). https://creativecommons.org/licenses/by-sa/4.0 nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://medianers.undip.ac.id 12(2):172-184, august 2022 https://doi.org/10.14710/v12i2.46084 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 original research quality of clinical nursing education programme in ghana: preceptors’ perspectives gilbert ti-enkawol nachinab1, susan jennifer armstrong1 1department of nursing education, school of therapeutic sciences, university of the witwatersrand, johannesburg, south africa article info abstract article history: received: 4 may 2022 revised: 6 august 2022 accepted: 8 august 2022 online: 31 august 2022 keywords: clinical education; ghana; nursing; preceptors; quality corresponding author: gilbert ti-enkawol nachinab department of nursing education, school of therapeutic sciences, university of the witwatersrand, johannesburg, south africa email: gilbertnaknab@gmail.com background: clinical education is an important component of the training of nursing students. preceptors play a key role in the clinical education of nursing students by providing support for the students during clinical placement. there is dearth of studies in the ghanaian context that has assessed preceptors’ perception of clinical nursing. purpose: the purpose of this study was to assess preceptors’ perceptions of the quality of clinical nursing education in northern ghana. methods: this study was a cross-sectional survey conducted using an already existing questionnaire. three hundred and nineteen (319) preceptors recruited from three hospitals participated in the study. a proportional quota sampling technique was used to allocate the sample size to the three hospitals and a simple random sampling technique was used to select the participants. the data were analysed using stata version 15 and the results were presented using descriptive and inferential statistics. results: the study findings indicate that the preceptors’ generally perceived that the quality of clinical placement area and clinical assessment were slightly above average as they scored each of them 2.30 on a scale of 0-4 (95% ci:2.21-2.39). the preceptors also perceived that the quality of clinical teaching and learning was average as the they scored it 2.04 on a scale of 0-4 (95% ci:1.95-2.13). also, the preceptors had a lower level of agreement, 1.75 on a scale of 0-4 (95% ci:2.15 -2.45) regarding teaching and development of the students being the responsibility of only the university. conclusion: preceptors perceived that nursing education institutions and clinical facilities need to work together to improve clinical nursing education. this calls for the need for an effective collaboration between clinical facilities and nursing education institutions to develop training programmes for preceptors to improve their skills in clinical teaching and clinical assessment of students. how to cite: nachinab, g. t., & armstrong, s. j. (2022). quality of clinical nursing education programme in ghana: preceptors’ perspectives. nurse media journal of nursing, 12(2), 172-184. https://doi.org/10.14710/nmjn v12i2.46084 1. introduction there is a need to ensure that the training of nurses meets international standards, which in turn requires the use of preceptors to guide students in the learning of clinical skills (girotto et al., 2019). preceptorship helps students transition to professional nurses through the acquisition of clinical competence and confidence (madhavanpraphakaran et al., 2013; panzavecchia & pearce, 2014). the introduction of the concept of preceptorship has led to increased collaboration between nursing education institutions and clinical facilities with preceptors being at the forefront of clinical teaching during clinical placement. preceptors are professionals with adequate knowledge and skills to support students during clinical placement. preceptors are often employed by academic institutions in part-time or fulltime positions to serve as teachers in the clinical setting (botma et al., 2012). in ghana, preceptors are often full-time employees of the clinical facilities which may affect their availability to interact with and support students due to conflicting responsibilities. ryan and mcallister (2019) indicated that spending time interacting with students and getting to know them was deemed necessary in enhancing the relationship between clinical staff and students. adequate preparation, which includes an in-depth understanding of the role of preceptorship, is necessary to efficiently facilitate the clinical teaching of students (bengtsson & carlson, 2015). this will be realized through a collaborative effort between academics and https://crossmark.crossref.org/dialog/?doi=10.14710/nmjn.v12i2.46084&domain=pdf&date_stamp=2022-08-31 nurse media journal of nursing, 12(2), 2022, 173 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 clinicians to design a training programme for clinical nurses to assist them to develop pedagogical competence in preceptorship (wu et al., 2017; atakro et al., 2019). aspects that need to be included in such a programme are teaching and learning strategies, reflective and critical thinking, communication skills and the role of the preceptor (bengtsson & carlson, 2015). in addition, preceptors need to enhance their assessment skills which should include the art of giving constructive feedback (wu et al., 2017). apart from training, some factors that will increase the effectiveness of preceptorship include having a protected time to guide students, scheduling the students to work the same shift as the preceptor, motivation of the students to learn skills and the need for students to show interest in direct patient care (madhavanpraphakaran et al., 2013). when preceptors devote time to students and ensure a good preceptor-student relationship, the students’ clinical learning is enhanced (mcsharry & lathlean, 2017). while working in the same shift facilitates a positive and useful preceptor-student relationship, the preceptor can provide one-on-one support. in ghana, preceptors are not given a protected time to support students during clinical placement (asirifi et al., 2017). the use of learning strategies which ensure that students are actively involved is necessary for improving the learning of clinical skills (girotto et al., 2019). clinical conferences with students are an important strategy that allows students to clarify their placement objectives to guide the clinical learning process (henderson et al., 2018). preceptors who use dialogue and appropriate questioning techniques promote critical thinking and problem-solving skills among students (mcsharry & lathlean, 2017). clinical teaching and learning is driven by effective communication (moonaghi et al., 2015; needham et al., 2016; cândida et al., 2017). preceptors and students need to discuss the barriers to learning that students face during clinical placement and identify possible strategies that could be used to resolve such barriers (cândida et al., 2017). clinical instructors’ communication with students should be based on fairness, openness, justice and respect (moonaghi et al., 2015). clinical facilitators agree that to have a successful clinical placement, the interaction between nurses, students and patients has to be effective (needham et al., 2016). clinical facilitators explain that effective communication will help unravel the individual needs of students so that clinical teaching can be tailored to meet such needs (needham et al., 2016). in ghana, key informants such as nurse managers, lecturers and clinical placement coordinators are of the view that lack of resources, inadequate staffing and students’ attitudes are major factors negatively affecting clinical nursing education (nachinab & armstrong, 2022). aside lack of resources, the effectiveness of clinical assessment of students is affected by inadequate training of examiners and lack of standardization of assessment processes in ghana (anim-boamah et al., 2022). also, students in ghana are of the view that incongruence in clinical teaching, practice and assessment were major factors affecting the development of clinical competencies (anim-boamah et al., 2021). there is dearth of studies on perspective of preceptors on the quality of clinical nursing education in the ghanaian context. the preceptors’ perspectives on how best the clinical placement area is conducive for learning of clinicals skills have not been adequately assessed. the quality of teaching and learning of clinical skills, and clinical assessment of nursing students have also not been adequately researched into in the ghanaian. this study was, therefore, conducted to assess preceptors’ perceptions of clinical placement area, clinical teaching and learning, and clinical assessment in the ghanaian context. 2. methods 2.1 research design a cross-sectional survey was employed to assess the preceptors’ perceptions of clinical nursing education. cross-sectional designs are used to describe the status of a phenomenon and the relationship among phenomena at a point (polit & beck, 2010). this design allows the researchers to collect sufficient original data to describe the preceptors’ perceptions of the current state of clinical nursing education in ghana. 2.2 setting and samples the survey was done at three hospitals in northern ghana which include one each of the district, regional and tertiary hospitals, all of which serve as clinical sites for undergraduate nurse media journal of nursing, 12(2), 2022, 174 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 nursing students. the district and regional hospitals serve as referral facilities for clinics and health centers in the region. the tertiary level facility serves as a referral facility for all health facilities within the northern part of ghana. the participants for this study were preceptors in hospitals that serve as clinical sites for undergraduate nursing students. preceptors were registered general nurses with a minimum academic qualification of a diploma in nursing and at least three years of working experience. they were permanent staff of the selected hospitals engaged by nursing educations institutions (neis) to support students during clinical placement. preceptors who were on leave or working in units where undergraduate nursing students were not frequently placed were excluded from the study. preceptors who met the inclusion criteria but did not voluntarily consent to participate in the study were also excluded. using the total number of preceptors in the three hospitals as the accessible population and an alpha level of 0.05, yamane’s (1967) formula for sample size calculation was applied. in all, 319 questionnaires were administered but only 307 preceptors completed and returned the questionnaire, representing a 96.2% response rate. the data were collected between november, 2019 and february, 2020. a multistage sampling technique was used to recruit the respondents. the hospitals were purposively selected because they serve as clinical placement sites for undergraduate nursing students. a proportional quota sampling technique was used to allocate the 319 questionnaires to the three selected hospitals. at each hospital, the clinical coordinator helped in purposively selecting units in which undergraduate nursing students are frequently placed when they come for clinical placement. the sample size for the hospital was divided among the selected wards. in each ward, a simple random sampling technique was applied to give all respondents an equal chance to participate. 2.3 measurement and data collection the questionnaire used for the study was originally developed by peter (2008) but was adapted and validated in a previous study by xaba (2015). the questionnaire is publicly available but the researcher obtained permission to use the questionnaire. the questionnaire was in english language and no significant changes were made. the questionnaire had four sections. section a had questions on demographic data. section b, c and d had questions on perceptions of clinical placement area, clinical teaching and learning, and clinical assessment respectively. section b had 13 items, section c had 10 items and section d had 9 items. the internal consistency of the instrument was checked in a previous study using cronbach alpha. the overall cronbach alpha was 0.750, and this made the instrument reliable because the minimum desired cronbach alpha is 0.7 (bujang et al., 2018). the questionnaire was also presented to the research supervisors who are all nursing education experts and two local clinical nursing education experts to check for face and content validity. the original questionnaire was measured on a scale of 1-5. in the present study, the scoring of the tool was reordered where neither agree nor disagree=0, strongly disagree=1, disagree=2, agree=3 and strongly agree=4. with the reordering of the scale of the original questionnaire, a pre-test was conducted where cronbach alpha reliability test was performed to ascertain if the scale was still consistent with the reliability score reported in the original questionnaire. thirty (30) preceptors were recruited from a hospital within the northern region of ghana for the pretesting. the hospital where the pretesting was done was excluded from the main study. in this study, the reordered questionnaire yielded an overall cronbach alpha of 0.925. the cronbach alpha for the clinical placement area subscale was 0.868, clinical teaching and learning was 0.811 and clinical assessment was 0.806 . the principal researcher obtained formal permission from the authorities of the hospitals. the first visit to each unit in the hospital was done by the researcher and a trained research assistant who met with the respective unit managers for a preliminary discussion on the data collection process. at each selected unit, the study was explained to respondents and the information sheet was given to them. respondents who voluntarily consented to participate were selected. a trained research assistant assigned to each unit continued visiting the unit at the beginning of each shift until all the required questionnaires were administered. a sealed box was placed in each unit to allow the respondents to return the questionnaire anonymously. nurse media journal of nursing, 12(2), 2022, 175 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 2.4 data analysis the questionnaires were coded and entered into epidata. the data were then exported and analysed using stata version 15. all the analyses were performed at a 95% level of confidence interval. descriptive statistics including frequencies and percentages were used to present the background characteristics of respondents. perception of the quality of clinical nursing education nursing was assessed on a scale of 0-4. three main components of clinical nursing education consisting of clinical placement area, clinical teaching and learning, and clinical assessment were assessed. the ratings were averaged to yield a perception score for each of these components of clinical nursing education. to make inferential statements, linear regression analysis was conducted to examine the extent to which perceptions of clinical placement area were explained by the other variables. the linear regression analysis consisted of two models; model 1 and model 2. in model 1, the background characteristics were examined to determine their contribution to the perception of the clinical placement area. in model 2, background characteristics, perception of clinical teaching and learning, and perception of clinical assessment of respondents were examined to determine their influence on the perception of clinical placement area. 2.5 ethical considerations ethical clearance was obtained from the human research ethics committee (medical) of university of the witwatersrand (m190807) and the ghana health service ethics committee (ghs-erc 007/09/19). participation in the study was voluntary and respondents could decide to withdraw from the study at any stage without any negative repercussions. no identifying information was collected from the participants and information collected was reported as aggregate data. the respondents gave their consent prior to answering the questionnaire. 3. results 3.1 demographic characteristics of preceptors table 1 indicates that 52.4% (n=161) of the preceptors were females and 47.6% (n=146) were males. most (42.4%, n=130) were within the age range 30-39 years, and 37.8% (n=116) were within 20-29 years. of the 307 preceptors, 74.3% (n=228) worked in the tertiary hospital, 14.0% (n=43) worked at the regional hospital and 11.7% (n=36) worked in a district hospital. table 1. demographic characteristics of preceptors characteristics frequency percent gender female 161 52.4 male 146 47.6 age (year) 20-29 116 37.8 30-39 130 42.4 40-49 52 16.9 50-59 8 2.6 60+ 1 0.3 facility type tertiary hospital 228 74.3 regional hospital 43 14.0 district hospital 36 11.7 academic qualification diploma 188 61.2 bachelor 115 37.5 masters 4 1.3 3.2 perceptions of quality of clinical nursing education amongst preceptors table 2 shows a descriptive summary of preceptors’ perceptions of the quality of clinical nursing education which was rated on a scale of 0-4. three main components of clinical nursing nurse media journal of nursing, 12(2), 2022, 176 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 education (clinical placement area, clinical teaching and learning, clinical assessment) were assessed. the ratings were averaged to yield a perception score for each of these clinical nursing education components and an overall score was obtained. perception of the clinical placement area (cpa), which was assessed with 13 items, yielded a composite score of 2.30 on a scale of 0-4 (95% ci:2.21-2.39). this translates into 57.5% level of agreement with the statements assessing perceptions on the quality of cpa. with the individual items, the highest score on the quality of cpa was on the question: “placement dates are prepublished before the placement of students to the clinical facilities” the preceptors rated this question 2.66 on a scale of 0-4 (95% ci:2.52-2.80). in contrast, the lowest level of quality on cpa related to the question that sought to find out if the development and teaching of student nurses is only the responsibility of the university. the preceptors rated this question 1.75 on a scale of 04 (95% ci:1.62-1.88). preceptors’ clinical teaching and learning (ctl) composite score was 2.04 on a scale of 0-4 (95% ci:1.95-2.13) translating into a 51.0% level of agreement with statements assessing perceptions on quality of ctl. of 11 items that were used to assess perception on ctl, the highest score was on the question: “clinical accompaniment does benefit students”. the preceptors rated this question 2.69 on a scale of 0-4 (95% ci:2.54-2.84). the lowest score of quality of ctl was on the question “the university has enough equipment and material resources for demonstration and feedback of clinical skills”, which was rated 1.75 on a scale of 0-4 (95% ci:1.61-1.89). nine items were used to assess the perception on quality of clinical assessment (ca). the composite score of preceptors’ perceptions of the quality of ca was 2.30 on a scale of 0-4 (95% ci:2.21-2.39), indicating a 58% level of agreement with statements assessing the perception of the quality of ca. the highest score on the perception of quality of ca was on the question “as preceptors, we are involved in clinical assessments of students” which was rated 2.64 on a scale of 0-4 (95% ci:2.48-2.80). the lowest score on ca was on the question “student and the facilitator discuss and evaluate performance against each competency thereby identifying areas of strength and areas needing improvement”. the preceptors rated this question 2.01 on a scale of 0-4 (95% ci: 1.85-2.17). 3.3 predictors of clinical nursing education perceptions to examine the extent to which clinical placement area perception is explained by the other variables, linear regression analysis was conducted. table 3 below indicates that the background characteristics of preceptors were examined in an initial model (model 1) to determine their influence on the perception of preceptors in the clinical placement area. the preceptors' background characteristics (gender, age, years of service and academic qualification) all together explained only 1.9% of the variations in perception of the clinical placement area (adjusted r2=0.019, p=0.22). in assessing the individual contribution of background characteristics, the contribution of academic qualifications to the perception of the clinical placement area was statistically significant (=0.202, p=0.042). gender, age and years of service did not make a statistically significant contribution to the perceptions on clinical placement area. however, being a female and increasing age are associated with a decreasing perception score for the clinical placement area. thus, all this being equal, being a female is associated with a .098 decrease in the perception score (=-0.098, p=0.312) and moving from one age bracket to the next higher one is associated with a decrease of 0.02 in the perception score (=-0.02, p=0.783). table 3 shows that in model 2, all the background characteristics of preceptors together with perception on clinical teaching and learning, and clinical assessment accounted for nearly 59% of the differences in their clinical placement area perception (adjusted r2=0.592, p<0.001). gender, age and years of service did not make a statistically significant contribution to the perceptions on the clinical placement area. however, similar to model 1, being a female and increasing age was associated with a decrease in the perception score. academic qualification had a statistically significant relationship with the perceptions on the clinical placement area (=0.147, p=0.023). also, holding all other factors constant, a unit increase in the clinical teaching and learning score is associated with a 0.042 increase in the perception score of the clinical placement area and this was statistically significant (=0.421, p<0.001). similarly, a unit increase in the clinical assessment score is associated with a 0.43 increase in the perception score of the clinical placement area which was statistically significant (=0.429, p<0.001). nurse media journal of nursing, 12(2), 2022, 177 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 2. descriptive summary of the perception of preceptors on clinical nursing education components of clinical nursing education mean std. error std. deviation 95% ci % score on a 4-point scale lower upper clinical placement area score 2.30 0.05 0.84 2.21 2.39 57.5% placement dates are pre-published before the placement of students to the clinical facilities. 2.66 0.07 1.25 2.52 2.80 66.5% students get enough clinical exposure in the clinical placements 2.51 0.08 1.32 2.36 2.66 62.8% there is sufficient clinical accompaniment by clinical instructors in the placement area 2.13 0.08 1.41 1.97 2.29 53.3% there is an effective communication between clinical facilitators and staff in the clinical facilities. 2.30 0.08 1.37 2.15 2.45 57.5% students and clinical facilitators have effective communication 2.30 0.08 1.41 2.14 2.46 57.5% there is effective communication between clinical facilitators and clinical staff 2.42 0.07 1.25 2.28 2.56 60.5% lecturers also visit the clinical area for accompaniment of students. 2.33 0.08 1.39 2.18 2.48 58.3% the learning needs of students are clarified to the students. 1.96 0.08 1.46 1.80 2.12 49.0% there is a joint responsibility between the lecturers and the clinical staff to develop the student nurses. 2.54 0.08 1.39 2.38 2.70 63.5% the development and teaching of the student nurses is only the responsibility of the university. 1.75 0.07 1.18 1.62 1.88 43.8% the clinical facilities are supportive of professional growth, skills development and practice of students. 2.61 0.08 1.32 2.46 2.76 65.3% there is a good relationship between clinical facilitators and the clinical staff in clinical placements. 2.07 0.08 1.44 1.91 2.23 51.8% there are enough clinical placement facilities to place students for clinical practice. 2.30 0.08 1.33 2.15 2.45 57.5% clinical teaching and learning score 2.04 0.05 0.81 1.95 2.13 51.0% the university has enough space for clinical teaching and learning activities. 1.81 0.07 1.20 1.68 1.94 45.3% the university has enough equipment and material resources for demonstration and feedback of clinical skills. 1.75 0.07 1.21 1.61 1.89 43.8% the clinical placement areas have enough equipment and material resources for demonstration and feedback of clinical skills. 1.86 0.07 1.29 1.72 2.00 46.5% students are theoretically prepared before they are sent to clinical facilities 2.07 0.08 1.40 1.91 2.23 51.8% nursing students are willing to learn. 2.28 0.08 1.42 2.12 2.44 57.0% students accept constructive criticism. 1.99 0.08 1.45 1.83 2.15 49.8% all students know the limitations of clinical teaching and learning process. 1.93 0.08 1.37 1.78 2.08 48.3% a remedial plan is implemented if a student fails to master a skill 1.95 0.07 1.26 1.81 2.09 48.8% clinical facilitators get full support from the lecturers. 2.07 0.08 1.38 1.92 2.22 51.8% clinical accompaniment does benefit students. 2.69 0.08 1.38 2.54 2.84 67.3% nurse media journal of nursing, 12(2), 2022, 178 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 2. continued components of clinical nursing education mean std. error std. deviation 95% ci % score on a 4-point scale lower upper clinical assessment 2.30 0.05 0.85 2.21 2.39 57.5% students are informed of the specific criteria and standards for each clinical placement against which they will be assessed. 2.24 0.08 1.31 2.09 2.39 56.0% all students sign an assessment contract before being assessed. 2.10 0.08 1.31 1.95 2.25 52.5% students are informed in time before clinical assessments start. 2.39 0.07 1.28 2.25 2.53 59.8% students avail themselves for clinical practice before they are assessed. 2.26 0.08 1.35 2.11 2.41 56.5% the assessment tools facilitate the integration of theory and practice. 2.39 0.08 1.34 2.24 2.54 59.8% there is confidentiality of the assessment outcome for each student. 2.14 0.08 1.32 1.99 2.29 53.5% student and the facilitator discuss and evaluate performance against each competency thereby identifying areas of strength and areas needing improvement. 2.01 0.08 1.40 1.85 2.17 50.3% preceptors have an input in the development of assessment tools. 2.52 0.08 1.44 2.36 2.68 63.0% as preceptors we are involved in clinical assessments of students. 2.64 0.08 1.41 2.48 2.80 66.0% clinical nursing education perception score 2.21 0.04 0.74 2.13 2.29 55.3% table 3. predictors of perception of clinical placement area model predictors coefficients std. error t-statistic p-value 1 (constant) 2.088 0.175 11.916 0.000 gender -0.098 0.097 -1.014 0.312 age -0.02 0.074 -0.275 0.783 years of service 0.013 0.104 0.123 0.902 academic qualification 0.202 0.099 2.039 0.042 model summary: adjusted r2=0.019, f(4, 302) =1.46, p=0.22 2 (constant) 0.292 0.144 2.032 0.043 gender -0.066 0.063 -1.056 0.292 age -0.051 0.048 -1.064 0.288 years of service 0.062 0.067 0.92 0.359 academic qualification 0.147 0.064 2.285 0.023 clinical teaching and learning score 0.421 0.049 8.628 0.000 clinical assessment 0.429 0.047 9.137 0.000 model summary: adjusted r2=0.592, f(2, 300) =210.72, p<0.001 notes: outcome variable: clinical placement area score 4. discussion the study aimed at assessing preceptors’ perceptions of the quality of clinical nursing education in ghanaian context. the quality of clinical nursing education was assessed under three main components, which include clinical placement area, clinical teaching and learning, and clinical assessment. the preceptors generally perceived that the quality of clinical placement area and clinical assessment were slightly above average as they score each of them 2.30 on a scale of 0-4 (95% ci:2.21-2.39). the preceptors also perceived that the quality of clinical teaching and nurse media journal of nursing, 12(2), 2022, 179 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 learning was average as the they scored it 2.04 on a scale of 0-4 (95% ci:1.95-2.13). despite the above average ratings on the quality of the three component of clinical nursing education, the findings point out specific areas that require improvement. 4.1 clinical placement area the clinical placement area plays an important role in the clinical skills training of nursing students. the study established that the preceptors generally expressed a 57.5% level of agreement with statements assessing the perceptions of the clinical placement area. thus, the preceptors’ ratings indicate a more than average favourable view of the clinical placement area. that notwithstanding, the general finding indicates that they believe there is room for improvement in the clinical placement area. the findings of the present study agree with a study among students in iran which revealed a positive perception of the clinical learning environment (rokhafrooz et al., 2022). the preceptors in the present study are employees of the clinical facilities hence this could influence how positive they perceived the clinical placement area. other studies have indicated the need to improve the clinical placement area (kananu et al., 2020; mbakaya et al., 2020; rajeswaran, 2017). it can therefore be suggested that the clinical placement area should be assessed at the beginning of every academic year to ensure that students get optimal clinical placement experiences. in the present study, the academic qualification of participants was found to have a significant influence on their perceptions of the clinical placement area. the participants in the present study with higher qualifications held more negative perceptions of the clinical placement area which may have been more realistic, and this could be because they had more exposure or understanding of the facilities required in a clinical placement area to enhance clinical education. similarly, a study in malawi revealed that preceptors with at least a bsc in nursing were more suitable for facilitation of clinical teaching and learning (mhango et al., 2021). however, nursing educations institutions (neis) could also collaborate with clinical facilities to organize continuous professional development programmes for experienced nurses who have the desire to be preceptors but have comparatively lower academic qualifications. also, it can be suggested that neis could consider assigning nurse educators to clinical facilities to support and collaborate with preceptors in the clinical teaching of students. the present study established that the preceptors’ level of agreement regarding whether clinical placement dates are pre-published was 2.66 on a scale of 0-4 translating to 66.5%. the finding in the present study, although above average, shows a need for improvement in communication from the academic faculty responsible for publishing clinical placement dates. the findings in the present study is consistent with other studies which have reported that communication is an essential driving force of clinical nursing education (moonaghi et al., 2015; needham et al., 2016; cândida et al., 2017). in the present study setting, the clinical facilities have to receive students from various neis, hence pre-publishing clinical placement dates will allow the clinical facilities to make a schedule for the various neis to avoid overcrowding during clinical placement. pre-publishing clinical placement dates early is also necessary in ensuring that preceptors prepare to receive students. the study findings revealed that there was an above average level of agreement that communication between students and clinical staff was effective. this study finding differs from an earlier study in ghana which cited communication as a major challenge in preceptorship (asirifi et al., 2017). also, ryan and mcallister (2019) indicated that spending time interacting with students and getting to know them was necessary for enhancing the relationship between clinical staff and students. the results of the present study suggest that clinical staff spend some amount of time interacting with students during clinical placement. however, preceptors in the present study are employees of the clinical facilities who combine their duties as nurses with the teaching of students during clinical placement. the lack of protected time to support students may negatively affect effectiveness of the communication. considering the key role communication plays in making clinical placement successful, there is the need to put in place strategies such as pre-briefing and debriefing sessions to enhance communication between students and preceptors. the study findings also indicate that the preceptors were of the view that the teaching and development of students is a joint responsibility of the university and the clinical facilities. this finding is consistent with that of other studies which also emphasised the collaborative role that nurse media journal of nursing, 12(2), 2022, 180 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 should be played by neis and clinical facilities in the clinical education of nursing students (direko & davhana-maselesele, 2017; maguire et al., 2012). clinical nursing education consists of students acquiring theoretical knowledge and translating it into skills acquisition in the clinical placement area. it can be suggested that stronger collaboration will therefore play an essential role in coming up with strategies to support students to acquire professional skills. the development of a memorandum of understanding between neis and clinical facilities could be an important step towards stronger stakeholder collaboration. 4.2 clinical teaching and learning clinical teaching and learning are core components of clinical nursing education. overall, the findings indicate that the preceptors had a favourable stance towards the present state of clinical teaching and learning. the preceptors are the main group of clinical staff expected to assist students with the learning of clinical skills hence they could have scored themselves favourably to indicate that they were doing well. also, clinical teaching and learning take place in the clinical facilities where the preceptors are employed so they could have been attempting to present the clinical environment in a favourable light. the preceptors scored the clinical facilities 1.86 on a scale of 0-4 regarding the ability of the clinical facilities to provide adequate equipment and material resources for demonstration. this finding indicates that the clinical facilities may not be in the best position to support students to learn clinical skills. the finding agrees with an earlier study in ghana in which the lack of material resources in the clinical area was reported as a major cause of the theory-practice gap (salifu et al., 2019). in ghana, though the clinical facilities provide the opportunity for clinical training of students, they are not obliged to provide equipment and material resources for clinical training. however, the neis could collaborate with clinical facilities to ensure the provision of adequate material resources for clinical skills teaching and learning. where possible, neis may need to ensure that students are placed in clinical facilities that have adequate equipment and material resources. aside, the neis should consider having pre-clinical placement meetings with preceptors to discuss how clinical placement objectives could be achieved in the face of the available equipment and material resources. students learn clinical skills at different rates and some may struggle to reach level of competency within the stipulated clinical placement duration. the development of a remedial plan that would assist students to gain mastery of clinical skills is an important factor in clinical teaching. the study established that the preceptors scored below average on the utilisation of a remedial plan to enable students to gain competence during clinical placement. the lower score may indicate that there is no utilisation of remedial plan or the preceptors have too many clinical responsibilities to ensure that remedial plans are implemented. in ghana, the curriculum for training nursing students is competency-based hence there is a need for increased efforts directed at supporting students to achieve clinical placement objectives. the preceptors also scored the students’ acceptance of constructive criticism as less than average. to improve the learning of clinical skills, there is the need for preceptors to identify and criticise students on areas of the clinical skills learning that require improvement. preceptors require some training on proper questioning techniques, giving cues and giving feedback to students during skills learning (botma et al., 2012). however, it may be difficult to determine if the criticisms given by preceptors in this study were actually constructive or not. this is because preceptors in the present study are not trained in preceptorship and this could account for an inability to give constructive criticism. 4.3 clinical assessment the need for assessment and the fairness of assessments is an essential component of clinical education. the results of the present study indicate that while the preceptors had a more favourable view of the current method of clinical assessment, there was a general perception that improvement was needed. the finding concurs with another study in ghana which identified the need to train assessors, standardise the assessment process and provide adequate resources for clinical competency assessment (anim-boamah et al., 2022). also, specific areas of clinical assessment that were identified as requiring improvement include the need for signing a performance contract by students before the assessment, involving preceptors in development of nurse media journal of nursing, 12(2), 2022, 181 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 the assessment tools, and preceptors discussing and evaluating performance against each competency. clinical learning contracts have demonstrated a positive impact on students’ clinical learning (sajadi et al., 2017). the present study revealed that the preceptors scored a less than average on the signing of learning performance contracts to enhance the achievement of clinical placement objectives. this finding is consistent with a study conducted in china which revealed that there was poor knowledge regarding the signing a performance contract (chan & wai-tong, 2000). by signing a performance contract, students and preceptors are able to understand their responsibilities in ensuring that students achieve their clinical placement objectives. to ensure effective application of performance contracts, neis should organise continuous professional development for preceptors to enhance their understanding of the concept. the level of agreement regarding whether the student and the facilitator discuss and evaluate performance against each competency was scored as average by the preceptors. receiving feedback has been identified as an important strategy in making clinical assessment more effective (bani-issa et al., 2019). students are expected to achieve specific competencies at every level of their study. one of the main reasons for the clinical assessment of students is to evaluate their performance against the expected competencies. a discussion after the clinical assessment will serve as feedback that will enable students to know the areas in which they need to put more effort. preceptors should therefore endeavour to hold feedback sessions for students after clinical assessment. 5. implications and limitations the study revealed that preceptors indicated that clinical nursing education is a joint responsibility between neis and clinical facilities. this calls for effective collaboration to ensure that clinical nursing education is well structured and supported by both neis and clinical facilities. the study also identified the need to develop and implement remedial plans for students who are unable to achieve clinical placement objectives within the clinical placement schedule. this will require neis ensuring that preparation of students includes clarifying the importance of instituting remedial plans to enhance the development of clinical competencies. also, the signing of performance during clinical placement was identified as a way of improving the clinical nursing education. this strategy should be given the required attention by first teaching students the importance of signing the performance contracts. the study had some limitations. the recruitment of preceptors from facilities in northern ghana did not allow for the assessment of views in the southern part of ghana. one will, therefore, not be able to tell if the views here represent that of southern ghana. also, the use of a quantitative approach did not allow the preceptors to express their views beyond what the questionnaire provided. 6. conclusion the study findings suggest that though the preceptors generally perceived the quality of clinical nursing education to be slightly above average; there is the need to take steps to ensure that it improves. the study findings indicate that preceptors viewed clinical nursing education as a shared responsibility between neis and the clinical facilities. this calls for the need to for collaboration and effective communication between neis and the clinical facilities. the collaboration could involve developing training programmes for preceptors to improve their skills in clinical teaching and clinical assessment of students. there is the need to have scheduled assessment of the quality of clinical nursing education to inform strategies for improvement. also, further studies should be done using qualitative approach to gain in-depth understanding of the issues that require redress to improve clinical nursing education. acknowledgment this manuscript is drawn from a broader study submitted to the university of the witwatersrand, johannesburg, south africa for the award of a ph.d. in nursing education. the first author was awarded postgraduate merit award by the university of the witwatersrand for his ph.d. studies. the authors wish to appreciate the contribution of dr hilary thurling for cosupervising the thesis. nurse media journal of nursing, 12(2), 2022, 182 copyright © 2022, nmjn, e-issn 2406-8799, p-issn 2087-7811 author contribution the first author (gtn) conducted the study under the guidance of the second author (sja). both authors (gtn and sja) were involved in the conceptualization, data collections, analysis and manuscript writing. conflict of interest the authors declare that there is no conflict of interest. references anim-boamah, o., christmals, c. dela, & armstrong, s. j. 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(1967). elementary sampling theory. prentice-hall, inc., englewood cliffs. copyright © 2022 nmjn. this article is an open access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). https://creativecommons.org/licenses/by-sa/4.0 nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://medianers.undip.ac.id 13(1):68-84, april 2023 https://doi.org/10.14710/nmjn.v13i1.48114 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 review effects of patient and family-centered care on quality of care in pediatric patients: a systematic review tuti seniwati1,2, dessie wanda3, nani nurhaeni3 1postgraduate program, faculty of nursing, universitas indonesia, depok, indonesia 2pediatric nursing department, faculty of nursing, universitas hasanuddin, makassar, indonesia 3pediatric nursing department, faculty of nursing, universitas indonesia, depok, indonesia article info abstract article history: received: 5 august 2022 revised: 26 april 2023 accepted: 27 april 2023 online: 30 april 2023 keywords: model; patient and familycentered care; pediatric patient; quality of care corresponding author: tuti seniwati pediatric nursing department, faculty of nursing, universitas hasanuddin, makassar, indonesia email: tutiseniwati@unhas.ac.id background: patient and family-centered care is one approach that is applied in pediatric care in various hospital settings to improve the quality of care. however, information related to the results of the entire study and its intervention model has not been identified effectively in child health care. purpose: this study aimed to describe and assess the effects of patient and familycentered care on the quality of care in pediatric patients. methods: a systematic review was used as a method in this study. seven databases were used, including sciencedirect, scopus, proquest, ebsco, sage journal, tailor and francis, and pubmed to search the literature for relevant published reviews that determined patient and family-centered care interventions between 2011 and 2021. the synthesis without meta-analysis guidelines was used to analyze the data in this review. the data were further analyzed by critically assessing the quality of the articles using the jbi and casp checklists. results: from a total of 29.780 articles identified, fifteen articles were included in this review. several models of patient and family-centered care interventions were identified, such as family-centered care, family-centered communication program, family-integrated care, family nurture intervention, family empowerment, parent participation, close collaboration, mother-nurse partnership program, and the newborn individualized developmental care and assessment program. from those models, the outcomes for quality of care were related to the pediatric quality of life, length of stay, patient safety, parent satisfaction, parent psychological response, and parent involvement and partnership with staff. conclusion: the shreds of evidence indicate that patient and family-centered care can improve the quality of care in the pediatric patients. it is recommended that patient and family-centered care can be implemented in pediatric care by increasing the participation of family during treatment. how to cite: seniwati, t, wanda, d., & nurhaeni, n. (2023). effects of patient and family-centered care on quality of care in pediatric patients: a systematic review. nurse media journal of nursing, 13(1), 68-84. https://doi.org/10.14710/nmjn.v13i1.48114 1. introduction children are hospitalized when there is a change in health conditions caused by having an acute or chronic disease that requires health care services (witt et al., 2014). young human children are more susceptible to disease because the body’s defense system is generally in the growth process compared to adults (simon et al., 2015). a study stated that children aged 0-3 years experienced 14 types of infections in their lives, of which 71% suffered from respiratory infections, and it was reported that the main cause of these infections came from the host (vissing et al., 2018). besides, research reported that a large proportion of mortality in hospitalized children occurs early during admission (bohn et al., 2016). during hospitalization, it is important to develop and implement an intervention that is feasible, acceptable, and positively impacts health outcomes (geerligs et al., 2018). one of the most fundamental changes in pediatric health care is the recognition of the importance of patients’ and families’ involvement in health care (national association of pediatric nurse practitioners, 2013). patient and family-centered care (pfcc) is an approach that recognizes the role of the family in the patient’s life and encourages mutually beneficial collaboration between patients, families, and health care professionals (brown et al., 2008). https://crossmark.crossref.org/dialog/?doi=10.14710/nmjn.v13i1.48114&domain=pdf&date_stamp=2023-04-30 nurse media journal of nursing, 13(1), 2023, 69 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 pfcc emphasizes partnership in the health care system to improve health quality, safety, and care delivery (brown et al., 2015). a better understanding of the factors influencing the implementation of the pfcc is an important element in improving its delivery. a study revealed that factors from a health care professional such as inadequate level of experience, high workload, time pressure, and unsupportive attitude are the barriers to patient and family-centered care (lloyd et al., 2018). this new perspective must overcome perceived barriers and foster a culture of partnership with patient relatives (van mol et al., 2017). pfcc consists of four core components that are associated with outcomes in pediatric patients, i.e., information sharing, social-emotional support, providing care based on family background, and shared decision-making (gallo et al., 2016). moreover, institute for patient-and family-centered care (2017) states that dignity and respect, information sharing, participation, and collaboration are the core components of pfcc. previous studies have widely developed some of these components as an intervention model in pediatric care services. the study conducted by hassanian et al. (2018) and heo and oh (2019) used parental participation as a component of pfcc in pediatric care. meanwhile, toivonen et al. (2020) used collaboration between parents and staff as an intervention model in pfcc. although many studies have used pfcc as an intervention model, it needs to be studied more deeply through systematic reviews to obtain solid and reliable scientific evidence. previously, research related to pfcc intervention models in improving the quality of care had been carried out using a systematic review approach; nevertheless, the focus of the respondents was adult patients. therefore, the pfcc needs to be further identified related to existing intervention models and its outcomes. accordingly, this review was conducted to describe and assess the effects of patient and family-centered care on the quality of care in pediatric patients. 2. methods 2.1 research design a systematic review was used as a method in this study. the researchers used pico (patient, intervention, comparison, and outcomes) to determine the clinical questions (table 1). pico is a widely used framework for developing research questions on systematic review (considine et al., 2017). the research question in this study was “how are the effectiveness of patient and family-centered care in improving the quality of care?” table 1. description of pico patients pediatric patients (aged 0-18 years) and their families intervention aspects of patient and family-centered care, such as those focused on the patient, the family, or both. also, interventions included components of patient and family-centered care (participation, information sharing, collaboration, and shared decision-making) comparison usual care outcomes quality of care resulting from patient and family-centered care interventions for patients and families 2.2 search methods literature searching was conducted using seven databases: sciencedirect, scopus, proquest, ebscohost, sage journal, tailor and francis, and pubmed within the year from 2011 to 2021. determination of keywords was conducted by using the boolean operators’ technique, i.e. and and or to combine words when searching. in addition, the author also used quotations or quotation marks (“) and also grouping on similar concepts symbolized by ( ). the keywords used: (“patient and family-centered care” or “patient-centered care” or “family-centered care”) and (intervention or effect) and (“usual care”) and (“quality of care” or “clinical outcome”) and (newborn or children or adolescent or teenager). 2.3 inclusion and exclusion criteria the inclusion criteria in this study were (1) studies that included pediatric patients aged 0-18 years and their families, (2) accredited international journal, (3) publication year of the journal nurse media journal of nursing, 13(1), 2023, 70 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 from 2011 to 2021, (4) articles with experimental design such as quasi-experimental, true experimental, and randomized controlled trials (rcts), (5) articles are written in english. meanwhile, the exclusion criteria were (1) articles written in the form of reviews, conference proceedings, protocols, case reports, surveys, and thesis/dissertation, and (2) articles that cannot be downloaded (not fully accessible). 2.4 screening of articles screening articles were conducted by two reviewers (ts and dw). the screening was carried out through several stages, such as identifying keywords in seven available databases, selecting the appropriate title and abstract, and identifying the availability of the full text and its suitability with the existing inclusion criteria. in case of disagreement between ts and dw, a third reviewer (nn) would be involved. nn would reconcile the disagreement to identify and ensure that both reviewers have done the screening process correctly. reconciliation can play a significant role in ensuring that abstract screeners make the right decision at each stage of the screening process (polanin et al., 2019). 2.5 data extraction fifteen selected articles were extracted by all reviewers using a grid synthesis format. this format contained some information, i.e., authors, year of publication, country, objective, design, hospital setting, intervention model, duration, results, and components of the patient and familycentered care. all reviewers identified all included articles based on the foregoing information and summarized them in a table (table 2, appendix 1). 2.6 quality assessment of the selected article the assessment of the quality of studies in this review used tools from the joanna briggs institute (jbi), i.e., the critical appraisal checklist for quasi-experimental research through https://jbi.global/critical-appraisal-tools. jbi critical appraisal tools were created by the jbi and partners and were subsequently accepted by the jbi scientific committee after undergoing thorough peer assessment (joanna briggs institute, 2020). meanwhile, the quality of studies for rct design was measured using the critical appraisal skills programme (casp) through https://casp-uk.net/casp-tools-checklists/ (table 3, appendix 2). the casp rct checklist was initially developed based on the journal of the american medical association (jama) users’ guides and piloted with medical professionals (critical appraisal skills programme, 2020). a critical appraisal of the article was conducted by ts and dw. if there was disagreement, nn would involve in reconciling the process based on guidelines from jbi and casp. 2.7 risk of bias the risk of bias in individual studies for quasi-experiment design was determined with the following cutoffs: low risk of bias if 70% of answers scored yes, moderate risk if 50 to 69% of questions scored yes, and high risk of bias if yes scores were below 50% (goplen et al., 2019). on the results of the risk assessment bias, it was found that of the nine articles reviewed, seven articles had a low risk of bias, two included a moderate risk, and none had a high risk of bias (table 4). meanwhile, assessment of the risk of bias in rct studies was conducted using the cochrane collaboration tool (higgins et al., 2011). of five articles on rct design, one study used single-blind, two studies did not show clear blindness, and two were non-blind studies (table 5). 2.8 data analysis the authors used synthesis without meta-analysis (swim) guidelines in analyzing the data (campbell et al., 2020). the swim guidelines were used to synthesize quantitative data in the form of intervention effects and present it in nine reporting items. item 1 was grouping the studies into several sections such as authors and year of publication, country, objective, design, hospital setting, intervention model, duration, results, and components of the patient and family-centered care. items 2-6 were reviewing full-text articles that meet the inclusion criteria to answer the clinical review questions. the article analysis was carried out by reviewing the study design, intervention methods, assessment tools, and intervention effects. the findings are presented in the form of a summary table (item 7), and then the similarities and differences of the outcomes https://jbi.global/critical-appraisal-tools https://casp-uk.net/casp-tools-checklists/ nurse media journal of nursing, 13(1), 2023, 71 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 are reported in the form of a narrative (item 8). furthermore, reporting on the limitations of this study was presented as the final stage of data analysis (item 9). table 4. risk of bias assessment for quasi experiment design author jbi assessment tools q1a q2 q3 q4 q5 q6 q7 q8 q9 % yes interpretationb (ladak et al., 2013) yes yes unclear yes yes no yes yes yes 78% low risk of bias (uhm & kim, 2019) yes yes unclear yes yes no yes yes yes 78% low risk of bias (sannino et al., 2016) yes yes unclear yes no no yes unclear yes 56% moderate risk of bias (minooei et al., 2016) yes yes unclear yes yes no yes yes yes 78% low risk of bias (he et al., 2018) yes yes no yes yes no yes yes yes 78% low risk of bias (khan et al., 2018) yes yes yes no yes yes yes yes yes 89% low risk of bias (toivonen et al., 2020) yes no unclear no yes no yes yes yes 56% moderate risk of bias (peyrovi et al., 2015) yes yes yes yes yes no yes yes yes 89% low risk of bias (rostami et al., 2017) yes yes yes yes yes no yes yes yes 89% low risk of bias (nurhaeni et al., 2018) yes yes yes yes yes no yes yes yes 89% low risk of bias notes: a q1 – q9 indicate questions 1 to 9 based on the jbi risk assessment b the risk of bias was ranked as high when the study reached up to 49% of “yes” scores, moderate when the study reached from 50 to 69% of “yes” scores, and low when the study reached more than 70% of “yes” scores table 5. cochrane risk of bias tool for rct cochrane risk-of-bias domain randomizati on process allocation concealment blinding of participants and researchers blinding of outcome assessment incomplete outcome selective reporting other bias (heo & oh, 2019) + + ? + + + (hassanian et al., 2018) + + ? + + + (bastani et al., 2015) + + + + + + (welch et al., 2013) + + ? + + (verma et al., 2017) + + + + + note: (+) indicates a low risk of bias, (-) indicates a high risk of bias, (?) shows unclear risk of bias 3. results 3.1 characteristics of the selected studies fifteen articles were included in the review process. the researchers identified 29,780 articles from seven databases, and 28,473 articles were excluded according to limiters (year of publication, type of article, subject area, and open access). fifty-three articles were selected for review after the remaining 1,307 papers were filtered based on their titles and abstracts. finally, fifteen articles were included in this review after assessing their eligibility and adding articles from the reference list (figure 1). five of the reviewed articles came from iran, two from south korea, and one from columbia, china, finland, india, indonesia, italy, north america, and pakistan. all of the articles in this study were conducted in the hospital setting. there were eight studies implemented in the nicu room, two studies in the picu room, four in the pediatric ward, and one in the pediatric nephrology office (see table 2). moreover, this review produced six outcomes related to the quality of care, including pediatric quality of life, length of stay, patient safety, parent satisfaction, parent psychological response, and parent involvement and partnership with staff. 3.2 participants the participants in this study were in the age range from 0 to 12 years. the majority (9 of 15 articles) of published studies involved newborn participants and their families in the intervention. the highest number of participants was 3106 children (1574 pre-intervention and 1532 postinterventions), and the number of parents was 2148 (khan et al., 2018). in comparison, the lowest number of participants was 43 children (21 in the intervention group and 22 in the control group) (sannino et al., 2016). nurse media journal of nursing, 13(1), 2023, 72 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 3.3 characteristics of the intervention and components of the pfcc the implementation of the treatment consists of several models including family-centered care (ladak et al., 2013; rostami et al., 2017; bastani et al., 2015; verma et al., 2017), mother– nurse partnership program (uhm & kim, 2019), the newborn individualized developmental care and assessment program (sannino et al., 2016), the family empowerment model (minooei et al., 2016; peyrovi et al., 2015; nurhaeni et al., 2018), family integrated care (he et al., 2018), family centered communication program (khan et al., 2018), the close collaboration (toivonen et al., 2020), and parent participation/participatory care (heo & oh, 2019; hassanian et al., 2018). the duration of the intervention varied in this review, ranging from the longest 18 months (toivonen et al., 2020) to the shortest 30-45 minutes (bastani et al., 2015; nurhaeni et al., 2018). the others have a duration of eight months (khan et al., 2018), two weeks (heo & oh, 2019), two days (ladak et al., 2013), two hours (verma et al., 2017), and 30 minutes twice a day (uhm & kim, 2019). each session used a duration from 0.5 to 1 hour (peyrovi et al., 2015; hassanian et al., 2018; minooei et al., 2016) and as many as possible or warranted by the infant's distress (welch et al., 2013). there was also implementation, starting from the first admission to discharge (sannino et al., 2016; he et al., 2018). however, there was a study where the duration of the intervention was unclear (rostami et al., 2017). pfcc components of the intervention include participation (patient and family), partnership, information sharing, collaboration, communication, family empowerment, and decision-making (table 6). table 6. findings of the quality of care outcomes with pfcc intervention quality of care outcomes number of studies (f) significant effects f (%) no significant effects f (%) pediatric quality of life 5 4 (80) 1 (20) length of stay 4 3 (75) 1 (25) patient safety 3 1 (33.33) 2 (66.67) parent satisfaction 6 6 (100) parent psychological response 2 2 (100) parent involvement and partnership with staff 6 6 (100) 3.4 quality of care outcomes of the 15 articles reviewed, six outcomes were obtained related to the quality of care, i.e., pediatric quality of life, length of stay, patient safety, parent satisfaction, parent psychological response, and parent involvement and partnership with staff (see table 2). the outcome measurement of this review refers to the quality of care domain issued by who (2018), including effectiveness, safety, and people-centredness. outcome indicators of effectiveness consist of hospital readmission rate, improvement in health status, and death prevention. meanwhile, outcome indicators of patient safety may include treatment complications or incidence of hospital-acquired infections. patient satisfaction, activities of daily living, and readiness to recommend the hospital are the outcome indicators of patient-centredness (european observatory on health systems and policies, 2019). 3.4.1 pediatric quality of life there were five (33.33%) published studies that reported quality of life as an outcome of pfcc intervention. the study by minooei et al. (2016) claimed that there were significant differences in the mean score of the children’s qol, including physical and psychosocial domain, and the total qol score in the intervention group before and after the training (p<0.05). in the physical domain, the percentage of normal visual orientation development in infants aged 40 weeks was higher (81%) in the intervention group compared to the control group (52.4%), and neurofunctional assessment at three months had normal scores of 66.6% of children compared to 47.6% of the control group (sannino et al., 2016). moreover, there was a significantly reduced respiratory support time, a significant positive weight gain, and a significant increase in breastfeeding for infants in the intervention compared with the control group (he et al., 2018; verma et al., 2017). however, there was no difference in infants’ weight between the intervention nurse media journal of nursing, 13(1), 2023, 73 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 and control groups during the parent's participation program in the nicu setting (heo & oh, 2019). figure 1. prisma flowchart 3.4.2 length of stay of 15 articles reviewed, four studies (26.67%) described length of stay as an outcome of this research. the results of 3 studies revealed that there was a significant decrease in the length of stay in children during hospitalization (ladak et al., 2013; nurhaeni et al., 2018; bastani et al., 2015). meanwhile, one article confirmed no significant difference between the intervention and control groups (welch et al., 2013). 3.4.3 patient safety there were three (20%) published studies that proclaimed patient safety as a result of this study, including medical complications and nosocomial infection. there was an unchanged rate of medical errors, but harmful errors (preventable adverse events) went down after intervention significantly by p<0.01 (khan et al., 2018). however, the other study stated no significant difference between groups in medical complications (welch et al., 2013) and nosocomial infection (verma et al., 2017). 3.4.4 parent satisfaction there were six (40%) published studies announced that parental satisfaction increased significantly with p<0.05 after pfcc intervention and its components for children hospitalized title and abstract screened (n = 53) id e n ti fi c a ti o n s c r e e n in g e li g ib il it y in c lu d e d 29,780 articles identified through database screening: sciencedirect = 1.710 proquest = 1.053 ebscohost = 26. 184 scopus = 451 sage journal = 130 taylor & francis = 70 pubmed = 182 limiter (n = 1.307) 1,254 articles were removed based on the abstract and title review with the following reasons: not experimental research nor rct patient aged >18 years article review, proceeding, protocols, case report, survey, and thesis/dissertation not available in english full-text articles assessed for eligibility (n = 13) article added from reference list (n=5) 45 articles were excluded based on the full text for eligibility with the following reasons: not full text patient aged >18 years not available for patient and family-centered care and outcome studies included (n=15) 28,473 articles were excluded according to the limiters. 3 articles were excluded due to the result focused on the checklist, feasibility of the study, and having low methodology quality. nurse media journal of nursing, 13(1), 2023, 74 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 (bastani et al., 2015; hassanian et al., 2018; ladak et al., 2013; nurhaeni et al., 2018; rostami et al., 2017; uhm & kim, 2019). 3.4.5 parent psychological response there were two (13.33%) reviewed articles that presented the psychological responses of parents as a result of the intervention in this study. there was a significant decrease in mothers’ anxiety with p<0.001 and increased parent self-efficacy with p<0.008 after the implementation of the partnership model between mothers and nurses (uhm & kim, 2019). furthermore, mothers reported an emotional readiness in preparing to care for their infant on discharge from nicu to home (peyrovi et al., 2015). 3.4.6 parent involvement and partnership with staff there were six (40%) published studies reported that parent involvement and partnership with health professionals as the result of the pfcc intervention. parents reported that there was an increase in parental involvement (khan et al., 2018; ladak et al., 2013; welch et al., 2013) and a significant raised in parent-staff partnership during child care in hospitals with p<0.001 (heo & oh, 2019; uhm & kim, 2019). this partnership is demonstrated through the support of doctors and nurses in helping them how to care for their infants (sannino et al., 2016). 4. discussion this study aimed to describe and assess the effects of patient and family-centered care on the quality of care in the pediatric patients. there were six outcomes related to the quality of care, including pediatric quality of life, length of stay, patient safety, parent satisfaction, parent psychological response, and parent involvement and partnership with staff. the majority of the components of the pfcc in the articles reviewed used family participation as a research intervention. pfcc in nursing is about treating patients and their families as a partner in care with fostering their participation or collaboration (seniwati et al., 2023). family participation in taking care of hospitalized children is a mutual relationship between parents and nurses in providing children’s health information and decisions making to improve the quality of care (vasli & salsali, 2014). parental participation can be in the form of involvement in daily care during hospitalization (melo et al., 2014). feeding the child or preparing the food tray, changing their clothes, assisting in elimination and sleeping, bathing/wiping with a washcloth, and performing oral care are forms of parental participation in nursing care delivery (abdelkader et al., 2016). improving children’s quality of life is an outcome resulting from the pfcc intervention in this review. in the physical domain, pfcc interventions are reported to improve children’s clinical outcomes by decreasing oxygen support time (he et al., 2018), promoting better motor, visual, and auditory development (sannino et al., 2016), and increasing breastfeeding rates predischarge (verma et al., 2017). quality of life in children is associated with the role of the family in terms of parent-child interactions (santos et al., 2015). during hospitalization, parents have an important role in child care by providing physical comfort, physiological needs, and psychosocial support and facilitating children to develop abilities in line with the stages of development (suparto et al., 2020). regarding the impact of pfcc on parents, there was a significant increase in the level of parent satisfaction, parent involvement, and parent-staff partnership scores. parental satisfaction is associated with the attitude of the professional staff, the treatment provided, information, and parental participation during the child's care (cintra et al., 2022). nurses as a team in implementing pfcc have a role in involving children and families in the nursing process to improve the quality of care ( palokas et al., 2015; uhl et al., 2013). a previous study reveals that involving parents in a child’s care leads to enhancing their satisfaction in health care (cimke & mucuk, 2017). furthermore, pfcc also has an impact on the psychological response of parents. according to aljabari et al. (2022), parental involvement in childcare can reduce anxiety in parents. parental involvement in care will provide opportunities for them to care for their children directly, receive information on their children's health conditions, and improve relationships with care providers (mccabe, 2014). in addition, the results showed a decrease in length of stay, a negative parent’s psychological response, and the incidence of side effects in children during hospitalization. the previous review using an adult sample also stated that the results obtained after the pfcc intervention included nurse media journal of nursing, 13(1), 2023, 75 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 decreased length of stay, family satisfaction, and achievement of medical goals (goldfarb et al., 2017). likewise, increasing quality of life, reducing the length of the hospital stay, reducing anxiety in family members, and increasing family satisfaction and relationship with healthcare providers an outcomes of pfcc intervention in adult patients (park et al., 2018). a study revealed that the positive impact of reducing the length of hospital stay in children is related to improved psychological well-being (segers et al., 2019). improved psychological conditions such as decreased anxiety, depression, and stress in children are due to the presence of families who accompany children during hospitalization (adineh et al., 2016). the presence of the family is considered to bring comfort to the patient. it has also been demonstrated that being able to stay in the moment while a family member is in the hospital helps them deal better (mccabe, 2014). the strength of this review is that the articles were selected using an experimental design, including quasi-experimental and rct. the results of the risk assessment bias also show that 80% of the quasi-experimental design and about 71% in the rct included the low risk of bias in the 15 reviewed articles in this study. a study categorized as low risk of bias indicates confidence on the part of the reviewer that the outcome shows the true treatment impact (study results are considered valid). the study informing is capable of judging that no major or minor sources of bias are likely to consequence results (viswanathan et al., 2012). 5. implications and limitations the results of this study have implications for childcare delivery during hospitalization. this review has provided evidence that patient and family-centered care can be an appropriate approach for improving the quality of care for the patient, family, and health care professional. nurses as a team in health care providers encourage families to be involved in child care, including planning, implementation, and evaluation based on partnerships. the limitation of this research is generalizations in the research setting and not specific to a particular treatment room. in addition, the types of childhood diseases are also screened in general, and there are no criteria for certain conditions that are included in this review. however, the researcher included all possible interventions within the pfcc components and included rcts and quasi-experimental designs to analyze the highest quality of evidence. therefore, recommendations for future research to conduct pfcc reviews by equalizing the research setting and diagnosis of diseases in children. 6. conclusion this review conclude that patient and family-centered care intervention is effective in improving the quality of care. the results of this study found that there was an increase in the quality of care in terms of pediatric quality of life, parental satisfaction, parental involvement, and parent-staff partnership scores. moreover, there was a decrease in the length of stay, the incidence of harmful errors, and a negative parent's psychological response during hospitalization. family participation is the most component of the pfcc that was applied as an intervention in this study. acknowledgment we would like to thank the ministry of finance, the republic of indonesia, for the scholarships through the educational fund management institutions (lpdp scholarships), which were supported during the study by the first author. author contribution ts was responsible for the conception and design of the study, screening articles, data extraction, data analysis, quality appraisal, drafting the manuscript, and revising the manuscript. while dw and nn were in charge of screening articles, data extraction, and assessing the quality of each included article. all authors have read and approved the manuscript and take full responsibility for its content. conflict of interest the authors have no conflict of interest regarding this article. nurse media journal of nursing, 13(1), 2023, 76 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 references abdelkader, r., khalaf, i., kridli, s., arabiat, d., & alrimawi, i. 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(2020). parents’ roles in overcoming the impact of hospitalization on preschool children. advance in health science research, 21(icsshpe 2019), 140–143. https://doi.org/10.2991/ahsr.k.200214.039 toivonen, m., lehtonen, l., loyttyniemi, e., ahlqvist-bjorkroth, s., & axelin, a. (2020). close collaboration with parents intervention improves family-centered care in different neonatal unit contexts: a pre–post study. pediatric research, 88(3), 421–428. https://doi.org/10.1038/s41390-020-0934-2 uhl, t., fisher, k., docherty, s. l., & brandon, d. h. (2013). insights into patient and family‐ centered care through the hospital experiences of parents. journal of obstetric, gynecologic & neonatal nursing, 42(1), 121–131. https://doi.org/https://doi.org/10.1111/15526909.12001 uhm, j. y., & kim, h. s. (2019). impact of the mother–nurse partnership programme on mother and infant outcomes in paediatric cardiac intensive care unit. intensive and critical care nursing, 50, 79–87. https://doi.org/10.1016/j.iccn.2018.03.006 van mol, m. m. c., boeter, t. g. w., verharen, l., kompanje, e. j. o., bakker, j., & nijkamp, m. d. (2017). patientand family-centred care in the intensive care unit: a challenge in the daily practice of healthcare professionals. journal of clinical nursing, 26(19–20), 3212–3223. https://doi.org/10.1111/jocn.13669 vasli, p., & salsali, m. (2014). parents’ participation in taking care of hospitalized children: a concept analysis with hybrid model. iranian journal of nursing and midwifery research, 19(2), 139–144. verma, a., maria, a., pandey, r. m., hans, c., verma, a., & sherwani, f. (2017). family-centered care to complement care of sick newborns: a randomized controlled trial. indian pediatric, 54(6), 455-459. htps://doi: 10.1007/s13312-017-1047-9. vissing, n. h., chawes, b. l., rasmussen, m. a., & bisgaard, h. (2018). epidemiology and risk factors of infection in early childhood. pediatrics, 141(6), e20170933. https://doi.org/10.1542/peds.2017-0933 https://doi.org/10.3109/14767058.2015.1017461 https://doi.org/10.1542/peds.2017-0933 nurse media journal of nursing, 13(1), 2023, 79 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 viswanathan, m., ansari, m. t., berkman, n. d., chang, s., hartling, l., mcpheeters, m., santaguida, p. l., shamliyan, t., singh, k., tsertsvadze, a., & treadwell, j. r. (2012). assessing the risk of bias in systematic reviews of health care interventions. in methods guide for effectiveness and comparative effectiveness reviews. agency for healthcare research and quality (us). welch, m. g., hofer, m. a., stark, r. i., andrews, h. f., austin, j., glickstein, s. b., ludwig, r. j., myers, m. m., afifi, l., bechar, a., beebe, b. s., brunelli, s. a., carnazza, k. e., chang, c. y., farrell, p. a., fiedor, e. s., karim, q., kofman, s., koukaz, y. a., … hane, a. a. (2013). randomized controlled trial of family nurture intervention in the nicu: assessments of length of stay, feasibility and safety. bmc pediatrics, 13(1), 1. https://doi.org/10.1186/14712431-13-148 who. (2018). global efforts in measuring quality of care (issue february). https://apps.who.int/iris/bitstream/handle/10665/260544/who-his-sds-2018.1eng.pdf witt, w. p., weiss, a. j., & elixhauser, a. (2014). overview of hospital stays for children in the united states, 2012. in healthcare cost and utilization project (hcup) statistical briefs. agency for healthcare research and quality (us). https://www.ncbi.nlm.nih.gov/books/nbk274247/ copyright © 2023 nmjn. this article is an open-access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). https://creativecommons.org/licenses/by-sa/4.0 nurse media journal of nursing, 13(1), 2023, 80 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 appendix 1. table 2. data extraction of the selected studies no authors, year of publication, and country design hospital setting intervention model duration results components of pfcc 1 (ladak et al., 2013), pakistan quasiexperimental pediatric icu and pediatric cardiac icu family-centered rounds two days there was a significant increase in terms of parental satisfaction, use of simple language, feeling involved in care, making decisions, and precedence in rounds. in addition, length of stay was significantly reduced after intervention family participation 2 (uhm & kim, 2019), south korea quasiexperimental paediatric cardiac icu mother–nurse partnership programme (mnpp) that delivered in four phases (orientation, information sharing, negotiation, participation) 30 minutes twice a day in the intervention group, the infant's mother reported significantly higher parental satisfaction, parental self-efficacy, perceived partnership, and lower anxiety compared to the control group. partnership between nurse and mothers. consist of 3 components : information sharing, negotiation, and participation 3 (sannino et al., 2016), italy quasi experimental neonatal intensive care unit the newborn individualized developmental care and assessment program (nidcap) first admission until discharge nidcap assessment was measured from birth to discharge every 10±2 days percentage of motor, visual and auditory development of infants to be normal at term increased in infants who received treatment compared to the control group. maternal support in infant care is higher than the control group involving mothers participation in infant health care 4 (nurhaeni et al., 2018), indonesia quasi experimental pediatric wards family empowerment model through health education using a flipchart and booklets maximum 45 minutes there was significant differences between the intervention and control groups in empowerment and satisfaction aspects after the intervention. length of stay indicates a significant difference between the intervention and control groups family empowerment 5 (hassanian et al., 2018), iran clinical trial study pediatric wards participatory care through skill training to parents a 1-hour session in the presence of 5 parents per session all aspects of parental satisfaction including welfare services, medical services, and nursing care in the intervention group was significantly higher than the control group parents participation in children’s wards nurse media journal of nursing, 13(1), 2023, 81 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 2. continued no authors, year of publication, and country design hospital setting intervention model duration results components of pfcc 6 (khan et al., 2018), north america prospective, multicenter before and after intervention study pediatric inpatient units/pediatric wards family centered communication programme nine-month intervention implementation the overall rate of medical errors was unchanged, but harmful errors (preventable adverse events) decreased by 37.9%. nonpreventable adverse events also decreased. family engagement and nurse engagement improved on rounds communication and collaboration between health care provider and family family participation 7 (minooei et al., 2016), iran quasiexperimental pediatric nephrologist’s office the family empowerment model through four organized steps; knowledge enhancement, selfefficacy enhancement, self-esteem enhancement through participatory training, and process evaluation seven 45minute sessions there was a significant difference in the mean score of the children’s qol from their own perspectives in the physical and psychosocial domains and the total qol score in the intervention group before and after the training information sharing through knowledge enhancement, selfefficacy enhancement, patient and family participation 8 (he et al., 2018), china a pre-post intervention study neonatal intensive care unit family integrated care (fic) through training; hand hygiene, neonatal feeding, neonatal contact, patting on the back of the infant, parents involvement of care 21 hours a day in the first admission until discharge compared with control group, the fic group had significantly increased breastfeeding rates, breastfeeding time, enteral nutrition time, weight gain, and significantly lower respiratory support time. oxygen exposure time decreased but not significant. parents participation in infant’s care information sharing 9 (toivonen et al., 2020), finland a mixedmethod pre– post intervention study neonatal intensive care unit the close collaboration with parents training program through educational intervention the training was delivered in 18 months the quality of family-centered care, as assessed by staff and parents, increased significantly after the intervention. the intervention was able to help staff define and apply elements of family-centered care, such as shared decision making and collaboration between parents and staff. shared decision making and collaboration between parents and staff nurse media journal of nursing, 13(1), 2023, 82 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 2. continued no authors, year of publication, and country design hospital setting intervention model duration results components of pfcc 10 (heo & oh, 2019), south korea randomized controlled trial neonatal intensive care unit parent participation improvement that consisting of three stages: an individualized interaction stage, a pre-participation stage, and an active participation stage twoweeks both the mothers and fathers in the intervention group reported significantly higher scores in partnership, and attachment, as well as significantly higher scores within all partnership subscales except communication. however, there was no difference in infants’ weight between the intervention and control groups. parents participation partnership nurseparents 11 (bastani et al., 2015), iran randomized controlled trial neonatal intensive care unit family-centered care program which consisted of information about neonatal care, maternal presence, and participation in the care process 30-45 minutes in the fcc group, the mean score of satisfaction increased after intervention, the mothers were more satisfied with maternal presence in the neonatal intensive care unit, the number of neonatal readmission was less, and the mean duration of hospitalization was lower compared with control groups participation sharing information 12 (peyrovi et al., 2015), iran quasiexperimental neonatal intensive care unit empowerment program through training for mothers each phase was conducted during a 0.5–1 hour session regularly (consisting of 3 phases) at discharge time, there was a statistically significant difference in technical readiness and emotional readiness of mothers between control and experimental groups according to mothers’ self-report and nurse evaluation family empowerment 13 (welch et al., 2013), columbia randomized controlled trial neonatal intensive care unit family nurture intervention (fni) through calming session activities that involving mother and infant. calming session consisting scent cloth exchange, calming touch, and holding each session was comprised of as many of the calming procedures as possible or warranted by the infant’s distress there was no significant difference between groups in medical complications. the mean length of stay was not significantly affected by fni. mothers were willing to involve in this intervention, and that fni was compatible with routine care in nicu patient and parent engagement nurse media journal of nursing, 13(1), 2023, 83 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 2. continued no authors, year of publication, and country design hospital setting intervention model duration results components of pfcc 14 (rostami et al., 2017), iran quasiexperimental pediatric wards family-centered care not mentioned in the fcc group, the mean score of satisfaction was increased among the parents after intervention. besides, there was a significant difference in satisfaction scores between the control and experimental groups, where all parents of the experimental group expressed high satisfaction. family participation collaboration 15 (verma et al., 2017), india randomized controlled trial neonatal intensive care unit family-centered care through trained for parents using a simple audio-video tool that covered domains of personal hygiene, hand washing, danger signs recognition and feeding of the sick neonate training conducted between 10 am to 12 noon (2 hours) incidence of nosocomial episodes of sepsis was not different between groups. exclusive breastfeeding rates pre-discharge were significantly higher in intervention group compared with control group. parents participation sharing information nurse media journal of nursing, 13(1), 2023, 84 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 appendix 2. table 3. critical appraisal for rct with casp no critical appraisal for rct (critical appraisal skills programme, 2020) (heo & oh, 2019) (hassanian et al., 2018) (bastani et al., 2015) (welch et al., 2013) (verma et al., 2017) 1 did the study address a clearly focused research question? yes yes yes yes yes 2 was the assignment of participants to interventions randomised? yes yes yes yes yes 3 were all participants who entered the study accounted for at its conclusion? yes yes yes yes yes 4 were the participants ‘blind’ to intervention they were given? were the investigators ‘blind’ to the intervention they were giving to participants? were the people assessing/analysing outcome/s ‘blinded’? can’t tell no no can’t tell no no yes no no no no no no no no 5 were the study groups similar at the start of the randomised controlled trial? yes yes yes yes yes 6 apart from the experimental intervention, did each study group receive the same level of care (that is, were they treated equally)? yes yes yes yes yes 7 were the effects of intervention reported comprehensively? yes yes yes yes yes 8 was the precision of the estimate of the intervention or treatment effect reported? no no no yes yes 9 do the benefits of the experimental intervention outweigh the harms and costs? yes yes yes yes yes 10 can the results be applied to your local population/in your context? yes yes yes yes yes 11 would the experimental intervention provide greater value to the people in your care than any of the existing interventions? yes yes yes can’t tell yes nurse media journal of nursing e-issn: 2406-8799, p-issn: 2087-7811 https://medianers.undip.ac.id 13(1):31-55, april 2023 https://doi.org/10.14710/nmjn.v13i1.45996 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 review resilience-related breast cancer: a concept analysis fitria endah janitra1,2, nur aini2,3, anggi lukman wicaksana2,4 1faculty of nursing, universitas islam sultan agung, semarang, indonesia 2school of nursing, college of nursing, taipei medical university, taipei, taiwan 3nursing department, faculty of health science, universitas muhammadiyah malang, malang, indonesia 4department of medical surgical nursing, universitas gadjah mada, yogyakarta, indonesia article info abstract article history: received: 27 april 2022 revised: 27 april 2023 accepted: 28 april 2023 online: 30 april 2023 keywords: breast cancer, concept analysis, resilience, walker-avant methods corresponding author: fitria endah janitra faculty of nursing, universitas islam sultan agung, semarang, indonesia email: fitria.janitra@unissula.ac.id background: breast cancer-related adversity can result in severe psychological issues. however, some patients were able to demonstrate resilience, while others were not. therefore, the concept of resilience in breast cancer patients requires further clarification. purpose: this study aimed to systematically analyze resilience in patients with breast cancer, its attributes, antecedents, consequences, and empirical referents. methods: this concept analysis used the walker and avant method. cinahl, embase, scopus, web of science, pubmed, cochrane, and medline-ovid databases were explored using the keywords ‘resilience*’ and ‘breast cancer’. papers discussing resilience among breast cancer patients were used as criteria for inclusion. the analysis focused on the redefinition of resilience-related breast cancer by identifying attributes, antecedents, and consequences. results: a total of 53 studies were analyzed to construct resilience among breast cancer patients. the analysis identified that resilience in breast cancer patients has three defining attributes: coping, optimism, and social support. the antecedents were body image after mastectomy, symptom distress, cancer-related stigma, and fear of cancer recurrence, while the consequences included recorded as the quality of life and post-traumatic growth. conclusion: critical characteristics of resilience in breast cancer patients were coping, optimism, and social support. thus, improving those characteristics might improve the quality of life and post-traumatic growth. how to cite: janitra, f. e., aini, n., & wicaksana, a. l. (2023). resilience-related breast cancer: a concept analysis. nurse media journal of nursing, 13(1), 31-55. https://doi.org/10.14710/nmjn.v13i1.45996 1. introduction breast cancer is the most frequent malignancy among women and the second most significant cause of cancer-related death. a breast cancer diagnosis potentially leads to a traumatic event, with both physical and psychological consequences, that occurs in late response after the end of medical treatment (martino et al., 2019). the fifth edition of the diagnostic and statistical manual of mental disorders (apa, 2013) classifies a cancer diagnosis as a sort of trauma that brings a slew of issues (romeo et al., 2019). because of the difficulty in recognizing a unique stressful event, breast cancer has a distinct and special nature of the disease. the risk of life crisis and bodily integrity are frequently high, and the agony, damage, and loss of social and occupational roles could cause overwhelming emotion in a significant minority of patients. lack of control, impairment, and the diagnosis’ swiftness will cause acute fear, hopelessness, terror, anxiety, and melancholy (quattropani et al., 2016). some people who have been traumatized may have serious issues, whereas others (who may have been subjected to the same traumatic event) may only have little or no trouble recovering. this condition is known as resilience. in general, “resilience” refers to regaining normal function following hardship, sustaining the regular part of life, or successfully adapting to stressful experiences in life (johnston et al., 2015). the ability to successfully adjust to adversity, difficult life experiences, major threat, or trauma is characterized widely as resilience. recent research indicates that resilience is an “active process” rather than simply reversing pathological mechanisms (feder et al., 2019). the ability to adapt to life circumstances positively is referred to as resilience. the process of dynamism involves a form of adaptable functioning that enables https://doi.org/10.14710/nmjn.v12i3.xxxx ttps://crossmark.crossref.org/dialog/?doi=10.14710/nmjn.v13i1.45996&domain=pdf&date_stamp=2023-04-30 nurse media journal of nursing, 13(1), 2023, 32 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 individuals to confront obstacles by restoring an initial equilibrium or rebounding as a chance for development (sisto et al., 2019). resilience is crucial for cancer patients as it can shield them from the harmful effects of stress. it helps in managing or adversity of a cancer diagnosis, coping with adverse events and making necessary life adjustments. this, in turn, improves mental health and treatment outcomes (seiler & jenewein, 2019). resilience is an important factor for cancer patients as they navigate the challenges of their diagnosis and treatment, such as chemotherapy, radiotherapy, or even surgery. resilience can help patients maintain a positive outlook and cope with their illness’ emotional and physical stress. previous research has indicated that the concept of resilience in cancer patients is tentative due to the fact that conceptualizations of resilience may change over time as the researcher’s comprehension of the concept improves or changes (luo et al., 2020). however, no study clearly defines resilience in breast cancer patients. considering the benefits of concept analysis and the need to redefine resilience among breast cancer patients, thus it is essential to conduct a study to explore the attributes, antecedents, and consequences. this study aimed to systematically analyze resilience in patients with breast cancer, its attributes, antecedents, and consequences. 2. methods this concept analysis is incorporated with a literature review of available evidence. databases from cinahl, embase, scopus, web of science, pubmed, cochrane, and medline-ovid were explored to gain the articles that discussed resilience. databases were searched until 1 february 2022. quantitative studies fulfilling the following inclusion criteria were included: (1) studied resilience in the breast cancer patient, and (2) resilience was measured by validated instruments. studies were excluded if the full text were not accessible. the search used ‘resilience*’ and ‘breast cancer’ as the keywords. studies from databases were carefully screened by endnote version 20. duplicates of articles were removed electronically and manually. two independent reviewers examined the title and abstract to ensure their eligibility criteria as included studies. following the systematic review guideline recommendation, the prisma flowchart was used to get the final included articles. the walker and avant approach was used to carry out the following concept analysis on resilience in a breast cancer patient. it is a common strategy to do concept analysis due to the simplicity and convenient usage to reach the aim of redefinition. walker and avant’s concept analysis consists of eight steps, including selecting a concept, determining the purpose of analysis, identifying all uses of the concept, defining attributes, identifying a model case, identifying borderline, related, and contrary cases, identifying antecedents and consequences and defining empirical referents (walker & avant, 2018). this approach was used as an analysis guide to construct resilience among breast cancer patients. 3. results a comprehensive literature search in seven electronic databases was performed, with 890 studies retrieved. after the screening and eligibility step, 53 papers were included to construct the concept analysis (figure 1). from those included studies, keywords were identified and clustered into antecedents, attributes, and consequences (table 1, figure 2). further analysis was conducted using the walker and avant approach (walker & avant, 2018). 3.1 the uses of the concept the word resilience derives from the participle of the latin verb resilire, meaning “to jump back” or “to recoil”. resilience can be defined as the ability to effectively adapt to challenging life experiences, which involves the capacity to exhibit mental, emotional, and behavioral flexibility in response to both internal and external demands (vandenbos, 2007). resilience refers to the capacity to adjust the changes in life circumstances. it involves a dynamic process and requires a particular sort of adaptive functioning to deal with the obstacles in life by regaining initial equilibrium or bouncing back to growth (sisto et al., 2019). resilience is intrinsically linked to mental health as a protective factor against psychological distress. all aspects, such as biological (e.g., gene-environment interaction), personal (e.g., feeling of coherence, optimism, hope), and social (e.g., social support, acceptance) aspects, contribute to the resilience of cancer patients. thus, it is primarily favorable to psychological and treatmentnurse media journal of nursing, 13(1), 2023, 33 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 related outcomes (seiler & jenewein, 2019). psychological resilience enables people to overcome challenges by preserving and increasing their resources to the point where personal strength and a positive restructuring of their biographical history are achieved. as a result, adopting resilient attitudes allows one to construct and reconstruct one’s life path, re-establish a new balance by bringing about change in oneself, and responding constructively to challenges, turning them into chances for progress (sisto et al., 2019; yi et al., 2020). figure 1. prisma flowchart 3.2 defining attributes identification of the defining attributes of a concept is the heart of concept analysis. protective factors refer to distinct characteristics or circumstances that are essential for the manifestation of resilience. several attributes of the concept of resilience in breast cancer patients were identified, including; 1) satisfaction with social support, 2) ability to cope with the disease and cancer treatment, and 3) optimism (see table 1, figure 2). the first antecedent is the ability to cope with the disease and treatment. the term coping refers to the ongoing cognitive and behavioral strategies employed by individuals to manage internal or external stressors that may be overwhelming or beyond their capacity to handle (lazarus & folkman, 1984). the diagnosis and treatment of cancer can elicit significant and enduring distress. the empirical data suggests that the patients' level of engagement with the treatment was correlated with their capacity to manage the stress and burden associated with their illness and treatment. the association between positive thinking and improved mental and physical health is linked to the employment of adaptive coping strategies (carver et al., 2005). emotional intelligence and resilience are essential for people to deal with difficult situations, including patients with breast cancer. this ability to cope with the crisis is modifiable through nurse media journal of nursing, 13(1), 2023, 34 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 support and training. patients who could enhance resilience and have better emotional intelligence are associated with better clinical outcomes (edward & warelow, 2005). the second attribute is satisfaction with social support. the concept of social support pertains to an individual’s subjective evaluation of their level of contentment with social interactions. there is a prevalent belief that it plays a crucial role in mitigating both psychological and physical stress responses (cohen & wills, 1985). the moderating influence of social support on genetic and environmental vulnerabilities for mental illness may be attributed to its impact on various psychosocial factors, including the promotion of effective coping strategies and the modulation of multiple neurobiological factors. the provision of social support appears to play a significant role in endowing individuals with the ability to withstand and recover from the negative effects of stress (pérez et al., 2016). stress can occur in patients with breast cancer from diagnosis to recovery, necessitating social support from the surrounding environment. social support is critical for developing resilience and an increase in the quality of life of breast cancer patients. health practitioners should establish appropriate recommendations to assist patients in obtaining adequate assistance and building resilience to improve their quality of life following breast cancer (zhang et al., 2017). the level of contentment with social support indicates that such contentment may serve as a mediator or moderator in relation to health outcomes. furthermore, the contentment pertaining to the origins and varieties of aid, the ability to recover from adversity, and a hopeful outlook demonstrate a favorable standard of living (simancas fernandez et al., 2021). a study by razurel and kaiser (2015) found that satisfaction with social support, primarily from the spouse, will reduce psychological disorders, depressive symptoms, and anxiety and increase self-efficacy. the third attribute is optimism. optimism refers to a widespread expectation of favorable outcomes (scheier & carver, 1985). breast cancer patients who had a higher level of optimism reported more significant social and mental health issues (colby & shifren, 2013). optimism can be characterized as a set of protective factors that facilitate emotional well-being, mitigate anxiety, promote adaptive health behaviors, and yield improved physical health results (gallagher et al., 2019). breast cancer patients who encounter substantial stressors and negative or cognitive processes are at an increased risk of developing anxiety and other emotional disorders. at this point, optimism promotes resilience and healthy coping (gallagher et al., 2019). 3.3 model case a model case demonstrates all its defining attributes and thus helps better articulate the concept’s meaning (walker & avant, 2018). the following are examples of model cases. in this model, patients experience all attributes. • body image after mastectomy • symptom of distress • stigma • fear of cancer recurrence antecedents • satisfaction with social support • coping • optimism attributes • increase quality of life • improve post traumatic growth consequences figure 2. attributes, antecedents, and consequences of resilience among breast cancer patients nurse media journal of nursing, 13(1), 2023, 35 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 angela, 44 years old, has been diagnosed with breast cancer stage 3 in the last two years. she is a gorgeous, successful businesswoman who has a wonderful family with her husband and two children before her illness. angela has already been unable to work following her cancer treatment due to the side effects of chemotherapy and the tremendous pain she endured. she always tries to cope with her illness and treatment by following yoga and some traditional herbs to reduce the pain. angela also attends a breast cancer awareness program led by nurses in the hospital where she is receiving treatment. she expressed her satisfaction with the care and support from her husband last two days. she has a high optimism that the disease is curable. after completing the chemotherapy session, the doctor declared her cancer-free survivorship. based on the above case, angela demonstrates all attributes, satisfaction with social support (breast cancer support group), coping (reducing her pain with medication and yoga), and optimism (believing that her disease is treatable). 3.4 borderline, related, and contrary cases 3.4.1 borderline case a borderline case exhibits a majority of the defining characteristics of a given concept, albeit not all of the attributes that are encompassed within the concept. clara, 37 years old, was diagnosed with breast cancer stage 2. clara is known as a tough person in the face of life’s problems. despite the illness she experienced, she still looked cheerful and excited, undergoing a series of cancer therapies. she told the nurse in charge that she could be a survivorship woman for her disease, and she was optimistic that her condition would be better. although she has not received much support from her husband, she believes to has positive outcomes from treatment. in this case, clara only experienced one attribute, namely optimism (believing that her condition would be better). 3.4.2 related case a comparable scenario exemplifies instances of apprehension that indicate the concept under investigation yet lacks all of its defining attributes. the concept in question exhibits resemblances to the primary point of interest as observed in analogous scenarios; however, it is important to note that the two concepts are separate and distinct. brunette, 34 years old, has come to the hospital for a medical check-up, and she recently received a breast cancer diagnosis. she is severely impacted by having breast cancer and the chemotherapy effects at such a young age, and she wishes to give up. however, she tries to undertake the treatment. brunette is satisfied with the hospital's services because her illness can be diagnosed early. the hospital also has complete treatment facilities so that her disease is not too late for treatment. in this case, brunette’s complaint relates to the concept or attribute, but the causes are different. she is satisfied with the hospital's services, not because of social support related to her disease. 3.4.3 contrary case in a contrary case, none of the attributes of the concept is present. a famous photo model, dorothy, 30 years old, was diagnosed with breast cancer stage iii b. when she came to the clinic, her doctor said that she required a total mastectomy before getting worse. she was very frustrated and depressed since she could not continue her carrier due to her cancer. she felt hopeless and thought that her body could not be normal even if the cancer was taken out. thus, she felt sad and unsatisfied with the doctor’s nurse media journal of nursing, 13(1), 2023, 36 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 treatment plan. because she is an orphan, she lives alone and has no more support from her significant, resulting in her blue feeling and inability to deal with his illness. in this case, dorothy shows the opposite symptom of the attribute. she experienced psychological distress, an inability to cope, and was unable to be resilient to her illness. 3.5 antecedents and consequences 3.5.1 antecedents antecedents are factors, events, or situations before or preceding the concept (walker & avant, 2018). the occurrences of traumatic or negative events were identified to be necessary for developing resilience throughout the literature. the events will threaten an individual’s ability to cope with the disease and impact the personal response to the life crisis (garcia-dia et al., 2013). the available literature indicated that the antecedent of resilience in breast cancer (figure 2) are body image issues after mastectomy, symptoms of distress, cancer-related stigma, and fear of cancer recurrence (izydorczyk et al., 2018; koral & cirak, 2021; lee & kim, 2018; ocel, 2017). the surgical intervention utilized in the management of breast cancer has the potential to adversely impact a woman’s perception of her physical appearance and self-concept (koçan & gürsoy, 2016). we can see this body image issue as a trauma for breast cancer that will trigger resilience in breast cancer patients. aside from body image disturbance, they will develop symptom distress. the experience of symptom distress has the potential to lead to physical dysfunction and emotional disturbances. this is especially true for upper-arm problems, sleep disturbance, fatigue, and body image disturbance, which may manifest as long-term side effects over time (boehmke, 2004). patients with higher distress will have a lower resilience level (matzka et al., 2016). cancer patients are often subjected to social stigma in numerous nations. stigmatization is linked to diverse clinical outcomes and social ramifications (fujisawa & hagiwara, 2015). people who are stigmatized frequently face prejudice and social exclusion. as was previously said, it is not unexpected that cancer stigma deters many people from getting medical care (matthews et al., 2002). resilience will moderate stigmatization in breast cancer patients through a higher level of psychological well-being (ocel, 2017). the phenomenon of fear of cancer recurrence is characterized by an individual’s apprehension, anxiety, or unease regarding the potential for cancer to reoccur or advance. this ailment is frequently encountered by individuals who have undergone therapy for cancer (ozakinci et al., 2014). patients with a lower fear of recurrence will have a higher resilience score. increased resilience can potentially decrease the level of anxiety associated with the possibility of a future occurrence. individuals possessing a high degree of resilience are anticipated to exhibit a greater capacity for managing stressors encountered throughout their lifespan (koral & cirak, 2021). 3.5.2 consequences consequences are the end-points that occur due to the critical components of the concept (windle, 2011). consequences aim to recognize or measure the essential characteristics or attributes of the resilience concept. the end-points of resilience in breast cancer patients (see figure 2) are quality of life and post-traumatic growth (celik et al., 2021; edward et al., 2019; li et al., 2020). quality of life refers to personal perception of their current expectation regarding their life with breast cancer. breast cancer is associated with reducing health-related qol (lidgren et al., 2007). the experience of a life crisis that arises during the diagnosis and/or treatment of breast cancer has the potential to foster personal resilience, ultimately impacting the individual's quality of life. patients who exhibit greater resilience tend to experience a notably higher quality of life across a wide range of quality of life domains (ristevska-dimitrovska et al., 2015). post-traumatic growth (ptg) refers to the positive psychological transformation that individuals undergo as a result of coping with highly challenging life circumstances. ptg emerges in a relatively short period of time following a diagnosis of breast cancer and is linked to the level of illness intrusiveness at the outset, as well as to subsequent increases in social support, spirituality, active-adaptive coping strategies, and mental health (danhauer et al., 2013). ptg can present itself in diverse forms, such as an augmented sense of gratitude towards life, deeper and nurse media journal of nursing, 13(1), 2023, 37 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 more significant connections with others, enhanced personal resilience, altered priorities, and a more profound existential or spiritual perspective on the existence (pat-horenczyk et al., 2015). insufficient levels of resilience have a direct and indirect impact on post-traumatic growth, as well as the utilization of maladaptive coping mechanisms, and may result in avoidance behaviors that hinder comprehensive processing of the traumatic event (gori et al., 2021). the presence of ptg has been found to be correlated with decreased levels of psychological distress and increased resilience. enhancing resilience among breast cancer patients is crucial, as it is widely acknowledged that resilience plays a pivotal role in determining an individual's quality of life and post-traumatic growth (pat-horenczyk et al., 2015). 3.6 empirical referents empirical referents pertain to factual data that can be subjected to testing, replication, and validation (walker & avant, 2011). several studies have utilized the available instrument to identify resilience among breast cancer patients. the most common tools are the connor– davidson resilience scale (cd-risc) (connor & davidson, 2003) followed by the resilience scale (rs) (wagnild & young, 1993), and the resilience scale for adults (rsa) (friborg et al., 2003). besides those standard tools, two instruments precisely measure the cancer patient’s resilience: the breast cancer survivor resilience scale and the resilience scale specific to cancer (rs-sc). the cd-risc consists of 25 items with the 5-point likert scale from not all true (0) to true nearly all the time (4). the tool encompasses five distinct domains, namely personal competence, high standards and tenacity, trust in one's instincts, tolerance of negative affect and strengthening effects of stress, positive acceptance of change and secure relationships, control, and spiritual influences. a positive correlation exists between higher scores and increased resilience among the patient population (connor & davidson, 2003). the resilience scale exists with 25 items, divided into five essential characteristics: meaningful (or purpose) life, perseverance, self-reliance, equanimity, and existential aloneness. the responses are available on a 7-point scale from 1, disagree, to 7, agree. possible scores range from 25 to 175, reflecting higher resilience scores (wagnild & young, 1993). the third tool, the resilience scale for adults, consists of six protective dimensions of resilience in adult patients. the aforementioned constructs include self-perception, future planning, social competence, familial cohesion, social resources, and a structured approach. the resilience scale for adults (rsa) comprises 33 items, with response options ranging from 1 to 7. the scores obtained from the rsa are indicative of the degree of protective factors associated with resilience, with higher scores indicating greater levels of resilience (friborg et al., 2003). most of the included studies used the cd-risc as the measurement tool to identify resilience among breast cancer patients. it makes sense since the critical characteristics of resilience in breast cancer patients are covered by this tool, making it more suitable and applicable to identifying resilience in breast cancer. the ability to cope with cancer is related to personal competence; satisfaction with social support includes a secure relationship, and optimism has tenacity. the breast cancer survivor’s resilience scale (bcrs) was originated in japan. the instrument in question was specifically designed for the purpose of assessing the resilience levels of individuals who have survived breast cancer. the bcrs scale is deemed to possess a considerable degree of validity and reliability due to its incorporation of both individual and social factors. healthcare professionals may contemplate implementing resilience interventions for breast cancer survivors based on personal and social perspectives, as indicated by the scale (kim et al., 2020). the resilience scale specific to cancer instrument (rs-sc) comprises five domains, namely generic element, benefit finding, support and coping, hope for the future, and meaning for existence. the scale is designed to measure resilience levels, with higher scores indicating greater resilience. there exist two distinct variations of rs-sc, namely the 25-item and 10-item versions. the psychometric properties of rs-sc-25 are favorable, indicating its potential utility in determining an asymptomatic threshold for informing the implementation of psychosocial or pharmacological intervention. a brief 10-item version (rs-sc-10) has been created utilizing multidimensional item response theory (mirt) to enhance item discrimination and alleviate the scale burden on patients. this abbreviated version has been employed for patients receiving care in outpatient wards (ye et al., 2020). nurse media journal of nursing, 13(1), 2023, 38 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 4. discussion the objective of this analysis was to conduct a comprehensive examination of resilience in individuals diagnosed with breast cancer, including an assessment of its defining characteristics, precursors, outcomes, and empirical evidence. the resilience of breast cancer patients is noteworthy, given the potentially traumatic nature of the diagnosis and treatment of breast cancer, which can result in both physical and psychological challenges (martino et al., 2019). although a cancer diagnosis and treatment can cause considerable distress, a considerable number of cancer patients exhibit remarkable resilience. regrettably, not all breast cancer patients exhibit a favorable response to adversity, and certain individuals experience a decline in their condition in response to the life crisis associated with breast cancer (seiler & jenewein, 2019). thus, this paper delivered the redefining of resilience among breast cancer patients. this study identified four antecedents in breast cancer resilience: body image issues after mastectomy, symptoms of distress, cancer-related stigma, and fear of cancer recurrence. mastectomy is a surgical procedure aimed at the complete removal of breast tissue in order to address or prevent the onset of breast cancer. the mastectomy procedure is commonly regarded as a distressing occurrence that induces psychological strain and, in certain instances, psychological complications (such as anxiety and depressive symptoms, low self-regard, body image concerns, and others). the body image includes the symbolic meaning and importance of her breasts. changes in body image after mastectomy will affect positive or negative adaptation or resilience (izydorczyk et al., 2018). some studies reported mastectomy hurts body image (ruizrodríguez et al., 2022; tü k & yı z, 8). this is because mastectomy will change the appearance and women’s perception that the cancer experience threatens their womanhood and make them feel less like a woman (tü k & yı z, 8). on the contrary, an alternative investigation demonstrated that certain women experienced heightened strength and selfassurance subsequent to undergoing surgery. these women refused to conform to conventional beauty standards and expressed a sense of pride in the scars resulting from their mastectomy (grogan & mechan, 2016). symptoms of distress can affect the resilience of breast cancer patients. the prevalent symptoms encountered by patients undergoing chemotherapy are pain, nausea, and vomiting. (booth et al., 2007; maida et al., 2009). the pain was a significant problem for many women with breast cancer, and this was generally poorly managed. physical pain caused by cancer wounds is a complex phenomenon and seriously impacts patients' quality of life (maida et al., 2009). the pain may be attributed to various factors such as the expanding neoplasm, compression of adjacent anatomical structures, edema arising from compromised lymphatic and capillary drainage, wound infection, contact with cutaneous nerve endings, or manipulation during dressing alterations (probst et al., 2012). wound-related problems were often uncontrollable and unpredictable, as they could appear at any time during the day or night, despite strategies to control the issues. it slowly became more and more of a challenge for the women to contain and disguise odor and exudate (probst et al., 2012). in addition, the rates of prevalence for nausea or vomiting were recorded as 37% and 13% after 24 hours and 70% and 15% during days 2-5 (booth et al., 2007). therefore, the patient must have an excellent coping ability to survive the disease and the side effects of therapy. attributes are crucial features that assist in distinguishing one concept from others and clarifying its meaning. the search results revealed several resilience attributes in breast cancer patients, including coping with the disease and cancer treatment, satisfaction with social support, “ external and/or internal demands that are appraised as taxing or exceeding the person’ ” (lazarus, 1993). coping strategies used during the diagnostic phases of breast cancer are indicators of psychological adjustment after surgery (drageset et al., 2010). a patient who has good psychological adjustment would solve the problem and seek support as their coping mechanism (werdani & silab, 2020). early intervention could assist patients in controlling cancer-related stress through effective coping mechanisms that could boost their resilience (borgi et al., 2020). social support provided by social engagement initiatives has the ability to improve coping mechanisms, resilience, and social connectedness, as well as have positive benefits on both physical and mental health (steptoe & fancourt, 2019). according to lam et al. (2010), there exists a positive correlation between optimism and resilience among individuals diagnosed with nurse media journal of nursing, 13(1), 2023, 39 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 cancer. according to seiler and jenewein’s (2019) study, a positive outlook and positive initial treatment outcomes were indicative of resilience and reduced distress in female breast cancer patients. according to stewart and yuen (2011), resilience will be achieved when individuals manage to maintain or regain their mentality in significant difficulties or risks. therefore, those three-concept play a vital role in developing resilience, especially in breast cancer patients. the results or ramifications manifest as the level of well-being and the positive psychological changes following a traumatic event. the concept of quality of life, specifically pertaining to health, has been operationalized as the subjective evaluation of breast cancer patients regarding their physical, mental, and social well-being, which is impacted by factors such as diagnosis, treatment, post-treatment, and survivorship. this evaluation is typically conducted using rigorously validated instruments (mokhatri-hesari & montazeri, 2020). the impact of psychological resilience on various domains of health-related quality of life is noteworthy. patients who exhibit greater resilience tend to experience a notably higher quality of life across a wide range of dimensions pertaining to their overall well-being (ristevska-dimitrovska et al., 2015). post-traumatic growth is a phenomenon that is observed when an individual is able to derive positive meaning from a traumatic event that has caused significant distress. this implies that the extent of the trauma experienced by the survivor is a crucial factor in determining the likelihood of post-traumatic growth. individuals who exhibit high levels of resilience may have a decreased tendency to perceive threats to their personal or ideological beliefs. consequently, individuals who possess greater resilience are better equipped to mitigate the impact of such events, thereby highlighting the necessity of providing education (jannat et al., 2022; levine et al., 2009). 5. implications and limitations this concept analysis of resilience in breast cancer patients helps nurses develop holistic patient-centered nursing interventions to enhance the resilience of breast cancer patients. nurses working with breast cancer patients may find resilience and its attributes for the assessment and implement the nursing intervention. this study suggests that resilience is an important concept in improving the quality of life and post-traumatic growth in breast cancer patients. despite its universal approach, the current concept analysis also has its limitation. as our literature search was based on mostly english-language academic databases, our perspective might be biased toward non-english academic literature. 6. conclusion this concept analysis provides in-depth insights into resilience among breast cancer patients. resilience reduces adversity and facilitates transition after a life crisis. identification from the literature reveals that significant characteristics of resilience in breast cancer patients include coping with the disease and treatment, optimism, and satisfaction with social support. furthermore, the body image issue after mastectomy, symptoms of distress, cancer-related stigma, and fear of cancer recurrence are identified as antecedents, and quality of life and posttraumatic growth are consequences of breast cancer patients' resilience. the cd-risc, rs, and rsa are the referent tools to measure resilience among breast cancer patients. identifying attributes, antecedents, consequences, and empirical referents of resilience makes further research and clinical service clearer. acknowledgment the authors of this document are accountable for its contents, including the findings and conclusions presented. the present study did not receive any dedicated financial support from public, commercial, or non-profit organizations. author contribution fej: data curation, formal analysis, software, visualization, writing – original draft. alw: software, validation. na: validation, writing – review & editing. conflict of interest no conflict of interest to be declared. nurse media journal of nursing, 13(1), 2023, 40 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 references ahn, j. y. 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(2017). resilience and quality of life: exploring the mediator role of social support in patients with breast cancer. medical science monitor: international medical journal of experimental and clinical research, 23, 5969-5979. https://doi.org/10.12659/msm.907730 copyright © 2023 nmjn. this article is an open-access article distributed under the terms and conditions of the creative commons attribution-share alike 4.0 (cc by-sa) international license (https://creativecommons.org/licenses/by-sa/4.0). https://creativecommons.org/licenses/by-sa/4.0 nurse media journal of nursing, 13(1), 2023, 47 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 appendix table 1. description of the articles and their contributions to the concept analysis no. title author/year methodology the study's contribution to the concept analysis contribution 1. the influence of symptoms, uncertainty, family support on resilience in patients with breast cancer receiving chemotherapy ahn (2016) quantitative family support was identified as the primary predictor variable of resilience. antecedent 2. religiosity, psychological resilience, and mental health among breast cancer patients in kingdom of saudi arabia al eid et al. (2020) quantitative the findings indicate that there exist significant statistical correlations between psychological resilience and quality of life. consequences 3. predictors of resilience in women treated for breast cancer: a prospective study bennett et al. (2012) quantitative the presence of distress symptoms was identified as a significant predictor of resilience. antecedent 4. mediating role of social support in resilience and quality of life in patients with breast cancer: structural equation model analysis celik et al. (2021) quantitative the relationship between resilience and functional quality of life was found to be partially mediated by social support. antecedent 5. resilience in breast cancer survivors: depression, anxiety, and quality of life after treatment deshields et al. (2006) quantitative a significant proportion of female participants demonstrated resilience by exhibiting minimal levels of distress. antecedent 6. predictive features of resilience in early breast cancer young patients: experience in real life di giacomo (2018) quantitative the capacity of the patient to manage a diagnosis of breast cancer is a prognostic factor that exhibits a stronger correlation with emotional traits. attributes 7. moderate stress exposure is associated with psychological resilience among breast cancer survivors dooley et al. (2017) quantitative the phenomenon of stress can potentially contribute to the development of resilience, provided that it is experienced within a finite timeframe. antecedent 8. characteristics of psychological resilience and body image in women in the early and late periods after mastectomy izydorczyk et al. (2018) quantitative the study participants exhibited superior coping strategies for managing setbacks and adverse emotional states, indicating a heightened capacity for disengagement from challenging circumstances and alterations in their physical appearance. antecedent, consequences nurse media journal of nursing, 13(1), 2023, 48 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 1. continued no. title author/year methodology the study's contribution to the concept analysis contribution 9. mechanisms of psychological resiliency in women after mastectomy kaczmarek et al. (2012) quantitative the present study aims to elucidate the relationship between coping strategies and the impact of resiliency on life satisfaction among women who have undergone mastectomy. this discovery offers supplementary proof of the essential function of coping mechanisms in the mechanisms of resilience. attributes 10. minority stress, psychosocial resources, and psychological distress among sexual minority breast cancer survivors kamen et al. (2017) quantitative the study suggests that there is a positive correlation between heightened minority stress and reduced psychosocial resources, such as resilience and social support, with increased psychological distress among breast cancer survivors who identify as sexual minorities. attributes, consequences 11. the causal relationship between perceived stress, perceived social support, and resilience with emotional adaptation mediated by body image of breast cancer patients kiaei et al. (2021) quantitative the mediating function of body image is observed in the correlation between perceived social support, perceived stress, and resilience with life satisfaction. antecedent, attributes, consequences 12. functional impairments in the mental health, depression and anxiety related to the viral epidemic, and disruption in healthcare service utilization among cancer patients in the covid-19 pandemic era kim et al. (2022) quantitative a statistically significant correlation was observed between reduced resilience and heightened anxiety in response to the covid-19 pandemic. antecedents 13. computational models for predicting resilience levels of women with breast cancer kourou et al. (2021) quantitative this study aims to investigate the clinical outcomes, quality of life, and patient well-being of women with breast cancer. the analysis will consider various factors, including biological, social, environmental, occupational, and lifestyle factors, to predict resilience in this population. consequences nurse media journal of nursing, 13(1), 2023, 49 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 1. continued no. title author/year methodology the study's contribution to the concept analysis contribution 14. do resilient breast cancer patients experience post-traumatic growth? lee et al. (2016) quantitative the study found that a strong sense of resilience was linked to decreased levels of overall distress, but not specifically distress related to cancer. in general, the findings indicate that possessing a moderate degree of resilience could potentially serve as a safeguard against depression and promote personal development. antecedent, attributes, consequences 15. resilience as a predictor for emotional distress and quality of life during neoadjuvant chemotherapy in women with breast cancer lee et al. (2017) quantitative a heightened level of resilience may serve as a protective factor for patients experiencing elevated emotional distress and help to sustain their quality of life while undergoing neoadjuvant chemotherapy. the implementation of psychosocial interventions aimed at enhancing resilience could potentially prove beneficial in ameliorating emotional distress and improving overall quality of life. antecedent, consequences 16. the mediating and moderating roles of resilience in the relationship between anxiety, depression, and post-traumatic growth among breast cancer patients based on structural equation modeling: an observational study li et al. (2020) quantitative the study found significant correlations between resilience and anxiety, depression, and posttraumatic growth (all p < .01). antecedent, consequences 17. nurse care and resilience in women with breast cancer in adjuvant chemotherapy menezes et al. (2013) qualitative the identified risk factors and protective factors included chemotherapy, fatigue, illness, prolonged hospitalization, alopecia, nausea, substance addiction, inadequate familial support, emotional suppression, and a self-perception of invincibility. attribute, antecedent 18. psychological resilience and healthrelated quality of life in swedish women with newly diagnosed breast cancer mohlin et al. (2020) quantitative the study found a significant positive correlation between psychological resilience and health-related quality of life (hrqol) among swedish women who were recently diagnosed with breast cancer. no modifying factor was detected in this relationship. consequences nurse media journal of nursing, 13(1), 2023, 50 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 1. continued no. title author/year methodology the study's contribution to the concept analysis contribution 19. psychological resilience and healthrelated quality of life in 418 swedish women with primary breast cancer: results from a prospective longitudinal study mohlin et al. (2021) quantitative the study findings indicate that there exists a positive correlation between resilience and health-related quality of life (hrqol) one year after diagnosis. this suggests that resilience plays a crucial role in sustaining hrqol. consequences 20. capacity of resilience during radiotherapy treatment in breast cancer muñoz carmona et al. (2018) quantitative resilience has been found to be associated with body image following mastectomy and standard radiotherapy treatment. antecedent 21. the relationship between emotional expression and resilience in a long-term telephone group for women with secondary breast cancer o'brien et al. (2013) quantitative the issue of family and friend relationships is a prominent concern for individuals who have been diagnosed with cancer. antecedent 22. structure equation modeling for resilience in patients with breast cancer rim et al. (2021) quantitative management strategies aimed at improving the resilience of breast cancer patients should focus on factors such as patients' optimism, spiritual wellbeing, hope, and symptom experience. attributes 23. the influence of resilience on anxiety, depression and quality of life in women with breast cancer before neoadjuvant chemotherapy son et al. (2017) quantitative the independent contribution of resilience to a decreased level of anxiety and depression, as well as an increased level of quality of life, has been observed in breast cancer patients prior to neoadjuvant chemotherapy. antecedent, consequences 24. the effects of personality traits and resilience on quality of life in breast cancer survivors song et al. (2021) quantitative the association between quality of life and personality profiles was moderated by resilience. antecedent, consequences 25. stress management and resilience training (smart) program to decrease stress and enhance resilience among breast cancer survivors: a randomized trial sood et al. (2012) quantitative at the 12-week mark, a statistically significant causal relationship has been observed between resilience, perceived stress, anxiety, and overall quality of life. antecedent, consequences 26. the effect of cognitive behaviour therapy on resilience and quality of life in women suffering from breast cancer srivastava et al. (2016) quantitative cognitive behavioral therapy (cbt) holds clinical significance in enhancing resilience and augmenting the quality of life among individuals who have survived breast cancer. additionally, it can serve as a supplementary approach to augment conventional oncologic therapy and enhance the rapport between healthcare providers and patients. antecedent nurse media journal of nursing, 13(1), 2023, 51 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 1. continued no. title author/year methodology the study's contribution to the concept analysis contribution 27. resilience and positive psychological changes after a cancer diagnosis and treatment tu (2018) quantitative the results underscored the significance of cultivating resilience and adaptive coping mechanisms in breast cancer survivors, as these factors are associated with enhanced psychological growth and overall well-being. attributes consequences 28. resilience and spiritual growth of chinese recovering from breast cancer: the mediating role of challenge cognitive appraisals and positive affectivity wan et al. (2015) quantitative breast cancer patients who exhibit resilience have reported experiencing spiritual growth, which can be attributed to their perception of the illness as a challenge and their capacity to experience positive emotions in the face of trauma. consequences 29. the factors influencing psychological resilience in breast cancer patients undergoing mastectomy and the effects of mindfulness-based stress reduction ’ and anxiety wang and zhang (2020) quantitative there exists a negative correlation between an individual's psychological resilience and their level of anxiety. the implementation of mindfulnessbased stress reduction (mbsr) has the potential to improve the psychological resilience of patients and alleviate their symptoms of anxiety. antecedent 30. resilience and associated factors among mainland chinese women newly diagnosed with breast cancer wu et al. (2016) quantitative the study found a positive correlation between resilience and both social support and optimism. antecedent, consequences 31. the relations between stigmatization and mindfulness with psychological well-being among working women diagnosed with breast cancer: the role of resilience ocel (2017) quantitative the study conducted a moderated regression analysis and found that the impact of stigmatization on quality of life was moderated by resilience. antecedent, consequences 32. exploring the psychosocial morbidity of women undergoing chemotherapy for breast cancer in a post-war setting: experiences of northern sri lankan women rajasooriyar et al. (2021) quantitative in addition to the acute consequences of chemotherapy, individuals contended with issues related to their physical appearance, societal disapproval, and reliance on others, all while navigating apprehensions regarding the well-being of their loved ones and the financial burden of cancer treatment. antecedents nurse media journal of nursing, 13(1), 2023, 52 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 1. continued no. title author/year methodology the study's contribution to the concept analysis contribution 33. the relationships between fear of cancer recurrence, spiritual well-being and psychological resilience in non‐ metastatic breast cancer survivors during the covid‐19 outbreak koral and cirak (2021) quantitative breast cancer survivors who exhibit high levels of subjective well-being (swb) and psychological resilience tend to experience lower levels of fear regarding cancer recurrence, even in cases where they have been unable to maintain regular medical follow-up due to the covid-19 pandemic. antecedent 34. fear of cancer recurrence, optimism and trait resilience predict emotional and physical functioning in breast cancer survivors peters and markovitz (2019) quantitative the present study examines the relationship between fear of cancer recurrence, optimism, and trait resilience, and their impact on the emotional and physical functioning of breast cancer survivors. the findings suggest that these factors play a significant role in predicting the emotional and physical well-being of breast cancer survivors. antecedent, attributes 35. pathways to post-traumatic growth in cancer patients: moderated mediation and single mediation analyses with resilience, personality, and coping strategies gori et al. (2021) quantitative the study found that the degree of resilience exhibited by individuals was a significant predictor of post-traumatic growth (ptg) and post-traumatic symptoms, both through direct and indirect pathways. the mediating role of various coping strategies was also observed. attributes, consequences 36. relationships between family resilience and post-traumatic growth in breast cancer survivors and caregiver burden liu et al. (2018) quantitative the results of our study suggest that there is a need for interventions aimed at promoting family resilience, fostering post-traumatic growth (ptg) among individuals who have survived breast cancer, and reducing the burden of caregiving on family members. consequences 37. resilience and quality of life in breast cancer patients ristevskadimitrovska et al. (2015) quantitative breast cancer patients who exhibit lower levels of resilience tend to experience poorer body image and future outlook, as well as more severe adverse effects of systemic therapy, including arm and breast symptoms. patients exhibiting higher levels of resilience tend to experience a notably enhanced quality of life across a wide range of domains pertaining to their overall well-being. antecedent, consequences nurse media journal of nursing, 13(1), 2023, 53 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 1. continued no. title author/year methodology the study's contribution to the concept analysis contribution 38. body image satisfaction, distress and resilience in women with breast cancer surgery: a within group study mushtaq and naz (2017) quantitative the study found notable variations in body image contentment, distress, and resilience between the pre and post evaluations of females who underwent breast cancer surgery. antecedent, consequences 39. trajectories of psychological distress among chinese women diagnosed with breast cancer lam et al. (2010) quantitative resilience to distress was predicted by optimism and improved early post-operative treatment outcomes. antecedent, attributes 40. relationship between resilience, psychological distress and physical activity in cancer patients: a crosssectional observation study matzka et al. (2016) quantitative cancer patients who exhibit greater resilience, particularly those in advanced age cohorts, tend to report lower levels of psychological distress. antecedent 41. psychological distress and resilience in women diagnosed with breast cancer in greece fradelos et al. (2017) quantitative based on our findings, it appears that resilience may have an adverse impact on depressive symptomatology. antecedent 42. resilience as a predictor for emotional response to the diagnosis and surgery in breast cancer patients markovitz et al. (2015) quantitative the presence of resilience may offer a degree of safeguarding against the experience of emotional distress among individuals diagnosed with cancer. the results of our study indicate that resilience could potentially be considered as a trait that exhibits stability and is not susceptible to the influence of adverse circumstances. antecedent 43. symptom distress and coping in young korean breast cancer survivors: the mediating effects of social support and resilience lee and kim (2018) quantitative the development and availability of intervention methods that reinforce resilience and offer social support can be beneficial in improving the coping mechanisms of young breast cancer survivors who frequently experience distress. antecedents attributes 44. resilience among breast cancer survivors of different sexual orientations bazzi et al. (2018) quantitative the results of this study indicate that interventions aimed at enhancing the quality of life and wellbeing of cancer survivors from various backgrounds could potentially utilize social support and other resilience-related factors. attributes consequences 45. post-traumatic growth in breast cancer survivors: new insights into its relationships with well-being and distress ruini et al. (2013) quantitative the levels of post-traumatic growth were found to be higher among survivors of breast cancer, and this was observed to be linked with a reduction in psychological distress and an increase in resilience. antecedent consequences nurse media journal of nursing, 13(1), 2023, 54 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 1. continued no. title author/year methodology the study's contribution to the concept analysis contribution 46. empirical analysis of post-traumatic growth status and influencing factors for breast cancer inpatients base on posttraumatic growth inventory fang et al. (2017) quantitative the results of the correlation analysis indicate that there is a statistically significant positive correlation (p<0.01; p<0.05) between the post-traumatic growth (ptg) experienced by breast cancer patients and their levels of self-management efficacy and resilience. consequences 47. the mediating and moderating roles of resilience in the relationship between anxiety, depression, and post-traumatic growth among breast cancer patients based on structural equation modeling: an observational study. li et al. (2020) quantitative the study found that there were significant correlations between resilience and anxiety, depression, and post-traumatic growth (all with a p-value of less than 0.01). attributes consequences 48. breast cancer: a manual for a proposed group treatment integrating evidencebased resilience factors friborg et al. (2005) quantitative the treatment objectives for breast cancer patients with regards to their psychological resilience involve facilitating the acquisition of novel coping mechanisms to alleviate stress, augmenting their personal and social aptitude, and promoting the utilization of existing social support systems. additionally, the goals include improving family cohesion, fostering optimism and enhancing the quality of life. furthermore, the treatment aims to assist patients in developing new values and priorities that align with their present and future life circumstances. antecedent attributes consequences 49. psychological resilience of women after breast cancer surgery: a cross-sectional study of associated influencing factors huang et al. (2019) quantitative the positive impact of physical exercise of moderate intensity, self-efficacy, family hardiness, and social support on the promotion of disease rehabilitation and improvement of quality of life is wellestablished. specifically, these factors have been found to have a positive effect on pr. attributes consequences 50. the relationship between resilience with selfcompassion, social support and sense of belonging in women with breast cancer alizadeh et al. (2018) quantitative the present study elucidated the impact of selfcompassion, social support, and sense of belonging on the resilience of iranian women diagnosed with breast cancer. attributes nurse media journal of nursing, 13(1), 2023, 55 copyright © 2023, nmjn, e-issn 2406-8799, p-issn 2087-7811 table 1. continued no. title author/year methodology the study's contribution to the concept analysis contribution 51. quality of life and personal resilience in the first two years after breast cancer diagnosis: systematic integrative review edward et al. (2019) review several factors were found to predict higher levels of quality of life and personal resilience, including younger age, disease progression at initial presentation, personality traits such as optimism, and various moderating factors such as social support, clinical interventions, and the development of self-management skills. attributes consequences 52. "he would never let me just give up": communicatively constructing dyadic resilience in the experience of breast cancer lillie et al. (2018) qualitative the findings indicate that the communication between couples has a dual effect on resilience, as it can both facilitate and impede it. attributes 53. mediator roles of social support and hope in the relationship between body image distress and resilience in breast cancer patients undergoing treatment: a modeling analysis hsu et al. (2021) quantitative the study found that social support played a partially mediating role in the association between body image distress and resilience. attributes antecedent