relationship between active physical exercise and sleep quality with physical fatigue in elderly corresponding author: ramdhany ismahmudi dhanyfikes@umkt.ac.id south east asia nursing research, vol 2 no 1, march 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.1.2020.11-15 original research relationship between active physical exercise and sleep quality with physical fatigue in elderly ramdhany ismahmudi1, alfi ari fakhrurizal1 1 universitas muhammadiyah kalimantan timur, indonesia article info abstract article history: accepted march 30th, 2020 keywords: physical exercise; sleep quality; physical exhaustion; elderly physical exercise is any form of activity carried out by an individual, especially the elderly, to improve physical fitness and physical conditions, with the main objective being to increase strength, cardiorespiratory endurance, speed, skills, and flexibility. in the elderly, physical training aims to improve the quality of life, so they can get through their old days in a fit. the purpose of this study is to find out how the relationship between active physical activity and sleep quality with physical fatigue that occurs in the elderly in the working area. this research is a descriptive qualitative study using a cross-sectional study approach. sampling is done by the method of total sampling, where all respondents will be involved in research activities, with a total sample of 125 respondents. the research activity was carried out for approximately 1 month starting from july 23-august 24, 2019 at the harapan baru health center in samarinda. the result of this research showed a significant relationship between physical activity with fatigue. introduction elderly experienced setbacks in various aspects, especially physical abilities that caused the occurrence include physical abilities that disrupt meeting the needs of life to increase dependence on others. physical activity has a big impact on health. some effects are well established; as a major component of energy expenditure, physical activity has a major influence on energy balance and body composition. it is also recognized that physical activity is a major, unmodifiable risk factor that has a protective effect against heart disease, stroke, type 2 diabetes, colon, and breast cancer, and is also associated with other important health outcomes such as mental health, injury, and falls1. some physical activity that is suitable and suitable for elderly people to do such as aerobic exercise, muscle strengthening, and flexibility exercises. when doing physical exercise several things that affect the physical activity of the elderly include body composition, flexibility, muscle strength, and endurance of the pulmonary heart2. some studies also explain that the prevalence of sleep disorders in the elderly is quite high at around 67%3. the elderly often report having difficulty falling asleep to be able to fall asleep while in bed. sleep quality is a condition where sleep experienced by an individual produces freshness and fitness when waking up from sleep. sleep quality that includes https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.1.2020.11-15&domain=pdf&date_stamp=2020-03-31 south east asia nursing research, vol 2 no 1, march 2020/ page 11-15 12 ramdhany ismahmudi / relationship between active physical exercise and sleep quality with physical fatigue in elderly quantitative aspects of sleep, such as duration, sleep retention, and subjective aspects, such as deep sleep and rest. changes in sleep patterns in the elderly are caused by changes in the nervous system that are physiologically where this results in the function of neurotransmitters in the nervous system decreases4. in research on sleep disorders in which the researchers found that sleep disturbance and lack of activity negatively influence each other5. the phenomenon found by researchers in the harapan baru health center elderly service room is a complaint of illness that is always associated with physical fatigue of elderly patients. patients complain of headaches associated with lack of sleep, unable to sleep, sleep soundly because this condition causes him to experience physical fatigue and even unable to do physical activity that is too heavy. information obtained from interviews with puskesmas staff holding the elderly health program is a problem that is always complained of by the elderly when they come for treatment or visits both at the puskesmas and at the posyandu where the disorders complained of when they arrive are always related to problems related to physical fatigue. some of the elderly also said that they also participated in active physical activities at the posyandu, and they said that with these activities they never felt any physical fatigue. improved physical quality in the elderly will also affect general health, such as blood pressure and pulse to stay within normal limits when the elderly are at rest. based on this background, researchers are interested in examining the purpose of seeing the extent of the relationship between active physical activity and sleep quality in an elderly person with physical fatigue in the elderly in the work area of the harapan baru health center in samarinda to improve the living standards of the elderly. methods this study was conducted for approximately 1 month starting from 23 july 24 august 2019 at the harapan baru health center in samarinda, with the sampling method being a total sampling with a total sample of 125 elderly people who were active in the posyandu elderly. all respondents who participated in the data collection activity actively answered and responded to the questions asked by the research team. data obtained in research activities were analyzed computerized using statistical software. the data in this study were analyzed with 2 models, namely univariate and bivariate analysis. univariate analysis is directed to describe the frequency distribution of the variables analyzed using descriptive statistical methods, after which the data will be presented in the form of frequency distribution tables to find out the proportions of each variable. the bivariate analysis of the researchers used the chisquare test with the significance of p <0.05 to find out the extent of the relationship between the dependent and independent variables of this study or in other words to see the extent of the relationship between physical activity undertaken by the elderly and sleep quality with physical fatigue. results after conducting research activities, a univariate analysis was performed for each variable and the results can be seen in the table below table 1 characteristic of the respondents research variable n % physical activity high 71 57 low 54 43 sleep quality good 68 54 poor 57 46 physical fatigue not fatigue 72 58 fatigue 53 42 south east asia nursing research, vol 2 no 1, march 2020/ page 11-15 13 ramdhany ismahmudi / relationship between active physical exercise and sleep quality with physical fatigue in elderly in table 1 above shows that of 125 respondents for the variable physical activity shows that the majority of respondents are in the high category with the number of respondents as many as 71 people (57%), for the sleep needs of 125 respondents indicate the majority of good sleep needs with the number of respondents as much 68 people (54%), and for the variable physical fatigue the majority of respondents are in the category of tired with the number of respondents as many as 72 people (58%). for bivariate analysis for each variable can be seen in table 2 below: table 2 crosstabulation of fatigue with the physical activity and sleep quality of the respondent indicators fatigue total p fatigue not fatigue physical activity high 28 43 71 0,025 low 25 29 54 sleep quality good 35 33 68 0,442 poor 18 39 57 in table 2 above it can be seen that between physical activity and fatigue where 43 out of 71 respondents (34%) did not experience fatigue after doing physical activity, the statistical test found that the p-value 0.025 <0.05, so it can be stated that there is a relationship significant between physical activity with fatigue experienced by the elderly, for the value of or = 2,298 shows that although the elderly who are active in physical activity will not experience fatigue. discussion physical activity is human behavior characterized by body movements from skeletal muscle that produce energy expenditure6. an experimental study of how active physical exercise can modulate brainderived peripheral neurotrophic factors (brain-derived neurotrophic factor / bdnf). in this study, in which the research subjects were grouped into 5 control groups and 5 treatment groups, the results showed that 5 groups had very significant differences between groups doing active physical activity in the form of aerobic exercise with changes in peripheral neurotrophic factors, in other words, could the conclusion is that good physical activity in the elderly will affect changes in brain quality and will certainly reduce the occurrence of problems related to brain disorders such as dementia7. this is also appropriate with other studies that examine physical exercise in the elderly have an impact on increasing changes in the brain structure of the elderly, wherein this study observation was made on the elderly who were actively exercising continuously without any disturbance indicating a change in the structure of the brain where it changed in the structure of the left hippocampus and the bilateral brain nucleus8. certain sports can be useful to overcome sleep disorders, one of which is insomnia. one of the sports that can improve the fulfillment of sleep needs is regular elderly exercise9. based on other research shows there is a positive relationship between regular gymnastics elderly with the fulfillment of elderly sleep needs10. the frequency of exercises that are useful for maintaining and improving physical fitness is done at least once a week and as much as five times a week with a duration of 15 minutes11. it can be concluded that good physical activity in the elderly will affect their physical fitness so that to do other activities the elderly can continue to do it. for the sleep needs variable of 39 people (31%) of respondents with the problem of lack of sleep do not experience fatigue, the statistical test obtained a p-value of 0.442> 0.05, so it can be stated that there is no significant relationship between sleep needs and fatigue experienced by an elderly person. the or = 0.755 shows that even the elderly who have adequate sleep will not affect the occurrence of physical fatigue. according to research that examines sleep health, lifestyle, and mental health in the south east asia nursing research, vol 2 no 1, march 2020/ page 11-15 14 ramdhany ismahmudi / relationship between active physical exercise and sleep quality with physical fatigue in elderly elderly in japan where the results of the study show short naps (30 minutes between 1300 and 1500 hours of sleep) and moderate sports activities such as walking are very important in efforts to maintain and improve sleep quality in the elderly. in this study, the variables studied were the effects of short naps and offset moderate physical activity carried out for 4 consecutive weeks showing a significant change in the quality of health of the elderly themselves, in addition to physical health as well as mental health12. these results indicate that this intervention is very effective in improving sleep quality and daily activities in the elderly. from this, it can be concluded that the need for sleep can affect physical fatigue that is experienced by the elderly so that the more adequate sleep a person, the better the level of physical and psychological fitness. conclusion from the conclusions obtained from the variable physical activity and sleep, needs can affect the physical undertaken by the elderly. the more physical activity and the elderly, the better the level of physical and psychological fitness. acknowledgments expression thank you for the financial assistance provided by the indonesian ministry of education's directorate of higher education for the financial assistance that has been provided through the program penelitian dosen pemula (pdp) in 2019 so that this research activity can be carried out as expected. do not forget also to all those who have provided assistance to support data collection activities in research, especially the samarinda harapan community health center. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. miles(2007).physical activity and health. journal compilation british nutrition foundation nutrition bulletin,32, 314–363. 2. ambardini rl. 2009. aktivitas fisik pada lanjut usia. yogyakarta: uny 3. amir, n. (2007).gangguan tidur pada lanjut usia. diagnosis dan penatalaksanaan, dalam cermin dunia kedokteran (hlm.196-206). jakarta. grup pt. kalbe farma 4. khasanah dan hidayati(2012).kualitas tidur lansia balai rehabilitasi sosial “mandiri” semarang. jurnal nursing studies, 1(1) : 189196. 5. hemalova garmas, f. u. (2010). sleep disorders and activities in long term care facilities a vicious cycle?.http://www.ncbi.nlm.nih.gov/pubmed/ 20603298. accessed 5 december 2018 2.00 pm wita.jurnal kesehatan psychology 6. caspersen cj, powell ke, christenson gm. physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. public health rep 1985;100:126-31. 7. coelho, f. g. de m., gobbi, s., andreatto, c. a. a., corazza, d. i., pedroso, r.v., & santos-galduróz, r. f. (2013, january). physical exercise modulates peripheral levels of brain-derived neurotrophic factor (bdnf): a systematic review of experimental studies in the elderly. archives of gerontology and geriatrics. https://doi.org/10.1016/j.archger.2012.06.00 3 8. boyke, j.,driemeyer, j. et.al(2008). traininginduced brain structure changes in the elderly. the journal of neuroscience, july 9, 2008•28(28):7031–7035 9. yanuarita, a.f. (2012),memaksimalkan otak melalui senam otak (brain gym),yogyakarta: cv. solusi distribusi. 10. mahardika, j., haryanto, j., & bakar, a. (2011) hubungan keteraturan mengikuti senam lansia dan kebutuhan tidur lansia di upt surabaya: keperawatan universitas airlangga. 11. maryam, s et all. (2008). mengenal usia lanjut dan perawatannya. jakarta: salemba medika. https://doi.org/10.1016/j.archger.2012.06.003 https://doi.org/10.1016/j.archger.2012.06.003 south east asia nursing research, vol 2 no 1, march 2020/ page 11-15 15 ramdhany ismahmudi / relationship between active physical exercise and sleep quality with physical fatigue in elderly 12. tanaka, h. & shirakawa, s. (2004) sleep health, lifestyle and mental health in the japanese elderly ensuring sleep to pro-mote a healthy brain and mind. j. psychosom. res., 56, 465-477 increased the intensity of elderly visit to posyandu with family support corresponding author: edy soesanto soesantoedisoes@gmail.com south east asia nursing research, vol 1 no 3, december 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.3.2019.137-141 original research increased the intensity of elderly visit to posyandu with family support desi sandra fatmawati1, edy soesanto2 1 indonesian national nurses association of central java, indonesia 2 university of muhammadiyah semarang, indonesia article info abstract article history: accepted december 28th, 2019 keywords: elderly; family support; intentional visits the decline in health, especially in the elderly will affect the independence and quality of life of the elderly. the role of the family is needed to motivate the elderly in health checks to health services. one of the health services for the elderly is the elderly posyandu which is an integrated health service for the community-based elderly. based on data the level of elderly visits to posyandu the elderly shows that the level of elderly visits to the posyandu of the elderly is relatively low. the low number of elderly visits to posyandu is influenced by several factors, one of them is the support from the family. the low number of elderly visits to posyandu is influenced by several factors, one of them is the support from the family. the purpose of the research was to found out the relationship between family support and the intensity of elderly visits to posyandusumber sehat. this research used a quantitative descriptive correlational study with a cross-sectional design. the sample in this study was 82 elderly respondents with a purposive sampling technique. the results showed that good family support was 46 (56,1%) and less family support was 36 (43,9%). the intensity of elderly visits in the low category was 48 (58.5%) and there were 34 (41.5%) with high visit intensity. there was a significant relationship between family support and the intensity of elderly visits to posyandu. introduction as a person ages, the physiological function will decrease due to the aging process thereby increasing the risk of many noncommunicable diseases appearing in the elderly. in addition, the degenerative process will reduce the body's resistance to infectious diseases. degenerative diseases commonly suffered by the elderly are hypertension (57.6), arthritis (51.9), stroke (46.1), copd (8.6) and dm (4.8).1 one of the government's efforts to improve the welfare and health status of the elderly is by organizing elderly posyandu activities. this health service program approach is focused on integrated services by prioritizing promotive and preventive efforts on elderly health through empowerment and the active role of the community. the health service program is expected to be able to detect early on the health problems experienced by the elderly.2 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.3.2019.137-141&domain=pdf&date_stamp=2019-12-30 south east asia nursing research, vol 1 no 3, december 2019/ page 137-141 138 edy soesanto / increased the intensity of elderly visit to posyandu with family support the elderly posyandu that is still actively held today is one form of health services for the elderly, one of which is the posyandu elder "sumber sehat" located at rw 05 kangkung village. the list of the attendance rates of the elderly in the health source posyandu for the period january 2018 december 2018, shows that the coverage rate of elderly visits to the health source posyandu is only 14.2%. this proves that the attendance rate is still very far from the expected coverage rate of 80% set by the ministry of health of the republic of indonesia.1 the low rate of absence of the elderly to the posyandu for the elderly is influenced by several factors including the age of the elderly, the knowledge of the elderly about the benefits of the posyandu, employment, the elderly attitude towards the use of the posyandu, infrastructure, geographical location (distance of the elderly home to the location of the elderly posyandu), the role of health workers and family support.3 family support is very important in motivating the elderly to check their health conditions for health services because of the good physical and emotional family relationships. the existence of a family becomes something that is very needed by the elderly where the family can accompany and accompany the elderly to visit the posyandu for the elderly.4 family support includes informative support in the form of advice, direction, and explanation. instrumental support is the provision of tangible or physical assistance which can be in the form of goods, services, and supporting infrastructure advice including providing time opportunities. emotional support in the form of giving attention, trust so that someone becomes convinced that other people are able to give love and affection to him and support assessment in the form of a positive assessment of the individual which includes feedback and approval.5 based on the results of research conducted by another research that the highest level of support from families is good support at 88.1% and less support at 11.9%. the majority of respondents received support from families, but in practice controlling their health respondents did not get full support from families, this indicated there were still 26.3% of families not taking time for respondents, and 24.9% did not want to take respondents to check into services health.6 the results of a preliminary study conducted by researchers on november 10, 2018, by conducting interviews with 8 elderly people at the posyandu elderly healthy sources, the results show that as many as 3 elderly people said that the factor that caused the elderly not to attend the posyandu was the healthy source because they forgot the posyandu schedule for the elderly and there were no family members who took the elderly to the elderly posyandu implementation site. lack of support from families due to family members busy with their work so that families tend not to have much time to accompany and accompany the elderly. methods this type of research is a quantitative study that uses a descriptive correlational design with an approach carried out in a crosssectional way. in this study the population was the elderly who participated in the posyandu elderly activities of sumber sehat in the last 3 months, amounting to 104 respondents. the sampling method used in this study is to use purposive sampling so that the sample becomes 82 respondents. this research was conducted at the sumber sehat elderly posyandu and in every elderly house registered following the elderly posyandu located in rw 05 kangkung village. data collection tool with a questionnaire sheet. the research process took place from 12 -25 july 2019. analyzed by univariate and bivariate (spearman rank correlation test). south east asia nursing research, vol 1 no 3, december 2019/ page 137-141 139 edy soesanto / increased the intensity of elderly visit to posyandu with family support results characteristics of respondents most of the respondents included in the category of elderly 76 (92.7%), the majority of elderly women were 69 (84.1%), education as many as 48 (58.5%) respondents did not attend school, the elderly worked as farmers 44 (53.7%), and 37 (45.1%) respondents lived with children. based on table 1 above shows that of 82 respondents there are 46 elderly (56.1%) get good family support while for the lack of support as many as 36 elderly (43.9%). based on table 1 above shows that of the 82 respondents there were 48 elderly (58.5%) with low visit intensity. while 34 elderly (41.5%) with high visits. table 1 frequency distribution of elderly characteristics in posyandu indicators f % age elderly 76 92,7 old age 6 7,3 gender male 13 15,9 famale 69 84,1 education no school 48 58,5 elementary school 32 39 middle school 2 2,4 occupation does not work 31 37,8 farmers 44 53,7 entrepreneur 7 8,5 status of stay son 37 45,1 couple 24 29,3 spouse and children 20 24,4 sibling 1 1,2 family support level support 46 56,1 less supportive 36 43,9 intensity of visit posyandu low 48 58,5 high 34 41,5 the results of the study revealed that the average visit intensity score was 5.9024 with a median value of 6. the highest value was 11 and the lowest value was 1 and the standard deviation was at 2.20826. the data normality test results using kolmogorovsmirnov obtained a p-value of 0,000 so that the data obtained were not normally distributed, then the categorization is based on a median value of 6. the results of the study revealed that the mean family support score was 13.41 with a median value of 15. the maximum value was 18 and the minimum value was 2 with the standard deviation being at 3.607. the results of normality test data using kolmogorov-smirnov obtained a p-value of 0,000 so that the data obtained were not normally distributed, then categorization is based on a median value of 15. table 2 description of family support for the elderly in posyandu variable mean sd family support 13,41 3,607 intensity of visits 5,9024 2,16373 table 3 shows that the majority of respondents who received active family support participated in posyandu for elderly with high intensity of visits as many as 28 (34.1%) respondents, and a small portion of respondents who did not get support from families not actively participated in elderly posyandu with low intensity of visits as much as 12 (14.6%) respondents. the spearman rank correlation test results obtained p-value = 0,000 meaning there is a significant relationship between family support and the intensity of elderly visits to the sumber sehat elderly posyandu in rw 05 kangkung village. table 3 relationship between family support and intensity of elderly visit to posyandu family support intensity of visit p high low f % f % support 28 34,1 18 22,0 0,000 less support 24 29,3 12 14,6 south east asia nursing research, vol 1 no 3, december 2019/ page 137-141 140 edy soesanto / increased the intensity of elderly visit to posyandu with family support discussion the results showed that the majority of respondents received support from families as many as 46 respondents (56.1%) while respondents who lacked family support were 36 respondents (43.9%). the size of the support given by the family is closely related to the family's understanding of the perception of the benefits of health services for the elderly. support can be described as a feeling of belonging or belief that other people can play an active role in everyday life. family support that is realized by giving attention, being sympathetic, and giving help and encouragement will lead to a feeling of being more stable and safe in the elderly.7,8 family support includes informative support in the form of giving information in solving a problem which includes giving advice, direction, and explanation, instrumental support is providing tangible assistance or fisk which can be in the form of goods, services and advice supporting infrastructure to help or help others including giving time opportunity. emotional support in the form of giving attention, trust so that someone becomes convinced that other people are able to give love and affection to him as well as assessment support in the form of a positive assessment of individuals consisting of social support which includes feedback and approval.5 the results showed that most of the elderly were not actively participating in the elderly posyandu with a low intensity of visits of 48 respondents (58.5%). while the rest are 34 elderly (41.5%) with high visit intensity. factors that influence the intensity of elderly visits to posyandu elderly are gender. based on the results of this study showed that the majority of the elderly who participated in the posyandu for the elderly were women, amounting to 69 elderly (84.1%). most of the elderly who are male do not attend the posyandu for the elderly because they are still active at work, therefore they tend to not have much time to attend the posyandu for the elderly. another factor that influences the intensity of elderly visits to posyandu is work. in this study, it is known that some are still working as farmers, amounting to 44 elderly (53.7%). work is an activity that is carried out by someone continually to get compensation. this is caused because the elderly do not want to depend either financially or otherwise on the family. most of the elderly want to live independently by not relying on family. the spearman rank correlation test results obtained a p-value of 0,000 (p <0.05) so that it can be concluded that there is a significant relationship between family support and the intensity of elderly visits to the posyandu of healthy elderly sources. the correlation coefficient (r) of 0.586, the value is in the range of a strong relationship level (0.51 0.75). these results are in line with another research which concludes that there is a relationship between family support and the level of depression in the elderly at the posyandu sejahtera gbi setia bakti kediri.9 family support is very instrumental in encouraging the interest of the elderly to participate in elderly posyandu activities. the family can be the main support for the elderly if they always take the time to accompany or take the elderly to the posyandu, remind the elderly if they forget the posyandu schedule and try to help overcome all problems with the elderly.4 this is consistent with the theory friedman which states that the family can function as the main support for its members so that members view that people who are supportive are always ready to provide help and assistance if needed. south east asia nursing research, vol 1 no 3, december 2019/ page 137-141 141 edy soesanto / increased the intensity of elderly visit to posyandu with family support conclusion the most family support given to the elderly is a good support of 46 respondents (56.1%). the intensity of elderly visits to posyandu for the elderly with healthy sources is mostly in the low category of 48 respondents (58.5%). there is a relationship between family support with the intensity of elderly visits to posyandu elderly. acknowledgments thank you to all of the respondents and those who have helped this research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. kemenkes ri. infodatin lanjut usia (lansia). indonesia; 2016:12. doi:10.1016/s00404039(98)00661-3 2. dinas kesehatan kota semarang. laporan posbindu di kota semarang tahun 2013. 2014. 3. sunaryo mk et al. asuhan keperawatan gerontik.; 2015. 4. sulistyorini, c., pebriantri, s., proverawati a. posyandu dan desa siaga. yogyakarta: nuha medika; 2010. 5. harnilawati. konsep dan proses keperawatan keluarga. pustaka as salam; 2013. 6. soesanto e, istiarti t, pietojo h. praktik lansia hipertensi dalam mengendalikan kesehatan diri di wilayah puskesmas mranggen demak. j promosi kesehat indones. 2018;5(2):127-139. doi:10.14710/jpki.7.3.127-139 7. friedman, m., bowden, v., & jones e. buku ajar keperawatan keluarga ; riset, teori dan praktek. 2010. 8. yanto a, setyawati d. dukungan keluarga pada pasien diabetes mellitus tipe 2 di kota semarang. in: seminar nasional universitas muhammadiyah semarang. vol 1. universitas muhammadiyah semarang: lppm universitas muhammadiyah semarang; 2017. http://eriset.unimus.ac.id/index.php/psn1201 2010/index. 9. astuti vw. hubungan dukungan keluarga dengan tingkat depresi pada lansia di posyandu sejahtera gbi setia bakti kediri. j penelit stikes rs baptis kediri. 2010;3(2):7884. effect of 35% hydrogen peroxide on in-office bleaching against changes in tooth enamel hardness: literature review corresponding author: asy-syifa brillian avicenna brillianavicenna@gmail.com south east asia nursing research, vol 4 no 1, march 2022 issn:2685-032x doi: https://doi.org/10.26714/seanr.4.1.2022.47-50 review article effect of 35% hydrogen peroxide on in-office bleaching against changes in tooth enamel hardness: literature review asy-syifa brillian avicenna1, christina mahardika1, lira wiet jayanti1 1 faculty of dentistry, universitas muhammadiyah semarang, indonesia article info abstract article history: submitted: feb 14th 2022 accepted: march 5th 2022 published: march 29th 2022 keywords: hydrogen peroxide; bleaching; enamel hardness teeth bleaching is one of the treatments for teeth discolouration. teeth bleaching can do in-home or in-office. the material for that use in-office bleaching is 35% hydrogen peroxide. hydrogen peroxide is a chemical compound that is tough and has a micro molecule that can easily penetrate enamel tissue and dentin tissue. bleaching with hydrogen peroxide in-office is now more attractive because can be faster to see the result. bleaching with hydrogen peroxide when done repeat will make teeth more sensitive, and damage enamel tissue and dentin tissue. the objective of this study is to know the influence of in-office bleaching using 35% hydrogen peroxide on microhardness enamel. this research is made with a literature review with search engine google scholar, pubmed, and science direct. the results of 10 articles show the effectiveness of teeth discolouration after bleaching using 35% hydrogen peroxide in-office. the reduction in enamel microhardness seen using sem, knob and vickers is visible although not significant. based on the literature review research that has been carried out, it can be concluded that there is a reduction in enamel hardness after the in-office bleaching process by using 35% hydrogen peroxide. introduction teeth discoloration is part of the aesthetic problem in society. teeth discoloration can be caused by intrinsic factors (the incorporation of substances inside enamel and dentin such as tetracyclin, imperfect dentinogenesis, fluorosis, dental trauma and drugs) and extrinsic factors caused by agents that cause changes in enamel (cigarettes, tea, and coffee).1 teeth bleaching is one of the measures taken to deal with tooth discoloration. the material commonly used for in-office bleaching is hydrogen peroxide.2 hydrogen proxide has the ability to dissociate into reactive oxygen species (ros) which is widely used in tooth bleaching. hydrogen peroxide is used for in-office bleaching because of its stronger properties than carbamide peroxide.3 the bleaching process occurs when lowmolecular hydrogen peroxide diffuses through enamel and dentin, then releases reactive oxygen species (ros) that react or bind to other weak substances. the penetration of oxidative agents in the tooth structure will damage the dye molecules so that it will give a brighter result to the tooth. https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.4.1.2022.47-50&domain=pdf&date_stamp=2022-03-29 south east asia nursing research, vol 4 no 1, march 2022/ page 47-50 48 asy-syifa brillian avicenna / effect of 35% hydrogen peroxide on in-office bleaching against changes in tooth enamel hardness: literature review this process is usually called a redox3 reaction. the high peroxide content makes the ph level of the teeth decrease so that it can cause changes in the enamel including increased roughness, decreased micro hardness of enamel, decreased strength of enamel and changes in the composition of enamel.4 hydrogen peroxide used in dentistry is between 5% to 38%. the process of bleaching teeth produces the effect of reducing the hardness of enamel, increasing tooth sensitivity and erosion.5 research conducted in 2015 by de paula using 35% hydrogen peroxide in in-office bleaching, teeth in contact with saliva can cause demineralization and dehydration processes after a few days post-bleaching.6 in in-office bleaching, the duration of contact with bleaching agents has a greater effect than the concentration of bleaching agents. one of the effects that appears after bleaching teeth is a decrease in the level of micro-hardness in enamel.7 enamel hardness can be tested with knoop or vickers, sem (scanning electron microscopy), and eds (energydispersive xray spectroscopy).8 method the research is in the form of literature review by collecting a number of data on 35% hydrogen peroxide in in-office bleaching related to changes in enamel hardness that have been carried out in previous studies. the research results listed were obtained using keywords in each database (google scholar, pubmed. and science direct) according to the problem of the research problem. the results of all databe obtained 489 articles which were then screened according to the inclusion and exclusion criteria from 2011-2021, accessible ful text, in the form of research articles and using english and indonesian. furthermore, an assessment of the feasibility of a copy of the ful text is carried out where a review of the entire article is carried out and then it is calculated with a critical appraisal to find out whether the relevant article is used to answer research problems that have been formulated in accordance with the research objectives. the article was analyzed for research problems and then concluded. result based on the search results of 3 databases, namely google scholar, pubmed, and science direct, there are 10 articles related to 35% hydrogen peroxide. the results of 10 articles show the effectiveness of teeth discoloration after bleaching using 35% hydrogen peroxide in-office. the reduction in enamel micro hardness seen using sem, knob and vickers is visible although not significant. the reduction of enamel micro hardness can be caused by several things. discussion the in-office bleaching process on teeth has been carried out in the past 100 years ago. the in-office bleaching method is currently widely practiced because of its advantages such as, it does not require a long time, and can minimize taboos in food consumption. a commonly used material for in-office bleaching is usually hydrogen peroxide. some also use non-additives in the bleaching process.9 hydrogen peroxide is a strong oxidizing agent and can cause the formation of other highly effective bleaching agents such as perihydroxyl anions (ho) and hydroxyl radicals (oh-). hydrogen peroxide material can cause burns or irritation to the gingiva if it accidentally hits soft tissues, because hydrogen peroxide has unstable and hard properties.10 in the redox reaction process, hydrogen peroxide which has small molecules can easily diffuse into the enamel matrix layer. the free radicals then interact with organic molecules to achieve stability. the south east asia nursing research, vol 4 no 1, march 2022/ page 47-50 49 asy-syifa brillian avicenna / effect of 35% hydrogen peroxide on in-office bleaching against changes in tooth enamel hardness: literature review effectiveness of bleaching is influenced by several things such as stains on teeth, ph, length of application time, temperature, hydrogen peroxide concentration, additives (rsa enhancing agents), and other factors (age and gender).11 hydrogen peroxide is active at an alkaline ph. however, a high ph can cause damage to the surface of tooth enamel.5 the temperature setting in the in-office bleaching process has an effect on removing ros so that hydrogen peroxide performance increases up to 2x.5 teeth bleaching with ph 5, ph 7, ph 8, ph 9, and ph 10 resulted in, teeth bleaching with ph 10 visible results were very significant, but side effects that appeared such as a significant decrease in enamel surface hardness were also.12 the length of time of application also affects the bleaching process. teeth repeated 3x15 minutes using 35% hydrogen peroxide produce a brighter tooth color than using 40% hydrogen peroxide once repeated.13 some of the effects arising from the bleaching process using 35% hydrogen peroxide include increasing tooth sensitivity, erosion, changing the hardness of enamel, hard tissue structure, and reducing micro hardness in enamel. the change is due to the demineraly process caused by redox reactions.14 the reduction in enamel hardness seen using the vickers tool, the presentation of micro hardness in enamel ranges from 22.1 to 0.4 values. the use of 35% hydrogen peroxide in in-office bleaching results in a change in the structure of enamel hardness seen using sem. side effects of bleaching can be minimized by using desensiting materials. the use of leds in applications can also minimize side effects that occur in teeth.15 the bleaching process begins with a subjective and objective examination and then determines the diagnosis of treatment and documentation before treatment. the patient is explained to be the cost and time of treatment, then the patient is instructed to fill in the informed concent. the installation of a check rectractor is done to protect the lips and as a marker to facilitate the part to be treated. prosilaxis actions using brushes and pumice are performed on the teeth to be bleached. this action is useful for removing debris or dirt that is still attached to the teeth. the initial color of the teeth is assessed first use the vita shade guide and the patient is educated to keep the mouth open during the procedure. cotton rollers are applied along the tooth fomix to be bleached. the application of opal dam green is 4-6 mm long and 1.5-2 mm thick on the gingiva of the cervical part of the tooth to be bleached. irradiation with light curing is carried out for 20 seconds in each jaw. bleaching material is applied to teeth 0.5-1 mm thick on the labial surface then incisal. apply for 20 minutes until the desired color is reached.16 the bleaching material is cleaned by disuction and using cotton pellets, after which the patient is instructed to gargle with warm water. after all the procedures are performed, the color of the teeth is checked again using the vita shade guide and documentation is carried out again after bleaching.16 conclusion based on the literature review research that has been carried out, it can be concluded that there is a reduction in enamel hardness after the in-office bleaching process by using 35% hydrogen peroxide which is influenced by several factors, namely, the ph level of the hydrogen peroxide content, the size of the hydrogen peroxide presentation content, the length of application time, the number of repetitions and temperature. acknowledgments the author would like to thank all those who have helped and supported the review process and writing this research article. south east asia nursing research, vol 4 no 1, march 2022/ page 47-50 50 asy-syifa brillian avicenna / effect of 35% hydrogen peroxide on in-office bleaching against changes in tooth enamel hardness: literature review references 1. kansal, s., jindal, l., garg, k., thakur, k., mehta, s., & pachori h. discoloration of teeth : a literature review. international journal of health and clinical research, 3(2), 58–62. 2020; 2. torres, c. r. g., zanatta, r. f., silva, t. j., & borges ab. effect of calcium and fluoride addition to hidrogen peroksida bleaching gel on tooth diffusion, color, and microhardness. operative dentistry, 44(4), 424–432. 2019; 3. de oliveira duque, c. c., soares, d. g., basso, f. g., hebling, j., & de souza costa ca. bleaching effectiveness, hidrogen peroksida diffusion, and cytotoxicity of a chemically activated bleaching gel. clinical oral investigations, 18(6), 1631–1637. 2014; 4. martins, i. e. b., onofre, s., franco, n., martins, l. m., montenegro, a., arana-gordillo, l. a., reis, a., loguercio, a. d., & da silva lm. effectiveness of in-office hidrogen peroksida with two different protocols: a two-center randomized clinical trial. operative dentistry, 43(4), 353–361. 2018; 5. chandra, bs ; gopikrishna v. grossman’s. endodontic practice (13th ed.). grossman. 2014. 6. de paula, e. a., nava, j. a., rosso, c., benazzi, c. m., fernandes, k. t., kossatz, s., loguercio, a. d., & reis a. in-office bleaching with a two and seven-day intervals between clinical sessions: a randomized clinical trial on tooth sensitivity. journal of dentistry, 43(4), 424– 429. 2015; 7. de almeida, l. c. a. g., soares, d. g., gallinari, m. o., de souza costa, c. a., dos santos, p. h., & briso alf. color alteration, hidrogen peroksida diffusion, and cytotoxicity caused by in-office bleaching protocols. 8. zanolla, j., marques, a. b. c., da costa, d. c., de souza, a. s., & coutinho m. influence of tooth bleaching on dental enamel microhardness: a systematic review and meta-analysis. australian dental journal, 62(3), 276–282. 2017; 9. abu-saq al yami, a., al qahtani, s., shokair, n., al ghamdi, m., & al bouni r. effect of home and in-office bleaching systems on the nanomechanical properties of tooth enamel. saudi dental journal, 32(7), 343–348. 2020; 10. llena, c., esteve, i., & forner l. effect of hydrogen and carbamide peroxide in bleaching, enamel morphology, and mineral composition: in vitro study. journal of contemporary dental practice, 18(7), 576– 582. 2017; 11. berman, louis h. hargeaves k. (ed. ). cohen’s pathway of the pulp (12th ed.). elsevier. 2021. 12. jurema, a. l. b., de souza, m. y., torres, c. r. g., borges, a. b., & caneppele tmf. effect of ph on whitening efficacy of 35% hidrogen peroksida and enamel microhardness. journal of esthetic and restorative dentistry, 30(2), e39–e44. 2018; 13. grazioli, g., valente, l. l., isolan, c. p., pinheiro, h. a., duarte, c. g., & münchow ea. bleaching and enamel surface interactions resulting from the use of highly-concentrated bleaching gels. archives of oral biology, 87(october 2017), 157–162. 2018; 14. fatima n. in-vitro comparative study of inoffice and home bleaching agents on surface micro-morphology of enamel. journal of the college of physicians and surgeons pakistan, 26(1), 9–12. 15. kutuk, z. b., ergin, e., cakir, f. y., & gurgan s. effects of in-office bleaching agent combined with different desensitizing agents on enamel. journal of applied oral science, 27, 1–10. 2019; 16. garg, n., & garg a (eds. ). operative dentistry (3rd ed.). jaypee publisher. 2015. nursing lecturers’ transformasional leadership in classroom management at nursing and health faculty of muhammadiyah university of semarang corresponding author: tri hartiti tri.hartiti@unimus.ac.id south east asia nursing research, vol 1 no 2, september 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.2.2019.83-87 original research nursing lecturers’ transformasional leadership in classroom management at nursing and health faculty of muhammadiyah university of semarang tri hartiti1, ernawati ernawati1 1 university of muhamadiyah semarang article info abstract article history: accepted september 30th, 2019 key words: lecturers; transformational leadership a nursing lecturer is an individual responsible for learning process management of nursing students who are expected to professionally provide health services (care provider) in the forms of biological, psychological, social, and spiritual services to individuals, families, and communities in the future. a nursing lecturer is expected to have competences as a classroom management leader who gives opportunities for students to properly actualize their emotions, the one who effectively utilizes resources, and who does not only focus on the working results (cummings et al., 2010 and wong, 2012) known as transformational leadership. transformational leadership is widely acknowledged as one leadership model which improves human resources. this research aims to figure out the lecturers’ transformational leadership in classroom management at nursing and health faculty of muhammadiyah university of semarang. this non experimental (descriptive) research is conducted with a survey approach on a population of 24 nursing lecturers fulfilling inclusion criteria. result of the reseacrh showed that 79.2% of nursing lecturers are females with an average of 42 years old. 93.9% are master graduates. 54.2% of lecturers have good transformational leadership while the other 45.8% still have poor transformational leadership. 70% of lecturers have charismatic competence while the other 30% have less charismatic competence. 62.5% of lecturers have idealistic persuasive competence while the other 37.5% have less idealistic persuasive competence. 54.2% of lecturers have good inspirational motivation competence while the other 45.8% have less inspirational motivation competence. most transformational leadership components in classroom management are classified into the good category. however, 45.5 % of them tend to be poor. introduction a nurse is an individual who professionally provides health care (care provider), in the forms of biological, psychological, social, and spiritual services to individuals, families, and communities. a nurse is expected to be professional and has both competences of hard and soft skills. soft skill is one aspect that a nurse should https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.2.2019.83-87&domain=pdf&date_stamp=2019-09-30 south east asia nursing research, vol 1 no 2, september 2019/ page 83-87 84 tri hartiti / nursing lecturers’ transformasional leadership in classroom management at nursing and health faculty of muhammadiyah university of semarang acquire. soft skills are greatly required to support hard skills known as technical skills that a nurse obtains during his/her educational processes as nursing students. soft skills include an ability to adapt, to communicate, to work together, to solve problems, as well as to be confident, discipline, and accurate (hartiti, 2012). it can be concluded that soft skills are greatly required in the real working environment. thus, an individual’s success is not only based on his/her intellectual quotient but also his/her soft skills which result in his/her working achievements. agustian (2007) reports the results of a research conducted by belt (2001), on respondents of six sigma magazine stating that the main problems regarding to soft skills include communication by 88%, interpersonal by 72%, and leadership by 56% while technical and analytical or known as hard skills are only by 18%. in facts, soft skill trainings are more frequently conducted than the hard skill ones in the real working environment due to the working necessities. christian (2008), as quoted by human capital magazine, estimates that people with high working complexities require high proportion of soft skill trainings than hard skill ones with a comparison of 70% to 30% or even 80% to 20%. those are conversely applicable to people with low working complexities. for time allocation, christian provides a general illustration that those deal with 10-15% working hours per individual per year. it can be concluded that soft skills are greatly required in the real working environment in which an individual may face various problems. ideal learning or training designs are expected to have more portions on soft skills including leadership, communication, relationship maintenance, and negotiation. soft skills have bigger portions to support individual’s success in the real working environment. having sophisticated hard skills without having good personality or soft skills may result in vain (ismail, 2007). a study on human resource problems in the last decade is conducted by an emotional quality inventory (eqi) institution. professionals from all over the world are collected as samples. the results show that iq which is maximally 20% of the brain capacity contributes only 6% for an individual’s success, than eq does. in addition, carnegie institute of teknology finds other proofs that from 10,000 successful persons, 15% of their success are determined by their technical skills, while the other 85% are dominated by personality or soft skill factors. edward wiggam also finds that 400 or 10% of 4,000 people lost their jobs due to their technical inability. it means that the other 90% of people are jobless due to their problems on personality (christian, 2008). soft skills have bigger portion in supporting an individual’s success in the real working environment. having sophisticated hard skills without having good personality or soft skills may result in vain (ismail, 2007). a study on human resource problems in the last decade is conducted by an emotional quality inventory (eqi) institution. professionals from the whole world are collected as samples. the results show that iq which is maximally 20% of the brain capacity contributes only 6% for an individual’s success, than eq does. in addition, carnegie institute of teknology finds other proofs that from 10,000 successful persons, 15% of their success are determined by their technical skills, while the other 85% are dominated by personality or soft skill factors. edward wiggam also finds that 400 or 10% of 4,000 people lost their jobs due to their technical inability. it means that the other 90% of people are jobless due to their problems on personality (christian, 2008). the objective of this research is to describe the nursing lecturer’s transformational competences in classroom management at south east asia nursing research, vol 1 no 2, september 2019/ page 83-87 85 tri hartiti / nursing lecturers’ transformasional leadership in classroom management at nursing and health faculty of muhammadiyah university of semarang faculty of nursing and health of muhammadiyah university of semarang. methods this non experimental or descriptive research is conducted with a survey approach to figure out the profile of nursing lecturers’ transformational competences in classroom management at faculty of nursing and health of muhammadiyah university of semarang by using questionnaire as the measuring device. the research samples are the entire lecturers of nursing undergraduate program of faculty of nursing and health of muhammadiyah university of semarang fulfilling inclusion criteria with a total of 24 respondents. results this research has been carried out on 24 lecturers at the university of muhammadiyah semarang. the nursing lecturers collected as the research samples, 79.2 % are female. the lecturers’ average age is 42. the youngest one of 31 years old and the oldest one is 52 years old, and 93,9% of them is master graduate. students’ perceptions on the nursing lecturers’ leadership competences describe on table 1 that 54.2% of lecturers have good transformational leadership while the other 45.8% have not. most lecturers have charismatic competence but not many of them have idealistic persuasive competence. based on the results above, the researchers provide a training module for lecturers to improve their transformational leadership methods in classroom, laboratory, or clinical management as outcomes to develop this research. this module consists of handout materials, lesson plans, schedules, and assessments. this module is prepared based on literature studies and is supervised by experts which is then used to improve their transformational leadership for the benefits of nursing students’ soft skill improvements. the module is enclosed. table 1 the nursing lecturers’ transformational leadership competences nursing lecturers’ transformational leadership component good poor f % f % 1. charismatic competence 17 70 7 30 2. idealistic persuasive competence 9 37.5 15 62.5 3. inspirational motivation competence 13 54.2 11 45.8 4. intellectual stimulation competence 13 54.2 11 45.8 5. individual consideration competence 13 54.2 11 45.8 overall 65 54.2 55 55 discussion transformational leadership is a vision achievement-based leadership. michael (2001), and eisenbeiss et al., (2008) state that transformational leadership improves a nurse’s empathy, understanding, working motivation, applicable values, and interests on jobs that he/she has already chosen. failla & stichler (2011) and stina et al (2008) state that transformational leadership improves a nurse’s working satisfaction and working environment. the results of a research conducted by akerjordet & severinsson (2008) suggest that transformational leader’s emotional quetient and interpersonal competence improve subordinates’ knowledge, care, confidence, participation, and communication that a nurse’s working satisfaction and patients’ satisfaction are also improving. a lecturer’s transformational leadership may influence students’ competences in improving their soft skills. a lecturer’s charismatic competence enables him/her to provide visions, goals, south east asia nursing research, vol 1 no 2, september 2019/ page 83-87 86 tri hartiti / nursing lecturers’ transformasional leadership in classroom management at nursing and health faculty of muhammadiyah university of semarang and strategies for students to become professional nurses. a lecturer’s idealistic persuasive competence may become a role model and an example to be followed. it may also encourage students to have positive attitudes on nursing profession, give examples of positive attitudes to develop his/her positive values as a nurse as well as an image of a professional nurse, and have a good interpersonal relationship. a lecturer’s inspirational motivation competence has a meaning to direct students to have values that being a nurse is a professional choice, to give acknowledgement of nursing profession, and to motivate students in completing their assignments based on their nursing profession, to proportionally give students rewards, to prepare a conducive learning environment. a lecturer’s intellectual stimulation competence enables him to lead the class, develop teaching materials, improve teaching methods, and assigning techniques which stimulate creativities. a lecturer’s individual consideration competence enables students to have confidence in pursuing a carrier and self actualization, to readily face competitions as professional nurse, and to be motivated in educational development. conclusion the nursing lecturers have good transformational leadership competencies. acknowledgements we wish to express our appreciation to all lectures’ who participated in this study and university of muhammadiyah semarang for valuable assistance during data collection. conflicts of interest neither of the authors have any conflicts of interests that would bias the findings presented here. references 1. ambarwati s.d (2003), mengelola perubahan organisasional: isu peran kepemimpinan transformasional dan organisasi pembelajaran dalam konteks perubahan jurnal siasat bisnis no. 8 vol. 2 2. balke m.j (2006), nurse executives: a grounded theory study of dynamic competenciesdisertasinursing university of capela 3. bass b.m. & avolio b.j. (2002). multifactor leadership quesionare sampler set (2nd.ed). redwood city, california : mind garden inc 4. bass b.m., & avolio b.j., berson y, jung.d.i, (2003), predicting unit performance by assesing transformational and transactional leadership. journal of applied psycology, 88(2) 207-218 5. bessie l.m & carol j.h (2006) leadership role and management function in nursing: theory & application 6th edition. lippincott & wilkins: new york 6. eisenbeiss s.a, knippenberg d.v, boerner s, (2008), transformational leadership and team innovation: integrating team climate principles, journal of applied psychology, vol. 93, no. 6, 1438–1446 0021-9010/08/$12.00 doi: 10.1037/a0012716 7. elfindri (2009), soft skill panduan bagi bidan dan perawat, badous media 8. hartiti (2009), studi diskriptif kepemimpinan transformasional dan soft skill perawat di rs roemani semarang 9. hartiti (2012),kepemimpinan transformasional dan soft skill perawat di rs sultan agung semarang, jurnal managemen 2013 10. hartiti (2013), efektivitas kepemimpinan transformasional kepala ruang berbasis soft skill terhadap peningkatan softskill perawat pelaksana di rs roemani semarang, jurnal managemen 2014 south east asia nursing research, vol 1 no 2, september 2019/ page 83-87 87 tri hartiti / nursing lecturers’ transformasional leadership in classroom management at nursing and health faculty of muhammadiyah university of semarang 11. herold d.m &fedor d.b, caldwell, liu y, (2009), the effects of transformational and change leadership on employees’ commitment to a change: a multilevel study journal of applied psychology copyright 2008 by the american psychological association, vol. 93, no. 2, 346–357 0021-9010/08/$12.00 doi: 10.1037/0021-9010.93.2.346 12. ismail g (2007), soft skill untuk menjual diri di dunia kerja, berita universitas muhammadiyah yogyakarta edisi desember 13. kaihatu t.s dan wahju a.r (2007), kepemimpinan transformasional dan pengaruhnya terhadap kepuasan atas kualitas kehidupan kerja, komitmen organisasi, dan perilaku ekstra peran: studi pada guru-guru smu di kota surabaya 14. kumar s.e, sreehari, dkk (2011), communication skills and soft skills dorling kindersley india pvt ltd 15. nurrachmats &wahyuddin m(2004), peran kepemimpinan transformasional, kepemimpinan transaksional, komunikasi internal, dan pengembangan karir terhadap kepuasan kerja di pt. sumber bengawan plasindo karanganyar 16. o’brien j. martin d.r, heyworth j , meyer n.r (2008) negotiating transformational leadership: a key to effective collaboration, nursing and health sciences (2008), 10, 137– 143 17. omer t.y (2005), leadership style of nurse manager at the saudi national hospitals disertasi nursing science university of george mason fairfax virginia 18. soegito, a.t (2010), kepemimpinan manajemen berbasis sekolah, unnes press semarang the application of post conference on shift operates in ward 16 and ward 21 hospitals mubarak al-kabir kuwait corresponding author: martin muslih ukar martinsamsuri@gmail.com south east asia nursing research, vol 4 no 1, march 2022 issn:2685-032x doi: https://doi.org/10.26714/seanr.4.1.2022.51-56 case report the application of post conference on shift operates in ward 16 and ward 21 hospitals mubarak al-kabir kuwait martin muslih ukar 1 1 nurse, mubarak al-kabir hospital, kuwait article info abstract article history: submitted: february 2nd 2022 accepted: march 5th 2022 published: march 29th 2022 keywords: post conference; nursing post-conference is a discussion of the clinical aspects after implementing nursing care for patients. the results of observations and pretest with the nurses in the ward 16 and ward 21 hospitals mubarakiyah al-kabir kuwait, the implementation of post-conferences was not optimal, because it was not in accordance with the rules of post-conference activities. this influences the nursing care provided by nurses. the purpose of this study was to optimize the implementation of the post-conference in room ward 16 and ward 21 hospitals mubarakiyah al-kabir kuwait in 2022. the study was conducted on 26 august 2022. the number of research samples was 7 team leaders in two rooms, 3 team leaders from ward 16 and 4 team leaders from ward 2, data collection was obtained through observations and questionnaires. after the implementation of nursing, the dissemination of knowledge and the application of role play about post conferences for 5 days showed the results of observation after science dissemination and role play showed an increase in nurses in implementing post conferences in ward 16 and ward 21 hospitals mubarakiyah al-kabir kuwait. the application of post-conference is very effective to improve the quality of shift operations in the room for this reason, it is expected that the hospital can follow the standard operating procedures in shift operations. introduction management nursing is service nursing professional where team nursing managed with performs 4 functions management that is planning, organizing, implementing, and controlling. fourth function each other connected and needed skills technical, relationship among human and conceptual support achievement care quality, effective nursing use and succeed to use to client. in carry out his job nurse give care the best nursing corresponding ability, deep nursing there is several methods one of them team method.1 team method is applied with use work same team heterogeneous nurses, consisting of professional nurses and helpers nurse for give care nursing to group patient.2 communication in practice professional nursing is element main for nurse in carry out care nursing in reach optimal results in activity nursing. communication is part of the coordinating strategy in force in settings home service it hurts especially in nursing units.3 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.4.1.2022.51-56&domain=pdf&date_stamp=2022-03-29 south east asia nursing research, vol 4 no 1, march 2022/ page 51-56 52 martin muslih ukar / the application of post conference on shift operates in ward 16 and ward 21 hospitals mubarak al-kabir kuwait communication to various information about development patient between profession health at home sick is deep fundamental component care patient. post conference is discussion about aspect clinic after carry out care patient care. research results permatasari (2014) researching about effectiveness post conference to shift operands in space take care hospitalization in ungaran hospital, research results this show exists influence among post conference with operand shift. post conference if done with good so will be influential to operand sif, operand shift that will be given will walk with max and information will deliver with ok. research results roberts (2017) in australia and several other countries that not enough more than 30% activity nursing depend on communication. if communication and knowledge nurse well, then the services provided efficient and effective. on the other hand, if communication and teamwork nurse bad, then results will be achieved bad. based on results interview with head room disease in as well as observation directly on august 26, 2022 implementation service management nursing in room 16 and room 21 of the mubarak al-kabir hospital kuwait in 2022 especially in ward 16 and ward 21 room where inside apply management nursing still not yet running optimally like post conference sometimes no done at the time operand shift but operand keep doing it whereas in do operand shift many things that need to be said. application post conference this is very important done because could upgrade service care nursing nurse to patient and can upgrade performance nurse. based on phenomena that exist, author interested in do application with title “application post conference to shift operands in room 21 and room 16 of the mubarak al-kabir hospital kuwait". methods method in creation scientific this is studies case with process approach to care nursing. subject studies use case 7 team heads in 2 rooms that is room 21 and room 16. study case this done for 5 days consecutive with post conference implementation on 26-30 august 2022. the instrument in this case study uses a questionnaire measuring tool which is adopted from his research permatasari (2014) who researched about effectiveness post conference to shift operands in space take care in ungaran hospital and adjusted with conditions in space take care stay home mubarak al-kabir hospital kuwait. respondents in the case study given the freedom to answer question as many as 15 questions. respondents case studies were asked to sign an informed consent form prepared by the author. the author does not display the name of the respondent in the report or publication text made by the author. management of case study data obtained is presented and analyzed to find out to what extent implementation of post conference against shift operand. data from case study results are presented in the form of tables and graphs. results the results of the study obtained in the case this is total respondents were 7 people including 4 people from team leader from ward 21 and 3 team leader people from ward 16. study case this done for 5 days in a row. at stage first writer observe and assess operand shift before done training about the post conference, later in the day to 2,3,4 and 5 authors give treatment about the post conference with writer equate perception with head room, team leader and nurse in the room the with method give dissemination knowledge about post conference and role play. after that head room lead post conference and researcher observe and assess what is the process of post conference and operand shift the, south east asia nursing research, vol 4 no 1, march 2022/ page 51-56 53 martin muslih ukar / the application of post conference on shift operates in ward 16 and ward 21 hospitals mubarak al-kabir kuwait whether walk with good or no. activity operand shift walk with fine, if nurse capable follow the post conference with well, in the post conference chairman team must capable discuss about problems that occur in patients, tell constraint what only faced and chairman team convey action what just have to done by the chairman team on shift next, later in the day to 5 authors evaluate every chairman the team that did operand shift . writers do observation to chairman team, about operand shift before there is a post conference and after there is a post conference. writer want knowing is there is difference operand shift before and after done treatment (intervention). characteristics nurse ( type gender, room and length of work ) results of data information obtained about characteristics team leader of 7 respondents recorded the most team leader works > 10 yrs that is as many as 5 people (71.4%), 4 people of this type of sex men (57.1%), and 4 people working in ward 21 (57.1%) presentation of pre and post test results based on figure 1 on consisting of a questionnaire of 15 statements from 7 respondents obtained results that post conference activities before done treatment highest value only 41 and after done treat happen enhancement until value is 60. presentation of observation results before and after treat based on results (figure 2) on so could see there is significant influence post conference treatment of operand shift in room 21 and room 16 of the house mubarak al-kabir hospital kuwait. table 1 distribution frequency type gender, room and length of work nurse in ward 16 and ward 21 on the month august 2022 (n = 7) indicators f % gender male 4 57,1 female 3 42,9 room wards 21 4 57,1 wards 16 3 42,9 length of work < 10 yrs 2 28,6 > 10 years 5 71,4 south east asia nursing research, vol 4 no 1, march 2022/ page 51-56 54 martin muslih ukar / the application of post conference on shift operates in ward 16 and ward 21 hospitals mubarak al-kabir kuwait description : bar chart color blue : pre test results bar chart color yellow : post test results figure 1 pre and post test result description : bar chart color blue : result observation before treatment bar chart color yellow: observation results after treatment figure 2 observation results before and after treatment ,0 10,0 20,0 30,0 40,0 50,0 60,0 70,0 katim 1 katim 2 katim 3 katim 4 katim 5 katim 6 katim 7 pre-test post test 0% 20% 40% 60% 80% 100% 120% katim 1 katim 2 katim 3 katim 4 katim 5 katim 6 katim 7 sebelum perlakuan sesudah perlakuan south east asia nursing research, vol 4 no 1, march 2022/ page 51-56 55 martin muslih ukar / the application of post conference on shift operates in ward 16 and ward 21 hospitals mubarak al-kabir kuwait discussion based on results identification from august 26, 2022, exists problem not yet optimal application of post conference then alternative solving the problem are: training / dissemination knowledge to power nurse about implementation of post conference. this corresponding with analysis results amelia 's journal needs to be carried out training to power nurse about implementation of post conference.6 the assessment or identification carried out is regarding data general and problem which relate with management nursing in ward 16 and ward 21 associated with post conference. based on theory, data results assessment through observation and questionnaire must synchronous kuntoro (2010) because aims to strengthen the data so that there are no discrepancies significant. research results hidayat (2021) on the implementation of post conference in the seagull room at bhayangkara hospital, makasar, the results of this study indicate an increase in the application of post conference in the inpatient room. post conference if done well it will have a positive impact on nursing care services and the impact will give patient satisfaction. the results of the study amalia (2015) examined the relationship between post conference nursing and the implementation of nursing care at rsud dr. achmad mochtar bukit tinggi, from the implementation of nursing care by the team leader and nursing supervision by the head of the room, it will be more effective if the post conference activities are carried out properly. nurses on the next shift will better understand the nursing care plan that will be given. the results of the study seniwati (2011) say that it affects the performance of nurses, because the implementation of the post conference has an impact on the performance of the implementing nurses, if the implementation of the post conference is good then the performance of the implementing nurses will be good, and vice versa. analysis journal this is taken corresponding with problems in ward 16 and ward 21 of the mubarak al-kabir hospital in kuwait that are related by post conference. dissemination knowledge is something method learning for spread information about something purposeful science for give knowledge and change behavior target.11 on august 30, 2022, already done dissemination knowledge about post conference to nurse in ward 16 and ward 21. change expected going to to appropriate direction with concept and the right way or should. writer has facilitated dissemination knowledge about application of post conference, explained material in a manner broadcast directly using lcd and laptop. the author also facilitates for held a roleplay regarding the post conference which was attended by all the nurse in ward 16 and ward 21. after done dissemination knowledge and roleplay about post conference is expected exists increase motivation nurse in do post conferences. observation and post test results after he did training/dissemination knowledge and roleplay about post conference seen exists enhancement nurse in implementation of post conference. apart from the post conference still many factors can influence operand shift including long time working research results this dominated chairman team ≥ 10 years’ work that is as many as 5 people (71.4%) and chairman team with ≤ 10 years of service as many as 2 people (28.6%). nurse on duty longer capable show more performance ok. it because the more senior the nurse have experience work longer. south east asia nursing research, vol 4 no 1, march 2022/ page 51-56 56 martin muslih ukar / the application of post conference on shift operates in ward 16 and ward 21 hospitals mubarak al-kabir kuwait conclusion based on the results of the case study it can be concluded that the application post conference is very effective to sip operand performed in room. this is shown in the increase in the average yield score pre-test ( before done intervention ) and posttest ( after done intervention ) for 5 days in a row. from the results observation is also possible seen that team leader and nurses in the ward 16 and ward 21 rooms did all items are a must done during the post conference. for that expected to party house sick could follow standard operational procedure in do sip operand for upgrade service care nursing to client. acknowledgments the author would like to thank all those who have helped and supported the study process and writing this article. references 1. nursalam. manajemen keperawatan aplikasi dalam praktek keperawatan profesional. jakarta: salemba medika; 2014. 2. galvin ec, wills t, coffey a. readiness for hospital discharge: a concept analysis. j adv nurs. 2017 nov;73(11):2547–57. 3. zhao z, wang w, wang s, jiang l, zhang s, zhao y. femoral rotation influences dynamic alignment of the lower extremity in total knee arthroplasty. int orthop. 2015 jan 10;39(1):55– 60. 4. permatasari d, suryani m, wulandari. efektifitas post conference terhadap operan sif di ruang rawat inap rsud ungaran. in 2014. 5. roberts s, chaboyer w, gonzalez r, marshall ap. using technology to engage hospitalised patients in their care: a realist review. bmc health serv res. 2017;17. 6. amelia r. hubungan perilaku perawatan kaki dengan terjadinya komplikasi luka kaki diabetes pada pasien diabetes melitus tipe 2 di puskesmas tuntungan kota medan. talenta conference series. 2018;1:124–31. 7. kuntoro a. manajemen keperawatan. 1st ed. yogyakarta: nuha medika; 2010. 8. hidayat a. penerapan pre dan post confrence di ruangcamar rumah sakit bhayangkara makassar . [makassar]: uin alauddin; 2021. 9. amalia e, akmal d, permata sari y. hubungan pre dan post conference keperawatan dengan pelaksanaan asuhan keperawatan di rsud dr. achmad mochtar bukittinggi. jurnal stikes perintis sumbar. 2015;117–24. 10. seniwati, nontji w, bahar b. evaluasi operan, pre post conference supervisi dan kinerja perawat di rsu haji makassar. jurnal keperawatan sriwijaya. 2011;44–56. 11. nursalam. konsep dan penerapan metodologi penelitian ilmu keperawatan. jakarta: salemba medika; 2008. medication adherence analysis of type 2 diabetes mellitus patients corresponding author: sulistyo andarmoyo sulistyoandarmoyo@gmail.com south east asia nursing research, vol 1 no 3, december 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.3.2019.107-111 original research medication adherence analysis of type 2 diabetes mellitus patients sulistyo andarmoyo1, harmy bin mohamed yusoff2, berhanudin bin abdullah3, yuzana bint mohd yusop2 1 faculty of health sciences, muhammadiyah university of ponorogo, east java, indonesia 2 faculty of medicine, sultan zainal abidin university, terengganu, malaysia 3 faculty of islamic contemporary studies, sultan zainal abidin university, terengganu, malaysia article info abstract article history: accepted december 25th, 2019 keywords: type 2 diabetes mellitus; adherence; treatment adherence has an important role in therapy management in patients with type 2 diabetes mellitus. this research is to identify and analyze factors related to medication adherence. the design used in this study was a descriptive-analytic design with a cross-sectional approach. the population is type 2 diabetes mellitus sufferers of prolanis group in primary health care facilities in the ponorogo regency. a sample of 180 respondents was taken by purposive sampling technique. variable x includes age, gender, education, occupation, income, and length of suffering. variable y was medication compliance with type 2 diabetes mellitus patients. data collection used a morisky medication adherence (mmas-8) questionnaire and was analyzed using the chi-square test with a significant level of α <0.05. from the results of the study, it was found that the factors of age, sex, education, employment, income and duration of suffering had a significant relationship with medication adherence for patients with type 2 diabetes mellitus. it is expected that health services develop family and communitybased service management. researchers are further advised to develop programs to improve medication adherence. introduction diabetes mellitus is a group of metabolic diseases with hyperglycemia characteristic that occurs due to abnormalities in insulin secretion, insulin action, or both. chronic hyperglycemia in diabetes is associated with long-term damage, and dysfunction of several organs, especially the eyes, kidneys, nerves, heart, and blood vessels, which cause various kinds of complications, including atherosclerosis, neuropathy, kidney failure, and retinopathy1. at present, the prevalence of diabetes in the world reaches 230 million people and that number is up by 3% or an increase of 7 million people every year. in 2025 there are an estimated 350 million people who have diabetes mellitus in the world. the world health organization (who) says that half of the adults with diabetes in the world are in 5 countries; china, india, the united states, brazil, and indonesia2. indonesia ranks 7th with the highest number of people with diabetes mellitus in the world. the international diabetes federation (idf) states that in 2016 indonesia has around 9.1 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.3.2019.107-111&domain=pdf&date_stamp=2019-12-30 south east asia nursing research, vol 1 no 3, december 2019/ page 107-111 108 sulistyo andarmoyo / medication adherence analysis of type 2 diabetes mellitus patients million people with dm3. it is estimated that the number could increase to 12.4 million people in 2025 and reach 14.1 million in 20352. one of the regions with the highest number of diabetics is east java province with a prevalence of dm sufferers of 2.1%, which ranks 5th in the top 10 of diabetes mellitus prevalence in indonesia4. the success of dm management to prevent complications is achievable, primarily through adherence to pharmacological therapy. compliance is a change in behavior according to the instructions given by the doctor in the form of exercise therapy, diet, treatment, and disease control. indirectly, the level of medication adherence can be measured by the morisky medication adherence scale (mmas)-8 questionnaire. the questionnaire is a method for assessing medication adherence in patients with chronic diseases, including diabetes that has been validated by who. noncompliance with taking medication can lead to complications, the risk of hospitalization, and high costs5. adherence to the treatment of dm is quite important in the management of dm yet still a big problem6. the level of adherence of patients with type 2 dm which is still low compared to type 1 can be caused by polypharmacy and therapeutic regimens which are generally more complex, as well as drug side effects that arise during treatment6. compliance with medication and taking medication in people with dm have a very important role in controlling blood sugar. this study was conducted to determine the description of compliance with type 2 diabetes mellitus patients in the prolanis (chronic disease management program) group in primary care facilities in ponorogo regency east java indonesia. methods the design used in this research is analytical descriptive design using a cross-sectional approach. the study was conducted from april 15th to may 30th, 2019, in the prolanis (chronic disease management program) group in the primary service facilities in ponorogo regency east java indonesia. the study sample of 180 patients with type 2 diabetes mellitus with inclusion criteria (male or female aged > 18 years; diagnosed with type 2 diabetes, received drug therapy, had attended a regular check-up at least one time, and was willing to take part in the study). exclusion criteria are patients who have met the inclusion criteria but are pregnant and breastfeeding, illiterate; patients diagnosed with chronic kidney or liver disease and who undergo hemodialysis. data analysis was done descriptively by describing patient characteristics consisting of age, sex, last education, occupation, income, and duration or the length of suffering. then tabulation is made. the compliance is measured using morisky medication adherence 8 items (mmas-8). it is said to be obedient if the total score of respondents answered "yes" on each questionnaire is < 2. it is said to be noncompliant if the total score of respondents answered "yes" on each questionnaire is 38. data were collected after obtaining patient approval from the human research ethics committee (uhrec) sultan zainal abidin university malaysia with number: unisza.c / 2 / uhrec / 628-2 (85) on 8 april 2019 with uhrec code number: unisza / uhrec / 2018/46 results based on the results of the study in the table above, it can be seen that there are 125 people ( 69.4%) are not compliant to the undergoing treatment programs and there are 55 people (30.6%) who are compliant to the undergoing treatment programs. based on the age, the highest noncompliance is in the age range > 45 years which is 115 people (63.9%), based on the south east asia nursing research, vol 1 no 3, december 2019/ page 107-111 109 sulistyo andarmoyo / medication adherence analysis of type 2 diabetes mellitus patients sex the highest non-compliance is female which reaches 115 people (63.9%), based on education, the highest non-compliance is the low education patients with 125 people (69.4%), based on occupation, the highest non-compliance is among working patients which is 125 people (69.4%), based on income, the highest non-compliance is highincome patients with 67 people (37.2%), based on length of suffering, the highest non-compliance patients are those who had a long duration of suffering < 74 (41.1%) 5 years. table 1 patient compliance based on patient demographic characteristics. indicators compliance p compl iance % noncompl iance % age 0,0 00 > 45 years 22 12,2 115 63,9 < 45 years 33 18,3 10 5,6 gender 0,0 00 men 22 12,2 10 5,6 women 33 18,3 115 63,9 education 0,0 00 low 45 25,0 125 69,4 high 10 5,6 0 0 occupation 0,0 00 working 44 24,5 125 69,4 not working 11 6,1 0 0 income 0,0 00 low 0 0 58 32,2 high 55 30,6 67 37,2 suffering duration 0,0 00 > 5 years 7 3,9 51 28,3 < 5 years 48 26,7 74 41,1 discussion during the + 6 weeks of data collection using a questionnaire it was found that as many as 672 type 2 dm patients have received treatment at prolanis (chronic disease management program) in primary health care facilities in ponorogo district. there are around 12 of them who refuse to become respondents so that only about 180 respondents meet the inclusion and exclusion criteria of the study. based on the results of research conducted it can be seen that age, sex, education, occupation, income and length of suffering have a significant relationship to medication adherence to type 2 diabetes mellitus sufferers. age factors the results of the study showed that the majority of respondents were over 45 years old. these results are consistent with the results of riskesdas which shows the majority of type 2 dm patients aged 56-64 years7. the high number of type 2 dm sufferers at age-susceptible is influenced by several causes, among others, pancreatic beta cells have decreased function in old age which can be influenced by the level and duration of insulin resistance8. chi-square statistical test results showed that the age factor had a significant value of 0,000 (p> 0.05), indicating that the correlation between age and medication adherence was significant. according to the older the age, the lower the level of compliance. this is due to the physiological function of the decline due to aging10. gender factor the highest proportion of respondents based on sex is female. the prevalence of dm in women is higher than in men, especially in type 2 dm, because they are likely to be obese due to an increase in body mass index, monthly cycle/menstruation, and menopause which cause them to experience fat accumulation in the body due to the hormonal process11. the results of chi-square the statistical test showed that the sex factor had a significant value of 0,000 (p> 0.05), indicating that the correlation between sexes with medication adherence was significant. states that gender is related to different life roles and behaviors between men and women in society. in maintaining health, women usually take better care of their health than men12. south east asia nursing research, vol 1 no 3, december 2019/ page 107-111 110 sulistyo andarmoyo / medication adherence analysis of type 2 diabetes mellitus patients educational factors educational factors have a significant value of 0,000 (p> 0.05), indicating that the correlation between education and medication adherence is significant. the results of this study are the same as13, that education has a significant relationship with medication adherence in patients with diabetes mellitus with a value of p = 0.012. the level of education affects a person's learning process, the higher the education obtained, the easier the person gets information, and the more information obtained, the more knowledge will be obtained14. occupational factors someone who does not work is more at risk of developing dm than those who work. that is because the group does not work are generally lacking in physical activities so that the burning of calories in the body or metabolic processes are not as high as the working group. the results of the chi-square statistical test showed that the occupational factor had a significant value of 0,000 (p> 0.05), indicating that the correlation between work and medication adherence was significant. according to other research, a person's work affects physical activity.15 the group not working tends to lack physical activity so that there is no movement of the limbs, this can make them easier to experience dm. income factor income factor has a significant value that is 0,000 (p> 0.05), indicating that the correlation between income and medication adherence is significant. economic status influences someone to conduct self-care management. state that the high cost of treatment in type 2 diabetes mellitus patients is still an important reason in terms of preventing suboptimal levels of adherence16. the suffering duration factor or the length of illness the length or the duration of illness affects compliance toward treatment. barriers to adherence can be caused by complex treatment regimens, duration of treatment, multi-therapy, drug efficacy, and lack of information provided by health care providers. other barriers are related to socioeconomic problems, memory disorders, psychological problems, and personal beliefs17. chi-square statistical test results indicate that the duration of the length of suffering has a significant value of 0,000 (p> 0.05), indicating that the correlation between the duration of the length of suffering from adherence to taking medication is significant. patients with type 2 diabetes mellitus with comorbidities will indirectly consume more complex types of drugs. complex types of drugs such as the number of drugs, frequency of administration, dosage forms, as well as special drug administration instructions can trigger noncompliance. conclusion the factors of age, sex, education, employment, income and duration of suffering have a significant relationship with medication compliance with type 2 diabetes mellitus patients in the prolanis group in primary health care facilities. acknowledgments we wish to express our appreciation to all respondents who participated in this study for valuable assistance during data collection. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. south east asia nursing research, vol 1 no 3, december 2019/ page 107-111 111 sulistyo andarmoyo / medication adherence analysis of type 2 diabetes mellitus patients references 1. american diabetes association. (2014). standars of medical care in diabetes-2014. diabetes care. 2014;37(1):s14-s80. doi:10.2337/dc14-s014 2. tandra, h. (2017). segala sesuatu yang harus anda ketahui tentang diabetes : panduan lengkap mengenal dan mengatasi diabetes dengan cepat dan mudah (edisi kedua). (gramedia pustaka utama). 3. international diabetes federation. diabetes atlas 7th ed in (2015). 4. kemenkes ri. (2014) situasi dan analisis diabetes. pusat data dan informasi kementerian kesehatan ri 2 (2014). doi:24427659 5. srikartika, v. m., cahya, a. d., suci, r., hardiati, w. & srikartika, v. m. (2015). analisis faktor yang memengaruhi kepatuhan penggunaan obat pasien diabetes melitus tipe 2. j. manaj. dan pelayanan farm. 6, 205–212. 6. puspitasari, a.w, (2012), analisis efektivitas pemberian booklet obat terhadap tingkat kepatuhan ditinjau dari kadar hemoglobin terglikasi (hba1c) dan morisky medication adherence scale (mmas)-8 pada pasien diabetes melitus tipe 2 di puskesma bakti jaya kota depok,tesis program studi magister ilmu kefarmasian, universitas indonesia, depok. 7. riskesdas, (2013). riset kesehatan dasar. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri, jakarta. 8. goldenberg, r., punthakee, z., (2013), definition, classification and diagnosis of diabetes, pre diabetes and metabolic syndrome, can j diabetes, 37:8-11. 9. brown, m.t., & bussell, j.k. (2011). medication adherence: who care. mayo clin proc, 86 (4). 304-314 10. rosyida, l.dkk. (2015). kepatuhan pasien pada penggunaan obat antidiabetes dengan metode pill count dan mmas-8 di puskesmas kedurus surabaya. jurnal farmasi komunitas. vol. 2(2) : 36-41 11. muflikhatin s. k & fahrudin. (2014). hubungan antara usia, riwatay keturunan dan pola makan dengan kejadian diabetes mellitus tipe 2 di ruang flamboyan rsud abdul wahab sjahranie samarinda. 12. novian a. (2013). kepatuhan diit pasien hipertensi. jurnal kesehatan masyarakat volume 1, nomor 9, 2013. 13. sweileh, w. m., zyoud, s. h., abu, r. j., deleq, m. i., & enaia, m. i. (2014). influence of patients disease knowledge and beliefs about medicines on medication adherence: findings from a cross-sectional survey among patients with type 2 diabetes mellitus in palestine. bmc public health, 14, 1–8. 14. notoatmodjo, s. (2012). pendidikan dan perilaku kesehatan. (rineka cipta). 15. palimbunga, t. m., ratag. b. t., kaunang, w. p. j., (2017). faktor-faktor yang berhubungan dengan kejadian diabetes melitus tipe 2 di rsu gmim pancaran kasih manado. 1-11. 16. abbas a., kachela b., arif j.m., tahir k.b., shoukat n. and ali n.b., (2015), assessment of medication adherence and knowledge regarding the disease among ambulatory patients with diabetes mellitus in karachi, pakistan, journal of young pharmacists, 7 (4), 328–340. 17. currie cj, peyrot m, morgan cl, poole cd, jenkins-jones s, rubin rr, et al. (2012) the impact of treatment noncompliance on mortality in people with type 2 diabetes. diabetes care. 2012;35(6):1279–84. doi:10.2337/dc11-1277 mgso4 and slow stroke back massage therapy on blood pressure of severe pre eclampsia pregnant women corresponding author: ulin nikmah ulinnikmah293@gmail.com south east asia nursing research, vol 1 no 1, june 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.1.2019.37-42 original article mgso4 and slow stroke back massage therapy on blood pressure of severe pre eclampsia pregnant women ulin nikmah1, machmudah2 1 roemani muhammadiyah hospital of semarang 2 university of muhamadiyah semarang article info abstract article history: accepted may 7th, 2019 key words: blood pressure; preeclampsia; mgso4; ssbm preeclampsia is a dangerous complication for pregnant women and their fetuses, this can cause damage to body organs namely heart failure, kidney failure, liver dysfunction, blood clotting disorders, death for the mother and fetus, if not immediately addressed well and correctly. management of severe preeclampsia by administering mgso4 intravenously to mothers as prevention of seizures, one of the nursing actions to overcome preeclampsia patients is the provision of relaxation techniques slow stroke back massage. the objective of this research to determine the effectiveness of mgso4 therapy and slow stroke back massage on blood pressure response in severe preeclampsia pregnant women at roemani hospital muhammadiyah semarang. this research uses the quasi-experimental design with the pre and post test perspective. this research measured 32 the pregnant women with severe preeclampsia at roemani muhammadiyah hospital semarang from purposive sampling technique. the result of this research was shown the effect of blood pressure reduction in all preeclampsia pregnant women given mgso4 therapy and slow stroke back massage. there is a significant influence on the provision of mgso4 therapy and slow stroke back massage on the blood pressure response of severe preeclampsia pregnant women. introduction the number of pregnant women at roemani muhammadiyah hospital semarang in 2017 was 1,589 people, of which 94 were pregnant women with preeclampsia, if at an average of 7.33% or as many as 7 pregnant women with preeclampsia each month. whereas in 2018, in 8 months from january to august 2018 there were 1048 pregnant women, in which pregnant women with preeclampsia reached 82 people, not even 12 months there had been an increase in pregnant women with preeclampsia, if on average every month pregnant women with preeclampsia as much as 10.25% or as many as 10 people every month. preeclampsia (toxemia gravidarum) is a condition that occurs in pregnant women, maternity and childbirth usually occurs in the second trimester until the first week after labor with symptoms of hypertension, https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.1.2019.37-42&domain=pdf&date_stamp=2019-06-23 south east asia nursing research, vol 1 no 1, june 2019/ page 37-42 38 ulin nikmah / mgso4 and slow stroke back massage therapy on blood pressure of severe pre eclampsia pregnant women edema and proteinuria.1 preeclampsia is a dangerous complication for pregnant women and their fetuses, this can cause damage to body organs such as heart failure, kidney failure, liver function disorders, blood clotting disorders, hellp syndrome, death for the mother and fetus, if not treated immediately properly and correctly.1,2 general management of severe preeclampsia by paying attention to the airway, breathing, and circulation if there is a seizure. then administer mgso4 intravenously to mothers as prevention of seizures.3 the mechanism of action of mgso4 is not fully understood but, it is thought to cause dilatation of the cerebral arteries so as to reduce cerebral ischemic (ischemia in the brain). magnesium blocks calcium receptors by inhibiting n-methyld-aspartate receptors in the brain. magnesium also produces peripheral (especially arterioles) vasodilation which reduces blood pressure. mgso4 plays a role in blocking calcium entry to the synaptic end so that it will change the neuro muscular transmission. this transmission is influenced by the presynaptic greater as well as the post synaptic effect. presynaptic acetylcholine release is also reduced so that it will alter neuromuscular transmission. the precise mechanism of action for the tocolytic effects of mgso4 is not clearly defined, but may be related to the action of magnesium as a calcium inhibitor which inhibits muscle contraction so that no seizures occur.3,4 side effects of administration of mgso4 in pregnant women with pre-eclampsia are usually associated with hypermagnesemia (excess magnesium levels), such as nausea, vomiting, thirst, flushing the skin, sleepiness, confusion, loss of tendon reflexes, muscle weakness, hypotension, arrhythmia, respiratory depression, and coma. the observation was carried out after the administration of mgso4 by examining blood pressure, frequency of pulse and respiration, patellar reflexes and urine count. this aims to determine the progress of the administration of mgso4 and if the results of the examination are less than normal, mgso4 will be stopped. how to reduce the risk that occurs in pregnant women with severe preeclampsia should be given independent therapy to help decrease blood pressure during pregnancy in a natural way and can be done easily. one care that can reduce high blood pressure is to give a gentle massage to the mother's back called slow stroke back massage. one factor that makes the occurrence of preeclampsia in pregnant women is a change in blood pressure during pregnancy that has increased so that one intervention that is nonpharmacological to help reduce pressure easily and cheaply is by slow stroke back massage.5,6 slow stroke back massage is a manipulation therapy with gentle massage on the tissue that aims to provide effects on physiology, especially in the vascular, muscular and nervous systems of the body. slow stroke back massage not only provides overall relaxation but also benefits health such as smoothing blood circulation, lowering blood pressure, reducing pain response and improving sleep quality.7 from the results of a brief interview with nurses in the ayyub 1 room, roemani muhammadiyah hospital, semarang, information was obtained that a nurse must specifically monitor the physiological response of pregnant women after administration of mgso4. because it turns out the effects of mgso4 on pregnant women can cause hypotension, also decrease contractions to arrhythmias, respiratory depression to the more severe, namely coma. whereas in the fetus the effects of mgso4 can cause a decrease in fhr so that it can cause death in the fetus. effects on giving birth after giving mgso4 can cause postpartum bleeding. and still, according to one nurse in theayyub 1 south east asia nursing research, vol 1 no 1, june 2019/ page 37-42 39 ulin nikmah / mgso4 and slow stroke back massage therapy on blood pressure of severe pre eclampsia pregnant women room, a massage performed on pregnant women with severe preeclampsia can help mothers relax so that it affects the decrease in blood pressure. based on these descriptions, researchers are interested in conducting research with the title "the effect of mgso4 therapy and slow stroke back massage on blood pressure in pregnant women with severe preeclampsia". methods the type of research used was quasiexperimental or quasi-experimental using a form of pre-post treatment planning divided into two groups (two-group pretest post-test design). this study aims to compare the blood pressure of pregnant women with severe preeclampsia before and after mgso4 therapy and compare the blood pressure of pregnant women before and after slow stroke back massage. in this study, the population is pregnant women with severe preeclampsia at roemani muhammadiyah hospital semarang from january to august 2018, namely 82 pregnant women with severe preeclampsia. the sampling technique used in this study is purposive sampling so that the number of samples is 32 respondents, the sample is divided into two different groups. the research was conducted at roemani muhammadiyah hospital semarang in january march 2019 data collection tools with observation sheets, data were analyzed by univariate and bivariate (wilcoxon match pairet test). results the characteristics of the respondents were 32 years old, the majority of respondents were 50% private workers (8 respondents in the group given mgso4 and ssbm), the average gestational age of the respondents was 37 weeks, the respondents' gravida status as much as the second pregnancy was 15 respondent (46.9%). table 1 characteristics of respondents indicators mgso4 mgso4 +ssbm age, mean (sd) 31,87 (4,334) 33,69 (4,813) gestational age, mean (sd) 36,938 (1,8062) 37,562 (2,3656) based on table 1, it can be seen that the youngest age in the group of pregnant women with severe preeclampsia who received mgso4 therapy was 24 years, and the oldest was 39 years. the average age is 31.87, with a standard deviation of ± 4.334. the youngest age in the group of pregnant women treated with mgso4 and slow stroke back massage was 26 years, and the oldest was 41 years. the average age is 33.69 with a standard deviation of ± 4.813. based on this table can be seen that gestational age in the group that received the lowest mgso4 therapy was 33 weeks and the highest was 39 weeks. the average age is 36.938 with a standard deviation of 1.8062. the gestational age in the group treated with mgso4 and the lowest stroke back massage was 31 weeks and the highest was 40 weeks. the average age is 37.562 with a standard deviation of 2.3656. table 2 the systole and diastolic blood pressure before and after receiving the therapy indicators mgso4 mgso4 +ssbm systolic blood pressure before receiving mgso4 therapy, mean (sd) 168,63 (11,865) 151,94 (6,082) systolic blood pressure after receiving mgso4 therapy, mean (sd) 153,75 (16,619) 141,87 (3,862) p 0,005 0,003 diastolic blood pressure before getting mgso4 therapy, mean (sd) 104,44 (16,496) 94,81 (6,901) diastole blood pressure after receiving mgso4 therapy, mean (sd) 91,88 (8,326) 87,00 (6,633) p 0,001 0,001 based on table 2, it can be seen that the systole blood pressure before the lowest mgso4 value is 160 mmhg and the highest south east asia nursing research, vol 1 no 1, june 2019/ page 37-42 40 ulin nikmah / mgso4 and slow stroke back massage therapy on blood pressure of severe pre eclampsia pregnant women value is 200 mmhg. the mean systole blood pressure before getting mgso4 therapy was 168.63 with a standard deviation of 11.865. diastole blood pressure before getting mgso4 therapy the lowest value is 90 mmhg and the highest value is 150 mmhg. the mean diastolic blood pressure before getting mgso4 therapy was 104.44 with a standard deviation of 16.496. based on the table, it can be seen that the systole blood pressure after getting mgso4 therapy the lowest value is 139 mmhg and the highest value is 190 mmhg. the mean systole blood pressure after getting mgso4 therapy was 153.75 with a standard deviation of 16.619. diastole blood pressure after getting mgso4 therapy the lowest value is 80 mmhg and the highest value is 110 mmhg. the mean diastolic blood pressure after obtaining mgso4 therapy was 91.88 with a standard deviation of 8.326. result of the research was shown that systolic blood pressure in pregnant women with severe preeclampsia before and after mgso4 therapy is p-value 0.005 (<0.05), so it is normally distributed ie there is influence of changes in systole in pregnant women with severe preeclampsia before and after mgso4 and there is an effect of changes in diastolic blood pressure in pregnant women with severe preeclampsia before and after mgso4 therapy (p-value 0.001). based on table 4.4 it can be seen that the systole blood pressure before getting mgso4 therapy and slow stroke back massage the lowest value is 140 mmhg and the highest value is 161 mmhg. the mean systole blood pressure before getting mgso4 therapy was 151.94 with a standard deviation of 6.082. diastole blood pressure before getting mgso4 therapy the lowest value was 88 mmhg and the highest value was 110 mmhg. the mean diastolic blood pressure before getting mgso4 therapy was 94.81 with a standard deviation of 6.901. based on table 2, it can be seen that systole blood pressure after getting mgso4 therapy and slow stroke back massage the lowest value is 137 mmhg and the highest value is 150 mmhg. the mean systole blood pressure after receiving mgso4 therapy was 141.87 with a standard deviation of 3.862. diastole blood pressure after getting mgso4 therapy the lowest value was 74 mmhg and the highest value was 100 mmhg. the mean diastole blood pressure after getting mgso4 therapy was 87.00 with a standard deviation of 6.633. based on table 4.4, it can be seen that pvalue = 0.001, this shows that there is a change in the physiological response of systolic blood pressure in pregnant women with severe preeclampsia before and after mgso4 therapy and slow stroke back massage and there is a change in the physiological response of systolic blood pressure in pregnant women with severe preeclampsia before and after mgso4 therapy and slow stroke back massage (pvalue 0.001). discussion research conducted on 32 respondents after therapy either given mgso4 or given mgso4 and slow stroke back massage showed a significant change in blood pressure reduction in both systole and diastole. the effect of therapy can be proven by wilcoxon bivariate analysis. p value is less than 0.005. the mechanism of slow stroke back massage is in the form of a long and soft swab that produces a relaxing effect in the body which causes a decrease in heart rate and blood pressure. relaxation is beneficial in reducing stress levels and vasodilation of blood vessels. the mechanism of slow stroke back massage increases relaxation by decreasing sympathetic nerve activity and increasing parasympathetic nerves which causes the release of endorphins which make blood vessels vasodilatory.8,9 the mechanism of therapy for mgso4 and slow stroke back massage both work as vasodilators to help reduce blood pressure south east asia nursing research, vol 1 no 1, june 2019/ page 37-42 41 ulin nikmah / mgso4 and slow stroke back massage therapy on blood pressure of severe pre eclampsia pregnant women in pregnant women with severe preeclampsia.10 mgso4 is an important mineral in the human body that is mostly in the bone. metabolism and distribution of other minerals in the body such as calcium and potassium are often associated with magnesium levels. mgso4 used as a vasodilator in preeclampsia and eclampsia is also indicated for replacement therapy in magnesium deficiency with signs of muscle spasms. the mechanism of action for the tocolytic effect of mgso4 is not clearly known but is used to reduce pe and se development where after administration of mgso4 intravenously in women with severe preeclampsia shows a strong potential to prevent the onset of eclampsia.11 this research was supported by another research, where the results showed that blood pressure decreased after slow stroke back massage, with the results that there was a decrease in systolic blood pressure decrease in diastolic blood pressure.5 conclusion besides primigravida who is at risk for severe preeclampsia also in pregnancies with grand multipara, as many as 3 respondents (18.8%) pregnant women with severe preeclampsia who received mgso4 therapy and slow stroke back massage because pregnancy more than 3 times will cause excessive uterine stretching so that cause excessive ischemia and affect the occurrence of severe preeclampsia. the influence of blood pressure on pregnant women with severe preeclampsia obtained the results of the study which showed p-value = 0.001 where p-value <0.05, so this shows that there are differences in the physiological response of blood pressure in pregnant women with severe preeclampsia before and after received mgso4 therapy. while the physical response of blood pressure in pregnant women with severe preeclampsia was obtained by the results of the study which showed that p-value = 0.001, this indicates that there are differences in the physiological response of systolic blood pressure in pregnant women with severe preeclampsia before and after mgso4 therapy and slow stroke back massage. conflicts of interest the author declares that none of them had any conflict of interests. references 1. shah s, gupta a. hypertensive disorders of pregnancy. cardiol clin [internet]. 2019 may [cited 2019 jun 22];0(0). available from: https://linkinghub.elsevier.com/retrieve/pii/s 0733865119300347 2. lowdermilk dl, perry se, cashion k, alden kr, olshansky ef. maternity & women’s health care. 11th editions. st. louis, mo: elsevier; 2016. xxiv, 973 pages. 3. graham nm, gimovsky ac, roman a, berghella v. blood loss at cesarean delivery in women on magnesium sulfate for preeclampsia. j matern neonatal med [internet]. 2015 aug 26 [cited 2019 jun 22];1–5. available from: http://www.tandfonline.com/doi/full/10.310 9/14767058.2015.1064107 4. kawasaki k, kondoh e, chigusa y, kawamura y, mogami h, takeda s, et al. metabolomic profiles of placenta in preeclampsia. hypertension [internet]. 2019 mar [cited 2019 jun 22];73(3):671–9. available from: https://www.ahajournals.org/doi/10.1161/h ypertensionaha.118.12389 5. aryani an, wahyuni s. pengaruh pemberian back exercise dan slow-stroke back massage terhadap penurunan nyeri haid primer [internet]. universitas muhammadiyah surakarta; 2016. available from: http://eprints.ums.ac.id/47832/ 6. mohaddes f, ehsanpour ng, ghezeljeh tn. the effect of slow-stroke back massage on anxiety in female patients with heart failure. bali med j [internet]. 2018 aug 5 [cited 2019 jun 22];7(2):475. available from: https://www.balimedicaljournal.org/index.ph south east asia nursing research, vol 1 no 1, june 2019/ page 37-42 42 ulin nikmah / mgso4 and slow stroke back massage therapy on blood pressure of severe pre eclampsia pregnant women p/bmj/article/view/899 7. dewi ap. efektifitas kombinasi terapi slow stroke back massage dan akupresur terhadap penurunan tekanan darah pada penderita hipertensi. j online mhs bid ilmu keperawatan. 2015;2(2):1299–307. 8. kozier b. fundamentals of nursing: concepts, process, and practice [internet]. pearson education, limited; 2011. available from: https://books.google.co.id/books?id=nbzfna eacaaj 9. potter, p. a., perry, a. g., stockert, p., & hall a. fundamentals of nursing-e-book. elsevier h. 2011. 10. gray c, vickers mh, dyson rm, reynolds cm, berry mj. magnesium sulfate has sex-specific, dose-dependent vasodilator effects on preterm placental vessels. biol sex differ [internet]. 2015 dec 4 [cited 2019 jun 22];6(1):22. available from: http://www.bsdjournal.com/content/6/1/22 11. saha pk, kaur j, goel p, kataria shalija, tandon r, saha l. safety and efficacy of low dose intramuscular magnesium sulphate (mgso4) compared to intravenous regimen for treatment of eclampsia. j obstet gynaecol res [internet]. 2017 oct 1 [cited 2019 jun 22];43(10):1543–9. available from: http://doi.wiley.com/10.1111/jog.13424 the effectiveness of prezi web-based teaching media to improve nursing students’ comprehension corresponding author: arief yanto arief.yanto@unimus.ac.id south east asia nursing research, vol 2 no 1, march 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.1.2020.16-21 original research the effectiveness of prezi web-based teaching media to improve nursing students’ comprehension arief yanto1, warsono warsono1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: accepted march 30th, 2020 keywords: nursing education; prezi; teaching media; mind-map the process of nursing education requires a teaching media which straightforward to be comprehend. inappropriate determining the teaching media leads nursing students face difficulties to receive an adequate course’s guidance from the educators. prezi is a web-based presentation program which comprehensively integrates text, picture, animation, video and audio into one presentation file. this study is aimed to determine the effectiveness of prezi web-based teaching media on improving nursing students’ comprehension. a quantitative-experimental method with pretest-posttest control group design was applied. a total of 176 nursing students were recruited by using non probability sampling approach. the study indicated prezi web-based teaching media showed significant result on improving students’ knowledge. the determination of prezi web-based program is suggested to improve students’ comprehension in nursing education. introduction learning media is one of the important components of the learning process. the ideal learning process is done by implementing the well-designed learning media.1 the implementation of learning media should be a focal point for an educator, especially a lecturer in every learning process.2,3 a well-designed learning media will help the students a lot in comprehending the learning material.4 the development in information technology could improve the performance and enable the fast, precise, and accurate completion of any activities which contribute to productivity improvement.5 the development of information technology could also be beneficial to convey information during the learning process. therefore, the developed multimedia should be employed as a learning media.6 prezi is one of the presentation programs which make use of digital information development. the appearance of prezi is in the form of a single slide zooming presentation.7 it enables the presenter to design a presentation with a linear and flexible storyline. just like the traditional presentation software, prezi can integrate text, images, animation, audio, and video neatly in a single presentation file.8–10 higher education is required to provide an attractive learning process. related to this, prezi is an attractive medium to deliver a https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.1.2020.16-21&domain=pdf&date_stamp=2020-03-31 south east asia nursing research, vol 2 no 1, march 2020/ page 16-21 17 arief yanto / the effectiveness of prezi web-based teaching media to improve nursing students’ comprehension material. certain research concluded that students found that prezi is more interesting than any other presentation media.11 prezi could also stimulate students to be more productive in writing the report.12 in this case, nursing education learns about humans as the learning object. therefore, comprehension and observation of the object of learning are highly required during the nursing subject learning process. prezi can integrate the interesting visual and storyline to make the viewer comprehend the material deeper.13 the result of the interview from 20 nursing students found that 40% of students did not interested in the presentation delivered by the lecturers. from the background above, the researcher would like to find out the significance of prezi as learning media toward nursing students; comprehension. methods it was an experimental quantitative research with a pretest-posttest control group design. the subject of the research was the students of undergraduate and diploma programs in nursing in the second semester who actively attended the lecturing in the classroom. the research subject was taken using non-probability sampling. meanwhile, the number of research subjects was counted using the gpower program by considering compute required sample size analysis which drawn 176 students to be divided into two groups. therefore, the sample size for each group was 88 students. the research was conducted from february to june 2019. in that period, the students attended classical lecturing. this research was conducted in undergraduate and diploma programs in nursing. one of the teaching methods used during the learning process was lecturing. the research data were obtained from multiple sources, which were students and other lecturer or the peer observer. the data was collected using a mini-quiz technique. the mini-quiz was designed to assess students' comprehension of the given material. it was in the form of questions to assess students’ knowledge and comprehension, the ability of students in comprehending the material was descriptively analyzed using comparative descriptive by comparing the result of the mini quiz before and after the implementation of prezi as the learning media. the research objectives and stages were explained to the respondents before the research process. therefore, the score from the data collection was not recorded as academic achievement. the name of the respondents was not written to keep the consent. results the research was conducted at the undergraduate and diploma program of nursing of the faculty of nursing and health sciences at universitas muhammadiyah semarang. the research subject was the second-semester students of the mentioned programs. all of the respondents had the same characteristics and treatments in terms of material. the treatment was in the form of learning media implementation. the research subject was divided into two groups of treatment. both groups received the same material, yet the lecturer implemented the different learning media for each group. it was prezi for one group, and microsoft powerpoint for the other group, therefore, the group was then named after the prezi group and powerpoint group. south east asia nursing research, vol 2 no 1, march 2020/ page 16-21 18 arief yanto / the effectiveness of prezi web-based teaching media to improve nursing students’ comprehension table 1 characteristics of research respondents, n = 176 indicators f % group power point 88 50.0 prezi 88 50.0 study program diploma program in nursing 60 34.1 the undergraduate program in nursing 116 65.9 gender male 32 18.2 female 144 81.8 the research finding showed that both groups had the same proportion, which was 50:50. however, the number of undergraduate students was more than the diploma students. meanwhile, the prezi group was dominated by female students with 79.9% and the rest 20.5% was male students. it was also the same in the powerpoint group, with 84.1% female students and 15.9% male students. the efficacy of the learning media implementation was scored based on the student comprehension of the given material. the students' comprehension included the knowledge and comprehension about the mind map of the nursing process. the measured points in knowledge comprehension were definition, new terms, clinical manifestation, cause, effect, and affecting factors. on the other hand, the measured points in mind map comprehension were mechanism on how problems affect human health, the mechanism of health problem along with the symptoms, and the process of nursing problem. the data were analyzed using the nonparametric statistical test as an alternative since the data distribution for each group was nonnormal. the difference of means between groups was analyzed using mannwhitney test, while the difference of means before and after the intervention was analyzed using the wilcoxon test. table 2 the difference of means between students’ knowledge comprehension, n = 176 indicators prezi powerpoint p the mean before the intervention, (sd) 16 (1,667) 16 (1,668) 0.502* the mean after the intervention, (sd) 18 (1,407) 17 (1,479) 0.018* p 0,0001** 0,0001** * mann-whitney test ** wilcoxon test the research data showed no difference between groups' mean in comprehending the knowledge (p>0.05). therefore, it could be concluded that both groups had the same comprehension baseline about knowledge. on the other hand, the mean of both groups’ knowledge comprehension after the implementation of the learning media showed a significant difference (p<0.05) with z value = -2.356. the students’ comprehension after the implementation of prezi as the learning media was significantly improved compared to the implementation of powerpoint. the research showed a significant difference in students' knowledge comprehension before and after the implementation of prezi (p=0.0001). it meant the implementation of prezi could significantly improve students’ knowledge comprehension. on the other hand, the implementation of powerpoint could also improve the students’ knowledge comprehension (p=0.0001). from the findings, it could be concluded that both learning media could improve students’ knowledge comprehension, especially prezi which was more effective in improving students’ knowledge comprehension. south east asia nursing research, vol 2 no 1, march 2020/ page 16-21 19 arief yanto / the effectiveness of prezi web-based teaching media to improve nursing students’ comprehension table 3 the difference of means between students’ mind map comprehension, n = 176 indicators prezi powerpoint p the mean before the intervention, (sd) 10 (1,138) 10 (1,387) 0.602 * the mean after the intervention, (sd) 18 (1,495) 13 (2,300) 0,0001 * p 0,0001 ** 0,0001 ** * mann-whitney test ** wilcoxon test the research data showed no difference in both groups' mean in mind map comprehension (p>0.05). therefore, it could be concluded that both groups had the same mind map comprehension baseline. on the other hand, the mean of both groups’ mind map comprehension after the implementation of the learning media showed a significant difference (p<0.05) with z = -10.211. the students' mind map comprehension improved more significantly after the implementation of prezi than after the implementation of powerpoint. the research showed a significant difference in students' mind map comprehension before and after the implementation of prezi (p=0.0001). it meant the implementation of prezi could significantly improve students’ mind map comprehension. on the other hand, the implementation of powerpoint could also improve the students’ mind map comprehension (p=0.0001). from the findings, it could be concluded that both learning media could improve students’ mind map comprehension, especially prezi which was more effective in improving students’ mind map comprehension. the research finding showed that prezi was more effective in improving students’ knowledge comprehension and stimulating students’ mind map comprehension. the significance of the media was further described in the table below: table 4 the significance of prezi implementation toward students’ comprehension, n = 176 indicators r square f p understanding of knowledge 0.029 5,278 0.023 understanding mind maps 0.613 275,455 0,0001 linear regression test from the research, it was shown that the implementation of prezi as the learning media affects students' knowledge comprehension at 2.9%, while the rest 97.1% was affected by the other factors. on the other hand, the implementation of prezi has significantly affected students' comprehension in the mechanism or process-related material at 61.3%, while the rest 38.7% was contributed by other factors. discussion from the finding above, it was mentioned that both groups of students had the same knowledge comprehension baseline. the subject of the research was the undergraduate and diploma program in nursing students in the second semester. the research subject was chosen based on the criteria of freshmen students. the freshmen were expected to be able to master basic concepts to learn nursing sciences. the basic concept material would later be employed in the next learning stages. the material learned by freshmen is emphasized on human anatomy and physiology which requires comprehension of each alteration. the proper learning management will lead to nursing students’ self-concept improvement.14 the material given as intervention to the students was the concept of human fulfillment of oxygenation needs. it was a basic material expected to be mastered by the students. the topic was chosen based on the existed curriculum for both diploma and undergraduate in nursing programs. the research finding showed that prezi was more effective in improving students’ south east asia nursing research, vol 2 no 1, march 2020/ page 16-21 20 arief yanto / the effectiveness of prezi web-based teaching media to improve nursing students’ comprehension knowledge comprehension. it was in line with previous research explained about the implementation of prezi which can improve students' cognitive ability, and able to be used as an alternative for more conceptual learning to reduce the cognitive load of students.15 prezi has a more attractive display compared to powerpoint media which triggered students to give more attention to the material delivered using prezi. an attractive learning media could improve students’ learning motivation.16 corresponding research also explained that students were more interested in prezi than powerpoint.11 the high students’ interest in visual media could be useful to achieve the learning objectives. students' interests may contribute to students' motivation to give more attention to the given learning material. prezi was found to be more effective media in improving students' comprehension related to mechanism or alteration process. the comprehension of the mechanism or process needed deeper internalization on the given material. the students were required to understand each component while studying the correlation between components as a whole. in this case, prezi offered unlimited reading room to display a mind-map.7 prezi was found to significantly improve students’ comprehension of process or mechanism related material. the mind map could be helpful for students in mastering knowledge about related factors, prevention, early observation and emergency treatment on the post-surgical complication.17 the improvement of critical thinking ability in students using mind map should also consider the risk of stress experienced by students, as stress might be contrary to the critical thinking ability.18 as nurses, they are required to think critically in making any decision related to the nursing care given to the patient. therefore, it is important to prepare the students as nurses candidates to think critically even from the early stage. as explained above, prezi based learning media could improve the critical thinking skill of students.19 it could be concluded that the right choice of media is one of the valid predictors for better nursing care in the future. therefore, prezi is highly recommended as a learning media for students, especially nursing students. conclusion the implementation of prezi during the learning process can improve students' knowledge and mind map comprehension, as prezi was found to be more effective in improving students' comprehension related to the knowledge and nursing process mind map. the implementation of prezi has less significant in improving students' knowledge related comprehension, yet highly significant in improving mechanism or process-related material (mind-map). acknowledgments the researcher would like to say thank you to all the students who participated as research respondents. a big thanks would also be expressed to the nursing study program for the permission and support during the research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. arsyad a. media pembelajaran. 2011. 2. cory a. etika berkomunikasi dalam penyampaian aspirasi. j komun. 2012;1(1). 3. burklow jt. chapter 41 the clinical researcher and the media. in: gallin ji, ognibene fp, johnson llbt-p and p of cr (fourth e, eds. boston: academic press; 2018:703-712. doi:https://doi.org/10.1016/b978-0-12south east asia nursing research, vol 2 no 1, march 2020/ page 16-21 21 arief yanto / the effectiveness of prezi web-based teaching media to improve nursing students’ comprehension 849905-4.00041-1 4. muhson a. pengembangan media pembelajaran berbasis teknologi informasi. j pendidik akunt indones. 2010;8(2). 5. kadir a. pengenalan sistem informasi edisi revisi. 2014. 6. rohmah l. pengembangan media pembelajaran berbasis. skripsi jur teknol pendidikanfakultas ilmu pendidik um. 2011. 7. perron b, stearns a. a review of a presentation technology: prezi. 2010. 8. ortega ra, brame cj. the synthesis map is a multidimensional educational tool that provides insight into students’ mental models and promotes students’ synthetic knowledge generation. cbe life sci educ. 2015;14(2). doi:10.1187/cbe.14-07-0114 9. duffy rm, guerandel a, casey p, malone k, kelly bd. experiences of using prezi in psychiatry teaching. acad psychiatry. 2015;39(6):615619. doi:10.1007/s40596-014-0204-x 10. chou p-n, chang c-c, lu p-f. prezi versus powerpoint: the effects of varied digital presentation tools on students’ learning performance. comput educ. 2015;91:73-82. doi:http://dx.doi.org/10.1016/j.compedu.201 5.10.020 11. moulton st, türkay s, kosslyn sm. does a presentation’s medium affect its message? powerpoint, prezi, and oral presentations. allen p, ed. plos one. 2017;12(7):e0178774. doi:10.1371/journal.pone.0178774 12. kiss g. ms power point vs prezi in higher education. turkish online j educ technol tojet. 2016;15(3):126-130. 13. mayhew e. the new generation of prezi presentation software, provided by prezi inc., and student engagement and learning within political science. j polit sci educ. 2019;15(3):406-409. doi:10.1080/15512169.2018.1485572 14. fatimah f. analisis perbedaan konsep diri awal dengan konsep diri setelah melewati proses pada mahasiswa memilih keperawatan sebagai profesi (studi longitudinal retrospektif) di kota makassar. j ilm kesehat diagnosis. 2018;12(5):522-525. 15. akgün öe, babur a, albayrak e. effects of lectures with powerpoint or prezi presentations on cognitive load, recall, and conceptual learning. int online j educ sci. 2016;8(3):1-11. doi:10.15345/iojes.2016.03.001 16. tafonao t. peranan media pembelajaran dalam meningkatkan minat belajar mahasiswa. j komun pendidik. 2018;2(2):103. doi:10.32585/jkp.v2i2.113 17. qing-fen z, ling y. application of mind map in the clinical teaching of postoperative complications of pancreatic cancer patients among undergraduate nursing students--《 chinese journal of nursing education》2016年 08期. chinese j nurs educ. 2016;12(8). http://en.cnki.com.cn/article_en/cjfdtotalzhhu201608016.htm. accessed april 8, 2019. 18. momeni h, salehi a, sadeghi h. comparing the effect of problem based learning and concept mapping on critical thinking disposition of nursing student education strategies in medical sciences. sci j educ strateg med sci. 2017;10(4):234-244. http://edcbmj.ir/article1-961-en.html. accessed april 8, 2019. 19. widowati c, purwanto a. pengembangan media pembelajaran berbasis prezi dalam meningkatkan berpikir kritis siswa pada materi sistem pernapasan makhluk hidup. proc open access j. 2018;1(01):115-119. effects of early warning score (ews) on outcomes of inpatient services teguh theryana bobonera1 , vivi yosafianti pohan1, mohammad fatkhul mubin1, yunie armiyati1 1 nursing departmen, faculty of nursing and health sciences, universitas muhammadiyah semarang article info abstract article history: key words : early warning score, outcomes of inpatient services the decrease in patient morbidity and mortality is influenced by quality inpatient services. hospitalized patients can be in stable or unstable conditions. there is a phenomenon of patients whose condition is not stable being placed in inpatient, due to the limitations of the intensive care unit. these patients are at risk for worsening clinical conditions that increase morbidity and mortality. one of the efforts to improve quality related to patient safety in hospitals is the application of the early warning score (ews) including in inpatient installations. an early warning score is one of the assessment parameters in hospital accreditation and quality of care. the aim of this literature review is to explain effects of early warning score (ews) on outcomes of inpatient services. this study uses a literature study approach with a descriptive review type. the articles used are international with a range of years from 2011-2021. the databases used are proquest, pubmed, and the google scholar search engine. implementation of ews has resulted in higher utilization of the rapid response system but a lower incidence of cardiopulmonary arrest; it is associated with lower mortality rates, and improved patient safety and clinical outcomes. the results obtained that there is a correlation between the ews value with mortality but not with the length of stay. research results related to the correlation of ews with referrals to icu/hcu and activation of code blue cannot be analyzed so that in the future a larger number of samples and case variations are needed. a clinical flow can be created in advance so that good patient management can be carried out if the ews score is higher. an early warning score (ews) can be used to predict the patient outcome which is an indicator of inpatient services. corresponding author : teguh theryana bobonera email : nera.nerfin@gmail.com   introduction the decrease in patient morbidity and mortality is influenced by quality inpatient services. hospitalized patients can be in stable or unstable conditions. there is a phenomenon of patients whose condition is not stable being placed in inpatient, due to the limitations of the intensive care unit. these patients are at risk for worsening clinical conditions that increase morbidity and mortality. one of the efforts to improve quality related to patient safety in hospitals is the application of the early warning score (ews) including in inpatient installations. an early warning score is one of the assessment parameters in hospital accreditation and quality of care [5]. an early warning score (ews) is a parameter used to assess the deterioration of the patient's physiological condition, namely identifying and responding to patients who come with acute disease conditions. the ews assessment was carried out based on seven parameters for assessing the patient's physiological response consisting of respiration, systolic blood pressure, temperature, pulse, oxygen saturation, supplemental oxygen, and the patient's level of consciousness. adult early warning score (aews) is a score monitoring tool that is specifically used to identify and assess changes in the condition of adult patients (over 15 years of age) using physiological parameters, such as respiration, peripheral oxygen saturation, oxygen use, systolic blood pressure, pulse/ heart rate, consciousness, and temperature [1][4]. the early warning score (ews) can be used to predict the short-term and long-term probability of death. this is associated with abnormality in the patient's high vital signs, regardless of the intervention or timeliness of medical personnel. the early warning score (ews) can be used as a predictor of patient outcomes including length of stay (los), mortality within 28 days or net death rate (ndr), and hcu/icu admission and activation of a code blue. based on the results of existing research, the impact of the application of ews on patient clinical outcomes is still varied so an overall conclusion cannot be drawn [2]. the results of previous studies found that there was a significant difference between the ndr and los of patients in the hospital after the application of ews. significant differences were found in the increase in code blue activation and admission to hcu. the implementation of the ews has resulted in higher utilization of the rapid response system, resulting in a lower incidence of cardiopulmonary arrest. the aim of this literature review is to explain effects of early warning score (ews) on outcomes of inpatient services [3]. methods this study uses a literature study approach with a descriptive review type. the articles used are international with a range of years from 2011-2021. the databases used are proquest, pubmed, and the google scholar search engine. the strategy used to search the literature is by using the keywords "early warning score" and "healthcare quality". the inclusion criteria in this study were full text, randomized control trial, quasi-experimental and english. while the exclusion criteria are articles with systematic reviews, literature reviews, and case reports. it was found that 2,136 articles came from the pubmed database, 38,760 articles came from the proquest database, and 19,400 articles came from the google scholar search engine, so the total articles found were 60,260 articles. after re-screening the 60,260 articles based on the exclusion criteria, it was found that 31,252 had the search exclusion criteria. a total of 3,439 articles were screened again and resulted in 5 articles that met the researcher's inclusion criteria. result based on the search results obtained from google scholar, proquest, and pubmed using the keywords used in this literature review using indonesian and english. the mortality rate of inpatients after the use of aews is included in the low category with a gross death rate of 3.2 per 1000 visits or the number of deaths of inpatients aged over 15 years as many as 12 people. an early warning score (ews) can be used to predict the patient outcome which is an indicator of inpatient services [7]. the results obtained that there is a correlation between the ews value with mortality but not with the length of stay. research results related to the correlation of ews with referrals to icu/hcu and activation of code blue cannot be analyzed so that in the future a larger number of samples and case variations are needed. a clinical flow can be created in advance so that good patient management can be carried out if the ews score is higher. data extraction table no. juduk artikel, author dan year desain penelitian sampel hasil penelitian 1. title : impact of early warning score model implementation on inpatient service quality author : sri wulan megawati, septy dian sondari, irisanna tambunan year : 2020 randommized controller trial samples obtained for one month amounted to 278. with the criteria the patient is an adult (≥16 years) but not included in the emergency room, intensive care unit, children's room (i.e.<16 years old), pregnant women, and patients with chronic obstructive pulmonary disease (copd). the results obtained indicate that there is no correlation between the ews value and length of stay, while for mortality there is a correlation. referrals to the icu/hcu and activation of code blue cannot be analyzed because of the homogeneity of the data so a larger number of samples and case variations are required. ews can be used as a predictor of inpatient service quality by looking at patient outcomes. 2. title : the effect of using adult early warning scoring (aews) on mortality rates at bali mandara hospital. author : budi ayu mira dewi, i made dwie pradnya susila,a.a. kompiang ngurah darmawan year : 2020 one groups pre test-post test the number of samples in this study was 21 people (march-november 2018) for the period before the use of aews and 12 people (march-november 2019) for the period after the use of aews. the tools used in data collection are observation sheets and medical record data. the mortality rate before the use of aews was included in the low category with a crude death of 8.8 per 1000 inpatient visits or as many as 21 people, while the mortality rate after the use of aews was included in the low category with a crude death of 3.2 per 1000 inpatient visits or as many as 12 people. 3. title : evaluasi penerapan early warning score di ruang rawat inap dewasa author : sri wulan megawati , r.siti jundiah , nur intan hhk , rizki muliani year : 2021 quasi experimental the sample in this study was 245 patients. data collection was carried out during the period (1 month) between 6 august – 6 september 2020. the implementation of ews in hospitals has not been carried out properly, it can be seen from the results that all documented patient ews sheets are incomplete. 4. title : adjusting early warning score by clinical assessment: a study protocol for a danish clusterrandomised, multicentre study of an individual early warning score (i-ews) author : pernille b nielsen , martin schultz, caroline sophie langkjaer, anne marie kodal, niels egholm pedersen,john asger petersen, theis lange, michael dan arvig,christian sahlholt meyhoff, morten bestle year : 2020 quasi experimental the main hypothesis is that i-ews will be noninferior to the existing news algorithm regarding 30day mortality but the addition of clinical assessment in the i-ews results in lower scores, fewer escalations, and consequently that patients on average are scored fewer times per day when i-ews is used rather than news. the i-ews study investigates the effect of integrating a clinical assessment on mortality in a head to head comparison with the internationally used news, which includes the opportunity to use cros. caring for the right patient at the right time could possibly allow for reallocation of resources. if our hypothesis is confirmed, considerations should be given towards allowing nursing staff to include their clinical assessment in tts. 5. title : evaluation of the initial general ward early warning score and icu admission, hospital length of stay and mortality. author : anneke gielen, md kristine koekkoek, md marijke van der steen, md martijn-looijen, bsc, arthur r.h. van zanten, md, phd year : 2021 quasi experimental we performed a retrospective cohort study of adult patients admitted to a general hospital ward between july 1, 2014–december 31, 2017. data were obtained from electronic health records (ehr). the primary outcome was in-hospital mortality. secondary outcomes were icu admission and hospital los. we categorized patients into three risk groups (low, medium or high risk of clinical deterioration) based on ews. our findings suggest that an initial high-risk ews in patients admitted to a general hospital ward was associated with an increased risk of in-hospital mortality, icu admission, and prolonged hospital los. close monitoring and precise documentation of the ews in the ehr may facilitate predicting poor outcomes in individual hospitalized patients and help to identify patients for whom timely and adequate management may improve outcomes. the ews scoring interventions carried out in the five studies above have different types of interventions with different durations. in the research conducted by sri wulan megawati (2020), the intervention of providing ews was carried out during the period (1 month) between august 6 september 6, 2020. while in the study conducted by budi mera (2020) this study was data on patient characteristics, outcomes of patients consisting of a length of stay (days), mortality, referral to icu/hcu, and activation of a code blue. the second instrument is the ews assessment instrument in the hospital. the population is all adult patients (=16 years) in the inpatient room. sampling used a consecutive sampling technique with the criteria of patients being adults (=16 years) but excluding those in the emergency room, intensive care unit, children's room (ie, aged <16 years), pregnant women, and patients with chronic obstructive disease. lungs (copd) for one month. samples obtained for one month amounted to 278 patients. patient deterioration can occur when the evaluation and execution of the ews do not match the algorithm. this requires the medical team and nurses to have professional competence in monitoring, measuring, and evaluating the patient's condition. the results showed that the implementation of nurse monitoring based on ews was very effective in improving the quality of inpatient services. discussion hospital service standards are grouped based on patient safety goals, patient-focused service standards, national programs, and the integration of health education in hospital services. one of the hospital accreditation assessments contains the application of early detection of changes in patient conditions using the early warning score [4]. an early warning score (ews) is a parameter used to assess the deterioration of the patient's physiological condition, namely identifying and responding to patients who come with or are in acute disease conditions. the early warning score (ews) assesses the patient's 6 physiological components, namely consciousness, systolic blood pressure, pulse, oxygen saturation, respiratory rate, and temperature [12]. in indonesia, there is no definite data regarding the mortality rate in all hospitals. in one indonesian hospital, it was found that the 2016 gdr showed 14.73 while the ndr value was 7.73, which means it is still high beyond the minimum standard for hospital services [7]. the ews assessment was carried out based on seven parameters for assessing the patient's physiological response consisting of respiration, systolic blood pressure, temperature, pulse, oxygen saturation, supplemental oxygen, and the patient's level of consciousness. the early warning score (ews) can be used to predict the short-term and long-term probability of death [8]. it is associated with abnormalities in the patient's vital signs, regardless of the intervention or timeliness of medical personnel. the early warning score (ews) can be used as a predictor of patient outcomes including length of stay (los), mortality within 28 days or net death rate (ndr), and hcu/icu admission and activation of a code blue [9]. based on the results of existing research, the impact of the application of ews on patient clinical outcomes is still varied so an overall conclusion cannot be drawn. the results of previous studies found that there was a significant difference between the ndr and los of patients in the hospital after the application of ews. significant differences were found in the increase in code blue activation and admission to hcu. implementation of ews has resulted in higher utilization of the rapid response system but a lower incidence of cardiopulmonary arrest; it is associated with lower mortality rates, and improved patient safety and clinical outcomes [10]. the ews assessment was carried out based on seven parameters for assessing the patient's physiological response consisting of respiration, systolic blood pressure, temperature, pulse, oxygen saturation, supplemental oxygen, and the patient's level of consciousness [11]. the early warning score (ews) can be used to predict the short-term and long-term probability of death. this is associated with abnormalities in the vital signs of patients who are at high risk of death, regardless of intervention or timeliness of medical personnel [3]. the early warning score (ews) can be used as a predictor of patient outcomes including length of stay (los), mortality within 28 days or net death rate (ndr), and hcu/icu admission and activation of a code blue. conclusion an early warning score (ews) can be used to predict the patient outcome which is an indicator of inpatient services. the results obtained that there is a correlation between the ews value with mortality but not with the length of stay. the results of the study related to the correlation of ews with referrals to the icu/hcu and activation of code blue could not be analyzed so that in the future a larger number of samples and case variations are needed. a clinical flow can be made in advance so that good patient management can be carried out if the ews score is higher. the ability of nurses to identify the patient's condition and fill out the early warning scoring observation sheet, the initial condition of the new patient arriving at the hospital and the history of initial treatment when the patient was found (primary survey), the existence of a code blue system or an adequate intensive care room in the hospital as a step when a high ews score is found. acknowledgment the author would like to thank universitas muhammadiyah semarang which has facilitated the writing of this research as well as to the respondents and all parties who have helped and supported the research process and writing of this research article. references [1] dewi, b. a. m., susila, i. m. d. p., & darmawan, a. k. n. (2020). pengaruh penggunaan adult early warning scoring (aews) terhadap tingkat mortalitas di rsud bali mandara. jurnal kesehatan saelmakers perdana (jksp), 3(2), 334-343. [2] duncan, k., & mcmullan, c. (2012). early warning system. philadelphia: lippincott williams & wilkins. [3] modified early warning score (mews) identifies critical illness among ward patients in a resource restricted setting in kampala, uganda: a prospective observational study. plos one, 11(3), e0151408 [4] kementerian kesehatan republik indonesia. (2011). juknis sirs. kementerian kesehatan republik indonesia. kementerian kesehatan republik indonesia. 2008. keputusan menteri kesehatan republik indonesia nomor 129/menkes/sk/ii/2008. jakarta: kementerian kesehatan republik indonesia [5] labellapansa, a., & yulianti, a. (2012). perancangan data warehouse untuk meningkatkan mutu pelayanan rumah sakit berdasarkan standar mutu nasional. in seminar nasional informatika medis (snimed). nurjannah, i., trisna, p. dan raharjo, b. b. 2019. status akreditasi puskesmas dengan tingkat kepuasan pasien. higeia (journal of public health research and development), 3(2): 324–336. [6] patterson, c., maclean, f., bell, c., mukherjee, e., bryan, l., woodcock, t., & bell, d. (2011). early warning systems in the uk: variation in content and implementation strategy has implications for a nhs early warning system. clinical medicine, 11(5), 424. [7] priyantini, d., farida, i., & setianingsih, h. (2018). early warning score system (ewss) and length of stay patients with dengue hemmoragic fever. [8] skaletzky, s. m., raszynski, a., & totapally, b. r. (2012). the effect of adult early warning systems education on nurses' knowledge, confidence and clinical performance: a systematic review. diakses dari https://www.ncbi.nlm.nih.gov/pubme d/28440892 doi 10.1111/jan.13322 . [9] skaletzky, s.m. , raszynski, a. , totapally, b.r. (2012). validation of a modified pediatric early warning system score: a retrospective case– control study. clinical pediatrics, 51(5), 431-435. [10] smith, g. b., prytherch, d.r., meredith, p., schmidt, p. e., & featherstone, p.i. 2013. the ability of the national early warning score (news) to discriminate patient at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. resuscitation, 84(4), 465470. [11] subbe cp, kruger m, rutherford p, gemmel l. validation of a modified early warning score in medical admissions. qjm 2001;94:521–6 [12] williams, b., alberti, g., ball, c., ball, d., binks, r., & durham, l. (2012). royal college of physicians, national early warning score (news), standardising the assessment of acute. yusnita, e. [13] dadkhah, s., shrestha, e., kansakar, a. r., faramarzi, n., parekh, a., dacenko-grawe, l., & sohal, s. (2018). effect of modified early warning system on rapid response team call outcome. 1(1), 1–3. https://doi.org/10.15761/jccr.1000 104 decreased the anxiety scale of hemodialysis patients with the spiritual emotional freedom technique (seft) and the autogenic relaxation corresponding author: liza fitri lina lizafitrilina@umb.ac.id south east asia nursing research, vol 1 no 3, december 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.3.2019.142-147 original research decreased the anxiety scale of hemodialysis patients with the spiritual emotional freedom technique (seft) and the autogenic relaxation liza fitri lina1, hazaroh eldis sabriyanti1, andry sartika1 1 universitas muhammadiyah bengkulu, indonesia article info abstract article history: accepted december 29th, 2019 keywords: spiritual emotional freedom technique (seft), autogenic relaxation, anxiety problems that can be rendered by hemodialysis include anxiety, relationships in marriage, and disobedience in diet and medicine, limitations in lifestyle and threat of death. the purpose of this study was to find out the effectiveness comparison between the spiritual emotional freedom technique (seft) with autogenic relaxation to decrease the anxiety scale of hemodialysis patients. the research design employed quasy experiment without control group design. the results of independent t-test analysis in the emotional spiritual intervention group freedom technique (seft) obtained results p = 0,000, in the autogenic relaxation intervention group the results were p = 0,000. the results of the independent t-test analysis showed that p = 0.184. the study indicates that there was no difference between the spiritual emotional freedom technique (seft) and autogenic relaxation on decreasing the anxiety scale of hemodialysis patients. it is looked forward that the hospital can enforce independent interventions such as spiritual emotional freedom technique (seft) and autogenic relaxation to degrade the anxiety scale of hemodialysis patients. introduction kidney failure is one of the frightening diseases due to there is no cure for it. the incidence of this disease has been increasing rapidly and the sufferer can be anyone both male and female (old or young), and young is no guarantee for not affected by this disease.1 one of the management efforts for patients with chronic kidney failure is through hemodialysis. clients who will undergo hemodialysis experience depression, fear, and anxiety. many impacts of this disease like excessive anxiety and not being handled properly. this becomes the obstacle in overall behavior and leads to the emergence of symptoms of mental disorders.2 the effort that can be done to overcome the anxiety of patients through hemodialysis; such as emotional spiritual freedom technique, which combines the spiritual power and energy psychology and uses autogenic relaxation is a relaxation that comes from within oneself in the form of words or a few short sentences can also be thoughts that can make our minds at ease.3 there are many studies that have done in term of seft, which are useful for overcoming emotional problems, another research has proved that seft therapy can reduce high blood pressure.4 there is an https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.3.2019.142-147&domain=pdf&date_stamp=2019-12-30 south east asia nursing research, vol 1 no 3, december 2019/ page 142-147 143 liza fitri lina / decreased the anxiety scale of hemodialysis patients with the spiritual emotional freedom technique (seft) and the autogenic relaxation influence of autogenic relaxation therapy on depression among the elderly.3 while other respondents told that they involved more in activities in the nursing home. other researchers who found that there was a significant influence between autogenic relaxation therapy on anxiety levels in third-trimester primigravida mothers.5 methods this research used numbers; it gets to start from data collection, interpretation, and description of the results. besides that, to allow a better understanding of research will be presented through tables, graphs, charts, pictures or other views. this study was an experimental quasy to investigate the comparison between the effectiveness of the emotional spiritual freedom technique (seft) and autogenic relaxation on the anxiety scale of hemodialysis patients. the type of this research used a quantitative method by using a quasiexperimental design; pre-post equivalent test without control group design, in which this study contained initial measurements (pre-test) and final measurements (posttest). the conclusion is obtained by comparing the pre-test and post-test data between treatment groups. the measurements were carried out 2 times toward 2 groups, namely group 1 with spiritual emotion freedom technique (seft), and group 2 with autogenic relaxation. results anxiety scale in hemodialysis patients before and after spiritual emotional freedom technique (seft) intervention. based on table 1 can be seen that the anxiety scale in hemodialysis patients prior to the spiritual emotional freedom technique (seft) intervention is 7 respondents (46.7%) experiencing moderate anxiety. table 1 can be seen that the anxiety scale in hemodialysis patients after the spiritual emotional freedom technique (seft) intervention, namely 11 respondents (73.3%) experienced mild anxiety. table 1 shows that p-value = 0,000 is obtained, it can be concluded that there is an influence between the spiritual emotional freedom technique (seft) on the anxiety scale of hemodialysis patients. table 1. anxiety scale in hemodialysis patients before and after seft intervention indicators pre post p f % f % there is no anxiety 0 0,0 2 13,3 0,000 mild anxiety 3 20,0 11 73,3 medium anxiety 7 46,7 2 13,3 severe anxiety 5 33,3 0 0,0 panic 0 0,0 0 0,0 anxiety scale in hemodialysis patients before and after autogenic relaxation intervention. base on table 2 can be seen that the anxiety scale in hemodialysis patients prior to the intervention of autogenic relaxation is 11 respondents (73.3%) experiencing moderate anxiety. based on table 2 can be seen that the anxiety scale in hemodialysis patients before the intervention of autogenic relaxation is 8 respondents (80.0%) do not experience anxiety. based on table 2 obtained p-value = 0,000, it can be concluded that there is an influence between autogenic relaxation on the anxiety scale of hemodialysis patients. table 2. anxiety scale in hemodialysis patients before and after autogenic relaxation intervention indicators pre post p f % f % there is no anxiety 0 0,0 8 53,3 0,000 mild anxiety 1 6,7 3 20,0 medium anxiety 11 73,3 4 26,7 severe anxiety 3 20,0 0 0,0 panic 0 0 0 0,0 south east asia nursing research, vol 1 no 3, december 2019/ page 142-147 144 liza fitri lina / decreased the anxiety scale of hemodialysis patients with the spiritual emotional freedom technique (seft) and the autogenic relaxation comparison between spiritual emotional freedom technique (seft) and autogenic relaxation on the reduction of the anxiety scale of hemodialysis patients based on table 3, p-value = 0.184 is obtained, it can be concluded that there is no difference between the spiritual emotional freedom technique (seft) and autogenic relaxation on the decrease in anxiety scale of hemodialysis patients. table 3. comparison between the spiritual emotional freedom technique (seft) and autogenic relaxation for reducing anxiety scale in hemodialysis patients indicators seft autogenic relaxations p anxiety scale, mean (sd) 17,07 (4,250) 14,53 (5,805) 0,184 discussion the results of this study showed that the majority of anxiety scales in hemodialysis patients before giving intervention of the spiritual emotional freedom technique (seft) were 46.7% of 7 respondents or moderate anxiety. based on the research results from the majority of respondents before giving emotional spiritual freedom technique (seft) intervention to reduce anxiety in chemotherapy patients at smc telogorejo hospital on a moderate anxiety scale.6 anxiety is an emotional condition with the emergence of discomfort in a person, and is a vague experience accompanied by feelings of helplessness and uncertainty caused by something that is not yet clear.7 the results of this study indicated that the majority of disorders scale in hemodialysis patients after conducting intervention spiritual emotional freedom technique (seft) were 73.3% of 11 respondents, which was in mild anxiety. the related study that has done there found significant differences between levels of depression, anxiety, and stress before and after seft intervention (p <0.05), between the intervention group and the control group (p <0.05).8 seft intervention helps to reduce depression, anxiety, and stress among chronic kidney failure patients. spiritual is able to build self-confidence, bring calm, relax, and feel the presence of god almighty, as a result, it can stimulate the hypothalamus for reducing the production of crf (corticotrophin releasing factor). moreover, it further stimulates the anterior pituitary gland to reduce the production of acth (adreno cortico tropin hormone). this hormone stimulates the adrenal cortex to reduce the secretion of stress hormones like cortisol, so that heart rate, high blood pressure, and muscle tension.9 the results of this study indicated that the majority of anxiety scale in hemodialysis patients before giving the autogenic relaxation intervention was moderate anxiety from 11 respondents (73.3%). based on research results the majority of respondents before giving the autogenic relaxation intervention to reduce anxiety in pre-operation patients at ungaran district hospital were on a moderate scale. the way to overcome anxiety through relax effort.10 relaxation is an essential way that is treated to reduce muscle tension, which can improve pulse, blood pressure and breathing. an autogenic relaxation is a simple form that can have extraordinary effect.11 the results of this study indicated that the majority of anxiety scale in hemodialysis patients after conducting autogenic relaxation intervention was 8 respondents (53.3%) without anxiety. based on research results the majority of respondents after giving an autogenic relaxation intervention to reduce anxiety in pregnant women at bpm lismarini and bpm kustirah palembang was on a scale of no anxiety 12 the purpose of the practice of autogenic relaxation is to emphasize self-suggestion to be more calm, light and warm so that the body relaxes. the changing occurs during south east asia nursing research, vol 1 no 3, december 2019/ page 142-147 145 liza fitri lina / decreased the anxiety scale of hemodialysis patients with the spiritual emotional freedom technique (seft) and the autogenic relaxation and after carrying out autogenic relaxation effects on the work of the autonomic nerve. emotional gives the response and the calming effects caused by this relaxation change the sympathetic dominant physiology into the dominant parasympathetic system.13 based on the results of statistical tests (dependent t-test), it is known that the value of p value=0,000, then there was an influence between the spiritual emotional freedom technique (seft) on the anxiety scale of hemodialysis patients. %). based on research results the statistical test results with the wilcoxon signed-rank test obtained value = 0,000, with a value <(0.05), then h0 is rejected. this showed there was an effect of seft on the anxiety of climacteric women at rw 6, pedalangan subdistrict, banyumanik district, semarang, central java. suggestion for climacteric women, seft therapy can be recommended as an alternative therapy to overcome the anxiety of climacteric women.9 anxiety is an unclear and pervasive concern, which is related to the feelings of uncertainty and harmless. seft therapy is useful to help someone becomes more relaxed and able to deal with severe situations or circumstances in his/her life because there is the flow of positive energy systems and this form of positive affirmation that makes seft therapy can be effective.14 spiritual-based interventions are very suitable for helping in achieving these meditative conditions. coupled with tapping can stimulate the release of antistress hormones so that subjects can decrease anxiety.15 furthermore, the seft technique is divided into the full and core versions, which stimulate key points along the 12 energy pathways (meridian energy) of the body. stimulating body meridian points with the same knock intensity for 1015 minutes can help reduce anxiety and make feelings feel calmer, more comfortable and stimulate the release of endorphins that function as happiness hormones.14 based on the results of statistical tests, it is known that the p-value = 0,000, then ho is rejected and ha is received because there was an influence between autogenic relaxation on the anxiety scale of hemodialysis patients. based on research results "the effect of nursing interventions on autogenic relaxation techniques on reducing anxiety levels in preoperative patients". she found there was an influence on the level of anxiety before and after autogenic relaxation techniques on preoperation patients with p-value 0.001. 10 autogenic exercise is used for stress and anxiety management because it is simple and its result is very deep, easy to do, can be done at any time, not related to culture or religion. importantly, this exercise can control the work of the autonomic nervous system (sympathetic and parasympathetic nervous system balance).5 the body feels warm, is a result of peripheral arteries undergoing vasodilation, while decreased body muscle tension results in a mild sensation. changes that occur during and after relaxation affect the work of the autonomic nerve. emotional responses and the calming effects caused by this relaxation change the physiological dominant sympathetic into the dominant parasympathetic system.16 based on the results of the independent ttest, pvalue = 0.184, it can be concluded that ha is rejected and h0 is accepted because there was no difference between the spiritual emotional freedom technique (seft) with autogenic relaxation toward the decreasing of anxiety scale of hemodialysis patients. complementary therapy is holistic and non-biomedical therapy that has been recognized and can be used as a companion to medical or pharmacological therapy. basically, complementary therapy in the nursing system aims to achieve harmony and south east asia nursing research, vol 1 no 3, december 2019/ page 142-147 146 liza fitri lina / decreased the anxiety scale of hemodialysis patients with the spiritual emotional freedom technique (seft) and the autogenic relaxation balance in a person. one of the complementary therapies recommended by researchers is spiritual emotional freedom technique (seft) and autogenic relaxation. the advantages of these they do not cause side effects, like cheaper, easier, safer, faster and simpler.3 it is because seft only uses spiritual and tapping elements, in which medically tapping is also not dangerous. so that seft therapy can be done by anyone. in addition, seft therapy is also universal, meaning it can be used based on the background of the client's beliefs.17 autogenic relaxation is a relaxation technique based on concentration by using body perception that has health benefits to allow the body to feel changes in the body's physiological responses, including emotional, sensory and subjective.18 in autogenic relaxation, the thing that becomes the main recommendation is surrender to oneself, it allows various areas in the body (arms, hands, legs, and feet) to be warm and heavy. this warm and severe sensation is caused by a shift in blood flow (from the center of the body to the desired area of the body), which acts like an internal message, soothing and relaxing the muscles around it.19 conclusion the spiritual emotional freedom technique (seft) and autogenic relaxation can reduce the anxiety scale of hemodialysis patients. the two therapies had no difference in reducing the patient's anxiety scale. acknowledgments thank you to all of the respondents, rsud dr. m. yunus bengkulu and those who have helped this research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. manurung m. faktor-faktor yang mempengaruhi tingkat kecemasan pasien hemodialisa di rsu hkbp balige kabupaten toba samosir tahun 2018. j keperawatan prior. 2018;1(2):38-50. 2. rahman a, heldawati, sudirman. hubungan tindakan hemodialisais dengan tingkat kecemasan pasien di ruangan hemodialisa rsud. labuang baji pemprov sulawesi selatan. 2014;4:619-622. 3. vidya pp, dedi s, evangeline h. pengaruh terapi relaksasi autogenik terhadap depresi pada lansia di bps tresna werdha ciparay. j keperawatan bsi. 2018;vi(vol 6, no 2 (2018): jurnal keperawatan):150-155. 4. faridah vn. pengaruh keperawataan spiritual emotional freedom technique (seft) islami terhadap tekanan darah penderita hipertensi usia 45-59 tahun di rsud dr. soegiri lamongan. surya. 2012;02(vii):1-14. 5. farada ra. pengaruh teknik relaksasi autogenik terhadap tingkat kecemasan pada ibu primigravida trimester iii di wilayah kerja puskesmas kotakulon kabupaten bondowoso. progr stud ilmu keperawatan univ jember. 2011. 6. kartikodaru, hartoyo wm. pengaruh pemberian spiritual emotional freedom technique (seft) terhadap penurunan kecemasan pasien kemoterapi di smc rs telogorejo. j ilmu keperawatan dan kebidanan. 2015;111(479):18. doi:10.1192/bjp.111.479.1009-a 7. annisa df, ifdil i. konsep kecemasan (anxiety) pada lanjut usia (lansia). konselor. 2016;5(2):93. doi:10.24036/02016526480-000 8. bakara md, ibrahim k, sriati a. efek spiritual emotional freedom technique terhadap cemas dan depresi, sindrom koroner akut. 2013;1(april 2013):48-55. 9. aulianita, y. & sudarmiati s. pengaruh spiritual emotional freedom technique terhadap kecemasan wanita klimakterium di rw 6 kelurahan pedalangan kecamatan banyumanik kota semarang jawa tengah. pros semin nas south east asia nursing research, vol 1 no 3, december 2019/ page 142-147 147 liza fitri lina / decreased the anxiety scale of hemodialysis patients with the spiritual emotional freedom technique (seft) and the autogenic relaxation keperawatan komunitas. 2015;(november):178-185. 10. tiana y. pengaruh intervensi keperawatan teknik relaksasi autogenik terhadap penurunan tingkat kecemasan pada pasien pre operasi di rsud ungaran. 2005:1-11. 11. priyo, margono nh. efektifitas relaksasi autogenik & akupresure menurunkan sakit kepala & tekanan darah pada lansia hipertensi. profesi (profesional islam. 2018;15(2):34-44. 12. sulastri. pengaruh teknik relaksasi autogenik terhadap tingkat kecemasan ibu hamil di bpm lismarini dan bpm kustirah palembang tahu.; 2018. 13. fitriani y, alsa a. relaksasi autogenik untuk meningkatkan regulasi emosi pada siswa smp. 2015;1(3):149-162. 14. rofacky hf dan fa. pengaruh terapi spiritual emotional freedom technique (seft) terhadap tekanan darah penderita hipertensi. j keperawatan soedirman (the soedirman j nursing). 2015;2(1):17-23. doi:http://dx.doi.org/10.20884/1.jks.2013.8.2. 470 15. yuniarsih sm. penggunaan seft ( spiritual emotional freedom technique ) untuk membantu ibu hamil menurunkan kecemasan menghadapi persalinan. stikes pku muhammadiyah surakarta. 2018;(i):262-270. 16. dewi wnp, widari np. teknik relaksasi autogenik dan relaksasi otot progresif terhadap tekanan darah pada lansia dengan hipertensi. semin nas dan work publ ilm. 2014;4(2):68-79. 17. nurwa ms. analysis of implementation of spritual emotion freedom technique ( seft ) therapy in psychological disorders ( stress , anxious and depression ) : a literature review analysis of implementation of spritual emotion freedom technique ( seft ) therapy in psy. 2018;(august). 18. aji sb, armiyati y, sn sa. efektifitas antara relaksasi autogenik dan slow deep breathing relaxation terhadap penurunan nyeri pada pasien post orif di rsud ambarawa. j ilmu keperawatan dan kebidanan. 2015;002:1-12. 19. supriadi d, hutabarat e, putri vp. pengaruh terapi relaksasi autogenik terhadap depresi pada lanjut usia di balai perlindungan sosial tresna werdha ciparay bandung. j kesehat kartika. 2015;10(2):56-67. effectiveness of guava leaf extract (syzygium aqueum) in inhibiting the growth of bacteria aggregatibacter actinomycetemcomitans corresponding author: attidhira citra lestari sudrajat attidhiracitra@ymail.com south east asia nursing research, vol 3 no 4, december 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.4.2021.179-178 article review effectiveness of guava leaf extract (syzygium aqueum) in inhibiting the growth of bacteria aggregatibacter actinomycetemcomitans attidhira citra lestari sudrajat1, puspito ratih hardhani1, ayuda nur sukmawati1, steffi triany arnov1, noor rimawati1 1 faculty of dentistry, universitas muhammadiyah semarang, indonesia article info abstract article history: submitted: nov 12th 2021 accepted: dec 20th 2021 published: dec 24th 2021 keywords: syzygium aqueum; aggregatibacter actinomycetemcomitans the role of aggregatibacter actinomycetemcomitans bacteria can lead to the occurrence of aggressive periodontitis. the bacterium infects periodontal tissue with its virulence factor. antibacterial administration such as chlorhexidine mouthwash is one of the treatments for periodontal disease due to bacteria. long-term use of chlorhexidine can cause irritation of the oral mucosa, burning sensation, changes in taste perception and the appearance of stains on the teeth. one alternative is to gargle the guava leaf extract water. the antibacterial effect of guava leaf extract is obtained from its chemical compounds, namely flavonoids, phenolics, alkaloids, ethanol and tannins. this research aims to know the potential of water guava leaf extract (syzygium aqueum) in inhibiting the growth of aggregatibacter actinomycetemcomitans bacteria. a literature review by reviewing research articles from sciencedirect and google scholar using the keywords "syzygium aqueum and aggregatibacter actinomycetemcomitans". guava leaves contain many derivatives of compounds such as flavonoids, alkaloids, tannins, saponins, and terpenoids. the content of these compounds can be used as antibacterial because they are effective in inhibiting the growth of bacteria. water guava leaf extract (syzygium aqueum) can inhibit the growth of aggregatibacter actinomycetemcomitans bacteria. introduction the role of aggregatibacter actinomycetemcomitans bacteria can lead tothe occurrence of aggressive periodontitis.1 aggressive periodontitis is one of the periodontal diseases that generally affects individuals under the age of 30 years but can also be at an older age. the results of data from riskesdas state that the prevalence of the population who have periodontal disease in indonesia reaches 73.1% – 75% consisting of young age and adult age.2 antibacterial administration is one of the options in dealing with periodontal tissue disease.3 chlorhexidine mouthwash can prevent plaque formation and remove plaque that has formed. long-term use of 0.2% chlorhexidine has side effects including causing irritation of the oral mucosa, burning sensation, changes in taste perception and the appearance of stains on teeth.4 antibacterial administration is one https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.4.2021.179-184&domain=pdf&date_stamp=2021-12-24 south east asia nursing research, vol 3 no 4, december 2021/ page 179-184 180 attidhira citra lestari sudrajat / effectiveness of guava leaf extract (syzygium aqueum) in inhibiting the growth of bacteria aggregatibacter actinomycetemcomitans of the options in dealing with infectious diseases. however, the uncontrolled use of antibacterials can encourage the development of resistance to the given antibacterial. the use of herbal plants in indonesia as medicines is part of indonesian culture. plants that are mandated as natural antibacterial agents, one of which is syzygium aqueum or guava leaves. the results of the other study of ethanol extracts in the leaves of s. aqueum contain 6 types of flavonoids, namely 4-hydmyricetinroxy benzadehyde, myricetin-3-o-rhamnoside, phloretin, myrigalone-b.5 in addition to containing flavonoids, guava also contains terponoid compounds, tannins and phenolics.6 based on the description above, researchers are interested in knowing the effectiveness of guava leaves (spyzygium aquerum) against the growth of the bacterium aggregatibacer actinomycetemcomitans. because this bacterium is one of the pathogenic bacteria that causes several diseases in the oral cavity, especially periodontitis. water guava leaf extract is expected as an alternative to prevention and treatment of the oral cavity. method the type of research used is literature study, which is a process or activity of collecting data from various literature such as books and journals to compare the results of one study with another. the purpose of this literature study research is to obtain a theoretical basis that can support the solution of the problem under study and reveal various theories relevant to case.7 the data used in this study are secondary data. secondary data is data or information obtained by researchers from existing and public sources, the data consists of documents, books, previous research, reports.8 the secondary data source used in this study is a journal or scientific article that can study the antibacterial extract of guava leaves against aggregatibacter actinomycetemcomitans bacteria. the data collection technique used in this study is documentation. documentation according to other research is a method used to obtain data or information in the form of writings, books, images, archives, and images in the form of reports and captions that can support research. the documentation used to collect the data is then reviewed.9 the search for articles and journals related to research that will be researched is obtained from google scholar https://scholar.google.com/, science direct www.sciencedirect.com, and pubmed www.pubmed.com using keywords that are in accordance with the research taken for further analysis. result search results for journals and scientific articles were conducted on august 29, 2020 on the pubmed database ( https://pubmed.ncbi.nlm.nih.gov ), google scholar (https://scholar.google.co.id), and science direct (https://www.sciencedirect.com/ ) related to the potential of guava leaf extract ( syzygium aqueum ) in inhibiting the growth of aggregatibacter actinomycetemcomitans bacteria using various keywords that have been determined as follows: table 1 keyword search results in the source database source database keywords extract syzygium aqueum antibacterial syzygium aqueum chemicals of syzygium aqueum pubmed august 29, 2020 12 1 3 googlescholar 29 august 2020 3120 1320 2270 sciencedirect august 29, 2020 31 7 29 about:blank about:blank about:blank about:blank about:blank about:blank https://scholar.google.co.id/ https://www.sciencedirect.com/ south east asia nursing research, vol 3 no 4, december 2021/ page 179-184 181 attidhira citra lestari sudrajat / effectiveness of guava leaf extract (syzygium aqueum) in inhibiting the growth of bacteria aggregatibacter actinomycetemcomitans the phytochemical test conducted by other research showed that the water guava leaf extract contains chemical compounds in the form of flavonoids, alkaloids, tannins, saponins, and terpenoids.5 this is evidenced by the formation of red or green color after mg and 3 drops of hcl are added, indicating that the sample contains flavonoids. there is a red or orange precipitate after dissolving with hcl and nacl indicating the presence of alkaloids. the formation of a bluish-black or green precipitate after being given 2-3 drops of 1% fecl3 proves that the sample contains tannin. the formation of stable bubbles or foam after being dissolved in distilled water and homogenized for 30 seconds indicates the sample contains saponins. meanwhile, the reddish brown color formed after the extract was dissolved in 3 ml of chloroform and dripped with h2so4 , indicated that the sample contained terpenoids. according to other research tested various concentrations of water guava leaf extract against staphylococcus aureus bacteria and found the ability to inhibit these bacteria with the least number of colonies at a concentration of 20%. the results of the phytochemical test of guava leaf extract conducted by other research to test antioxidant activity showed that guava leaf extract contains flavonoids, alkaloids, tannins, saponins and terpenoids which are explained in the following table: table 2 phytochemical tests of water guava leaf extract phytochemical test research result information flavonoids the solution is red or green positive alkaloids red or orange precipitate positive tannins precipitate of bluish black or green color positive saponins stable bubble or foam positive terpenoids the solution is reddish brown positive the test results from the study also showed the presence of other antioxidant active compounds such as steroids and polyphenols. other research carried out extracting guava leaves by maceration with ethanol solvent and obtained antibacterial active compounds contained in guava leaf extract in the form of flavonoids, phenolics and tannins. discussion antibacterial activity can be aimed at the presence of positive results on phytochemical tests on flavonoid compounds, alkaloids, tannins, saponins and terpenoids.10 choesrina conducted an antibacterial test of guava leaf extract against the growth of sthaphylococcus aureus and escherichia coli bacteria, in the study it can be concluded that there is antibacterial activity. when compared to the use of chlorhexidine, guava leaf extract is safer than long-term use of chlorhexidine. long-term use of chlorhexidine can cause effects such as brownish-yellow stains on teeth and the edges of tooth spills, and a bitter taste. while the use of guava leaf extract is safer from side effects such as those caused by the use of chlorhexidine. antibacterial tests of guava leaf extract also affect the growth of salmonella typhy bacteria.11 in guava leaf extract, there is also a high content of compounds such as minerals, and vitamin c.12 the bacterium aggregatibacter actinomycetemcomitans invades the tissues of the oral cavity by attaching to periodontal tissue or on the surface of the teeth. when bacteria attach to periodontal tissue or tooth surface, aggregatibacter actinomycetemcomitans bacteria will fight against normal flora bacteria in the oral cavity. after that, the bacterium aggregatibacter actinomycetemcomitans will infect the surrounding tissues with a virulence factor.1,13,14 one way to prevent bacteria from infecting surrounding tissues is with the use of antibacterials. the use of chemical compounds in guava leaf extract can damage the structure of bacteria, so it south east asia nursing research, vol 3 no 4, december 2021/ page 179-184 182 attidhira citra lestari sudrajat / effectiveness of guava leaf extract (syzygium aqueum) in inhibiting the growth of bacteria aggregatibacter actinomycetemcomitans can inhibit the virulence produced by bacteria. the first chemical compounds are flavonoids. the mechanism of action of flavonoids as antibacterials is divided into 3 ways, namely inhibiting the synthesis of nucleic acids, inhibiting the function of cell membranes, and inhibiting the energy metabolism of bacteria. flavonoids can inhibit the synthesis of nucleic acids because there are rings a and b that play an important role in the process of interclass or hydrogen bonding. the a and b rings will create a buildup of nucleic acid bases in bacteria so that they can inhibit the formation of dna and rna.15 meanwhile, flavonoids inhibit the function of cell membranes by forming complex compounds with extracellular proteins in bacteria so that the compounds formed can damage the permeability of bacterial cell walls, microsomes, and lysosomes.16 in addition, flavonoids can inhibit energy metabolism by inhibiting the use of oxygen by bacteria. inhibition of oxygen use by bacteria will inhibit the formation of metabolism as well so that bacteria will experience cell death.17 in addition to being antibacterial, flavonoids are also useful as antioxidants.18 alkaloids can be used as antibacterials by damaging the constituent components of peptidoglycan in bacterial cells, so that the cell wall layer is not formed intact and causes cell death.16 in addition, in alkaloid compounds there is also an alkaline group containing nitrogen which when reacting with amino acid compounds will result in structural changes in bacteria. the arrangement of amino acids can also cause changes in the genetic balance in the dna chain so that bacteria will be damaged and encourage lysis which will result in cell death in bacteria.19 the mechanism of action of tannins as antibacterials is by inhibiting the enzymes reverse transcriptase and dna topoisomerase so that bacterial cells cannot form. aninhas the ability to turn off microbial cell adhesins, kill enzymes, and interfere with protein transport in the inner layer of bacterial cells. in addition, tanin can also damage cell wall polypeptides so that the formation of cell walls becomes less than perfect. this causes bacterial cells to become lysis due to osmotic and physical pressure so that bacterial cells will die.20 the astringent content in tannins can also increase the toxicity of tannins.21 apart from being antibacterial, tannins also have benefits as an antidote to free radicals in the body.22 the mechanism of action of saponins as antibacterials isto cause leakage of proteins and enzymes from the cell. saponins can be anti-bacterial because the surface-active substances are similar to detergents, as a result of which saponins will lower the surface tension of the bacterial cell wall and damage the membrane perme abiality. the permeability of this cell membrane permeability greatly interferes with the survival of bacteria. saponins will diffuse through the outer membrane of the vulnerable cell wall and then bind to the cytoplasmic membrane of bacteria so that it can disrupt and reduce the stability of the cell membrane. this causes the cytoplasm to leak out of the cells resulting in the death of cells.16,23 terpenoid compounds can function as antibacterials by inhibiting growth by disrupting the process of forming membranes or cell walls so that the bacterial cell wall is not formed perfectly.6 the mechanism of terpenoids as antibacterials is to react with purines on the outer membrane of bacterial cells to form strong polymer bonds, resulting in the destruction of purines. the destruction of purines will cause the entrance and exit of the compound to decrease the permeability of the bacterial cell membrane which will result in bacterial cells lacking nutrients so that bacterial growth decreases and even results in the death of bacteria.16,17 south east asia nursing research, vol 3 no 4, december 2021/ page 179-184 183 attidhira citra lestari sudrajat / effectiveness of guava leaf extract (syzygium aqueum) in inhibiting the growth of bacteria aggregatibacter actinomycetemcomitans conclusion the conclusion of this literature study is that guava leaf extract (syzygium aqueum) which contains flavonoid compounds, alkaloids, tannins, saponins and terpenoids is able to be antibacterial in the oral cavity. thus, when used as an alternative to mouthwash, it can reduce the occurrence of periodontal infection. acknowledgments the author would like to thank all those who have helped and supported the review process and writing this review article. references 1. dent c. aggregatibacter actinomycetemcomitans, bay leaves, aggressive periodontitis. 2016;79–87:8(2). 2. ri kk. laporan hasil riset kesehatan dasar (riskesdas) indonesia tahun 2018. riset kesehatan dasar. 2018;pp. 182-18. 3. dutt, d. p., kr rat, d. p. and khurana dd. chlorhexidine an antiseptic in periodontics. iosr journal of dental and medical sciences 13(9). 2014;pp. 85-88. 4. attamimi, f. a., ruslami, r. , and maskoen am. uji aktivitas antibakteri ekstrak kasar umbi sarang semut (myrmecodia pendens) dibanding dengan klorheksidin terhadap streptococcus sanguinis. majalah kedokteran bandung, 49(2). 2017;pp. 94-101. 5. agustina, eva, funsu andiarna, nova lusiana, risa purnamasari and mih. identifikasi senyawa aktif dari ekstrak daun jambu air (syzygium aqueum) dengan perbandingan beberapa pelarut pada metode maserasi. biotropic : the journal of tropical biology, 2(2). 2018;pp. 108-11. 6. palanisamy, u. d., l. t. ling, t. mataharan, v. sivapalan, t. subramaniam, m. h. helme tm. standardized extract of syzygium aqueum: a safe cosmetic ingredient. international journal of cosmetic science, 33(3). 2011;pp. 269-27. 7. mirzaqon, a. and purwoko b. studi kepustakaan mengenai landasan teori dan praktik konseling expressive writing. journal of bk unesa. 2018; 8. tanujaya, b., p rahmana, r. c. i. and mumu j. mathematics instruction, problems, challenges and opportunities: a case study in manokwari regency, indonesia. world transactions on engineering and technology education. 2017; 9. nugroho w. pengaruh layanan mediasi terhadap perilaku bullying. jurnal medi kons, 5(2),. 2019;pp. 103-11. 10. choesrina, queen, suwendar, mulqie, lanny mardliyani and dieni. potensi aktivitas antibakteri dari fraksi etil asetat daun jambu air [eugenia aqueum (burn f.) alston] terhadap sthaphylococcus aureus dan escherichia coli. jurnal ilmiah farmasi farmasyifa, 2(1),. 2019;pp. 33-39. 11. yanti swp. pengaruh kadar ekstrak daun jambu air terhadap pertumbuhan bakteri salmonella typhi. skripsi fk uwks. 2019; 12. aritonang sp. analisis kandungan antioksidan dan mineral kalsium (ca), kalium (k),dan besi (fe) dari ekstrak buah jambu air (syzygium samarangense)varietasmadu deli hijau (mdh). majalah ilmiah methodagro. 2019;volume 5,. 13. . sriraman, p., mohanraj, r. and neelakantan p. aggregatibacter actinomyctemcomitans in periodontal disease. research journal of pharmaceutical, biological and chemical sciences, 5(2). 2014;pp. 406-41. 14. malik, rajvir, radha changela , prerna krishan, shalini gugnani db. virulence factors of aggregatibacter actinomycetemcomitans a status update. journal of the international clinical dental research organization, 7(2), p 137. 2015; 15. farhadi faegheh, khameneh bahman, iranshahi mehrdad im. antibacterial activity of flavonoids and their structure–activity relationship: an update review. phytotherapy research, 33(1), pp 13–40. 2019; 16. arlofa n. uji kandungan senyawa fitokimia kulit durian sebagai bahan aktif pembuatan sabun. journal chemtech, 1(1), pp 18–22. 2015; 17. bontjura, s., waworuntu, o. a. and siagian k v. uji efek antibakteri ekstrak daun leilem (clerodendrum minahassae l.) terhadap bakteri streptococcus mutans. pharmacon, 4(4). 2015; 18. auliasari, n. , gozali, d. and santiani a. formulasi emulgel ekstrak daun jambu air ( syzygium aqueum ( burm . f .) alston ) sebagai antioksidan. journal farmako bahari, 7(2), pp 1–11. 2016; 19. maliana y ks and df. aktifitas antibakteri kulit garcinia mangostana linn. terhadap pertumbuhan flavobacterium dan enterobacter dari captotermes curvignathus holmgren. journal protobiont, 2(1), pp 7–11. 2013; 20. ngajow, m. , abidjulu, j. and you vs. antibacterial effect of matoa stem (pometia pinnata) peels extract to staphylococcus aureus bacteria in vitro. journal of mathematics and natural sciences unsrat, 2(november 2013), pp 128–132. 2013; south east asia nursing research, vol 3 no 4, december 2021/ page 179-184 184 attidhira citra lestari sudrajat / effectiveness of guava leaf extract (syzygium aqueum) in inhibiting the growth of bacteria aggregatibacter actinomycetemcomitans 21. words, k. , n.-o. hübner, r. matthes, koban, c. rändler, g. müller, c. bender , e. kindel, t. kocher ak. efficacy of chlorhexidine, polihexanide and tissue-tolerable plasma against pseudomonas aeruginosa biofilms grown on polystyrene and silicone materials. skin pharmacol physiol 2010;23(suppl 1):28– 34. 2010; 22. suwendar, hazar, s. and subarnas a. uji aktivitas antioksidan ekstrak etanol daun jambu air [eugenia aqueum (burm. f) alston] secara in vitro dengan metode carotene bleaching. makara journal of health research, 15(1), pp 44–50. 2014; 23. m aatalah, m. b. , n. bouzidi sb. antimicrobial activity of the alkaloids and saponin ex tracts ofanabasis articulata. e3 journal of biotechnology and pharmaceutical research. 2012; the relationship between nurses’ job stress and the implementation of patient safety in the hospital corresponding author: menik kustriyani menikkustriyani@gmail.com south east asia nursing research, vol 2 no 2, june 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.2.2020.19-24 original research the relationship between nurses’ job stress and the implementation of patient safety in the hospital menik kustriyani1, mariyati2 1,2 universitas widya husada semarang, indonesia article info abstract article history: accepted june 27th, 2020 keywords: nurses’ job stress; patient safety nurses’ job stress is considered as a human resource management’s issue in the hospital. study literature reviewed 13.6% of icu nurses encounter the potential threat related to the patient safety occurrences. this study was designed to investigate the correlation between nurses’ job stress and the implementation of patient safety in the hospital in-patient room. this study used a quantitative-analytical method with a cross-sectional approach. a total of 30 respondents were recruited by using proportionate random sampling. a self-reported questionnaire was utilized to collect the data. the normality data was tested by using kolmogorov smirnov analysis (p<0.05). spearman rank test was applied to analyze the overall data. the study findings revealed there was no significant relationship between nurses’ job stress and the patient safety on the target 1 (implementation of patient identification), target 3 (drug safety improvement), target 4 (definitive location and procedure of surgery patient), target 5 (post-health-services infection risk) and target 6 (risk-falls reduction). however, the analysis was found to be statistically significant between nurses’ job stress and effectivecommunication enhancement (target 2 of patient safety). the study findings concluded that stress could positively impact to improve nurses’ awareness to maintain the 6 targets of patient safety introduction stress is a serious issue faced by nurses working in a hospital setting. a survey conducted in the united states described that 46% of nurses experienced job stress and 34% of them have the intention to leave their job. from the survey, 31.2% of nurses were categorized at the high-stress level and 43.8% moderate stress level. several factors contribute to moderate stress levels such as fatigue (degrades physical strength and immunity system), workload (the high burden to provide standard care to the patients) and work characteristics (consistently be prepared for all shifts). americans’ stress levels in 2017 are consistent with those in 2016, with an average stress level of 4.8 (on a scale of 1 to 10) across both years. of the symptoms reported, around one-third of adults reported experiencing feeling nervous or anxious (36 percent), irritability or anger (35 percent), and fatigue (34 percent) due to their stress (american psychological association, 2017).1 https://doi.org/10.26714/seanr.2.2.2020.19-24 south east asia nursing research, vol 2 no 2, june 2020/ page 19-24 20 menik kustriyani / the relationship between nurses’ job stress and the implementation of patient safety in the hospital a previous study described that 13.6% of icu nurses encountered the potential threat related to patient safety such as fall occurrences (48.8%), and un-documented fall incidents by nurses (88%). hence, nurses’ awareness and knowledge about patient safety are crucial and need to be frequently updated through discussion or training.2 in addition, mulyani (2016) explained that 61.4% of nurses faced job stress and 77.8% of them implemented unsatisfactory patient safety. the high workload and the commitment to accomplish the 6 targets of patient safety in maintaining the quality of care could be a stressor for the nursing staff. therefore, the targets of patient safety could stimulate a particular improvement in patient safety.3 methods this study used a quantitative-analytical method with a cross-sectional approach. a self-reported questionnaire consisted of job stress statements and patient safety target indicators (target 1=implementation of patient identification; target 2= effectivecommunication enhancement; target 3=drug safety improvement; target 4=definitive location and procedure of surgery patient; target 5=post-healthservices infection risk; target 6=risk-falls reduction) was utilized to collect the data. the study was conducted in february 2020 at an inpatient ward of ariyo wirawan salatiga hospital. proportionate random sampling was applied to select 60 participants. the normality data was tested by using kolmogorov smirnov analysis (p<0.05). spearman rank test was applied to analyze the overall data. results table 1 describes the nurses’ job stress level is categorized at moderate level. this study also provides non-normal distribution of the nurses’ job stress data which ranged from 28 to 59. table 1 nurses’ job stress at ario wirawan salatiga hospital, february 2020 indicator means sd nurses’ job stress 46.50 6.354 the data of the 6 targets of patients safety shows non normally distributed with the range score for every target such as: target 1 (lower=4; higher=6), target 2 (lower=2; higher=7), target 3 (lower=0; higher=6), target 4 (lower=0; higher=4), target 5 (lower=6; higher=18), and target 6 (lower=2; higher=4). table 2 the implementation of 6 targets of patient safety at ario wirawan salatiga hospital, february 2020 (n = 60) indicator(s) means sd target 1 implementation of patient identification 6.00 0.399 target 2 effectivecommunication enhancement 7.00 0.792 target 3 drug safety improvement 3.00 1.357 target 4 definitive location and procedure of surgery patient 4.00 1.110 target 5 post-health-services infection risk 15.00 2.109 target 6 risk-falls reduction 4.00 0.646 the results show there was no significant relationship between nurses’ job stress and the patient safety on the target 1 (implementation of patient identification), target 3 (drug safety improvement), target 4 (definitive location and procedure of surgery patient), target 5 (post-healthservices infection risk) and target 6 (riskfalls reduction). however, the analysis was found to be statistically significant between nurses’ job stress and effectivecommunication enhancement (target 2 of patient safety) (table 3). south east asia nursing research, vol 2 no 2, june 2020/ page 19-24 21 menik kustriyani / the relationship between nurses’ job stress and the implementation of patient safety in the hospital table 3 the relationship between nurses’ job stress and implementation of 6 targets of patient safety at ario wirawan salatiga hospital, february 2020 (n = 60) indicator(s) coefficient correlation p target 1 implementation of patient identification 0,023 0,859 target 2 effective-communication enhancement 0,329 0,010 target 3 drug safety improvement -0,016 0,901 target 4 definitive location and procedure of surgery patient 0,154 0,239 target 5 post-health-services infection risk -0,026 0,842 target 6 risk-falls reduction 0,164 0,210 independent variable: nurses’ job stress discussion nurses’ job stress at ario wirawan salatiga hospital our study shows that nurses’ job stress is classified in the moderate stress level. in line with the previous study conducted by natsir (2015) most of the study samples were categorized as moderate level (64%).4 amin (2020) also outlined that nurses’ job stress was indicated at a moderate level (39%) and mild low level (41%).5 several stressors contribute to job stress such as workload, nurses’ care experience with pain and death patients, conflict of interactions, and ambiguity roles. moreover, job welfare, seniority interaction, staff’s personal characteristics and the relationship could also arise the job stress condition. job stress is a condition that arises as a result of the interaction between individuals and their jobs, where there are mismatches of characteristics and unclear changes that occur in a company. in certain situations, the condition of the workplace can be another potential source of job stress. nurse, an important element in a hospital is required to provide satisfactory nursing care to the patient and family. comparing to the nurses who work outside of the hospital, stress experienced by nurses working in the hospital is relatively higher.5 however, there are several conditions which cause work burden among nurses such as perceive responsible for the lives of others, substantial workload situation, the condition need to deal with the dying or dead people, and the image of consequences if shortcomings were made in the critical ward such as intensive care unit or emergency room. in addition, in line with a study examined by anggitasari (2020) explained that stress levels classified based on respondent distribution showed a high-stress level among nurses (86.3%). that study suggested stress is not a reduce nurses’ work performance. nurses can control their stress felling with an exercise, and set a period of time for rest and do relaxation.6 the most significant factors affecting nurses’ job stress are workload.7 the implementation of 6 targets of patient safety in ario wirawan hospital salatiga the current study findings of 6 targets of patients safety implementation show that nurses were identified in a good category. equivalent to a study conducted by putri (2018) described that 55.9% of nurses implemented patient safety adequately.8 in accordance to indonesian ministry of health policy, nurses need to implement nursing care to the patient by applying patient safety principals which includes risk assessment, identification and management related to patient’s risk, incidents’ analysis and report, follow up of the incidents, implement the solution to minimize risks and injuries caused of work errors. besides, 6 targets of patient safety are suggested to be implemented which includes target 1 implementation of patient identification, target 2 effective-communication enhancement, target 3 drug safety south east asia nursing research, vol 2 no 2, june 2020/ page 19-24 22 menik kustriyani / the relationship between nurses’ job stress and the implementation of patient safety in the hospital improvement, target 4 definitive location and procedure of surgery patient, target 5 post-health-services infection risk, and target 6 risk-falls reduction.9 however, the statistical data reported non normally distributed with the range score for every target such as: target 1 (lower=4; higher=6), target 2 (lower=2; higher=7), target 3 (lower=0; higher=6), target 4 (lower=0; higher=4), target 5 (lower=6; higher=18), and target 6 (lower=2; higher=4). those result defines that nurses in this study implement all of 6 targets of patient safety effectively. as the results reported, a prior study conducted by fatimah (2018) mentioned that 71.9% of nurses completely performed patient identification before delivering nursing care. nurses do a lot of things during the work period and also deal with many patients. the risk of error could happen. patient identification is crucial to minimize the error10. previous studies performed by ulva (2017) also supported the current study findings of the second target of patient safety implementation which described that communication in the hospitals was effectively implemented by using verbal and telephone. it is rational because those two hospitals integrated patient safety training to the nurses. another concern when applying effective communication is a record. record is required when implementing verbal and telephone communication between nurses and other professionals or nurses and patients. it can be beneficial to minimize the occurrence of miscommunication which arises error.11 furthermore, nurses in this study were also administering drug safety improvement through double-checking and high-alert drug recognizing as the third target of patient safety indicator. in line with a study conducted by aprisila (2018), the majority of nurses (58.5%) in rasyidin and bayangkara hospital padang implemented high awareness about drug safety preserved to the patients12. moreover, the fourth target of patient safety implementation in this study is also categorized as a good result. it is because the study setting was administering hospital policies and standard operating procedures related to the definitive location and procedure of surgery patients. consistent with the prior study reported by alfiyah (2016), 83.8% of nurses were obeyed and applied procedures affiliated with the correct location, procedure and patient. besides, the fifth and sixth target of patient safety in this study is reported as a good classification. it is consistent with the study result that mentioned majority nurses in ario wirawan hospital practicing handwashing by applying 6 steps of who standard to minimize infection risk and assessing the risk of falls for all of the patients to reduce fall incidents. similar to a study reported by alfiyah (2016), 89.7% of nurses performed 6 steps method of handwashing based on who recommendation which the easiest and most important method to decrease microorganisms transmission and prevent infection. while catur (2018) and oktaviana (2019) supported the current study result that 95% of nurses at panti waluya hospital carried out fall-risk prevention properly based on the standard operating procedures.13,14 the relationship between nurses’ job stress and implementation of patient safety in ario wirawan salatiga hospital the study findings decline a previous study examined by mulyati,et.al (2016) which reported data among 61.4% of nurses who experienced job stress were comprising poor patient safety culture (77.8%). meanwhile, 38.8% of nurses whom unexperienced job stress were encountering a good job safety culture (52.9%). nurses are a large number of south east asia nursing research, vol 2 no 2, june 2020/ page 19-24 23 menik kustriyani / the relationship between nurses’ job stress and the implementation of patient safety in the hospital health workers in the hospital who are required to always implement the six targets of patient safety in the nursing care process.3 the nurses’ conviction in supporting the 6 targets of patient safety implementation is essential to ensure patient safety outcomes. nursing care plays an important role in preventing adverse events that occur in patients and the nursing environment. compared to the other health workers, nurses’ assistance is needed for 24 hours since nurses have the most interaction time with patients. unsurprisingly, it also contributes to the pressure on nurses is averagely higher. stress condition experienced by an individual is determined by the balance between the demands (e.g. workload) and the individual resources to overcome these demands (e.g. experience, skills). when the received demands exceed the individual capabilities, it will cause unpleasant conditions such as anxiety or unwell feeling, lack of concentration or high temper. several factors are defined as stressors such as workload, seniority conflict, and patient's characteristics. stressor reactions related to the job situation depend on the nurse's personality, health status, and coping mechanisms. job stress related to patient safety, job stress or emotional exhaustion affect patient safety. emotional exhaustion negatively affects patient safety, job stress resulted in nurse turnover intention.15–17 when nurses carry out patient safety can minimize missed nursing care.18 the study findings declare a significant relationship between nurses’ job stress and the target 2 of patient safety (effectivecommunication enhancement). the result strongly reported that heavier nurses’ job stress increased the implementation of effective communication. stress can generate positive and negative impacts, the positive impact will motivate and develop new discoveries and awareness. conversely, negative stress fosters feelings of distress, rejection, depression and generates physical and mental problems. effective communication enhancement by using sbar method has been implemented in ario wirawan hospital to maintain patient safety. conclusion this study indicates a correlation result between nurses’ job stress and the implementation of patient safety in the hospital setting. from the 6 targets of patient safety, the effective communication enhancement of patient safety targets presents a significant correlation with job stress status. it is concluded that heavier nurses’ job stress increases the implementation of effective communication. several stressors contribute to nurses’ stress which positively impacted to enhance nurses’ awareness and maintain 6 targets of patient safety. acknowledgments we thank lppm of widya husada university semarang for the research funding support and all of the participant involved in this study. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. american psychological assocition. stress in americatm: the state of our nation.; 2017. 2. yilmaz z, goris s. determination of the patient safety culture among nurses working at intensive care units. pakistan j med sci. 2015;31(3):597-601. doi:10.12669/pjms.313.7059 3. mulyati, l dr. fakor determinan yang memengaruhi budaya keselamatan pasien di rs pemerintah kabupaten kuningan. j keperawatan. published online 2016. 4. natsir m, hartiti t, sulisno m. hubungan antara self efficacy dan stres kerja dengan burnout pada perawat dalam melakukan asuhan. j manaj keperawatan. 2015;3(1). south east asia nursing research, vol 2 no 2, june 2020/ page 19-24 24 menik kustriyani / the relationship between nurses’ job stress and the implementation of patient safety in the hospital 5. amin m, ekwinaldo y, novrianti y, muhammadiyah bengkulu u. stress kerja dan konflik kerja mempengaruhi kinerja perawat. j telenursing. 2020;2(1):31-40. doi:10.31539/joting.v2i1.521 6. anggitasari n, budiman b, rosnawati r. hubungan stres kerja dan motivasi kerja dengan kinerja perawat di rumah. vol 1.; 2019. doi:10.31934/jom.v1i1.783 7. kokoroko e, sanda ma. effect of workload on job stress of ghanaian opd nurses: the role of coworker support. saf health work. 2019;10(3):341-346. doi:10.1016/j.shaw.2019.04.002 8. putri me. dampak penerapan keselamatan pasien terhadap kepuasan kerja perawat pelaksana. j psikol jambi. 2018;3(1):1-1. accessed september 13, 2020. https://onlinejournal.unja.ac.id/jpj/article/view/6363 9. kementerian kesehatan ri. profile kesehatan indonesia tahun 2017. minist heal indones. published online 2018:107-108. doi:10.1002/qj 10. siti fatimah f, sulistiarini l, rumah sakit a, et al. gambaran pelaksanaan identifikasi pasien sebelum melakukan tindakan keperawatan di rsud wates description of the implementation of patient identification before taking nursing action in rsud wates. vol 1.; 2018. 11. ulva f. gambaran komunikasi efektif dalam penerapan keselamatan pasien. j pembang nagari. 2017;2(1):95. doi:10.30559/jpn.v2i1.17 12. aprisila as. gambaran penerapan independent double-check dalam pemberian obat high-alert di intensive care unit rumah sakit siloam sriwijaya palembang. published online january 2018. http://repository.uph.edu/4048/ 13. catur k, candrawati e, adi w rc. hubungan pengetahuan perawat tentang keselamatan pasien pada pencegahan risiko jatuh dengan pelaksanaan sop pencegahan risiko jatuh di ruang rawat inap dewasa rs. panti waluya malang. nurs news j ilm keperawatan. 2018;3(3). https://publikasi.unitri.ac.id/index.php/fikes/ article/view/1389 14. oktaviana c, aryoko a, fakultas l, et al. the correlation between nurse caring with patient fall prevention in patient ward. eprints.ukmc.ac.id. published online 2019. http://eprints.ukmc.ac.id/3733/ 15. huang ch, wu hh, lee yc, van nieuwenhuyse i, lin mc, wu cf. patient safety in work environments: perceptions of pediatric healthcare providers in taiwan. j pediatr nurs. 2020;53:6-13. doi:10.1016/j.pedn.2020.03.005 16. choi js, kim km. effects of nursing organizational culture and job stress on korean infection control nurses’ turnover intention. am j infect control. published online april 2020. doi:10.1016/j.ajic.2020.04.002 17. park y-m, kim sy. impacts of job stress and cognitive failure on patient safety incidents among hospital nurses. saf health work. 2013;4(4):210-215. doi:10.1016/j.shaw.2013.10.003 18. kim kj, yoo ms, seo ej. exploring the influence of nursing work environment and patient safety culture on missed nursing care in korea. asian nurs res (korean soc nurs sci). 2018;12(2):121-126. doi:10.1016/j.anr.2018.04.003 position of fowler and semi-fowler to reduce of shortness of breath (dyspnea) level while undergoing nebulizer therapy corresponding author: chanif chanif@unimus.ac.id south east asia nursing research, vol 1 no 1, june 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.1.2019.14-19 original article position of fowler and semi-fowler to reduce of shortness of breath (dyspnea) level while undergoing nebulizer therapy chanif1, dewi prastika1 1 university of muhammadiyah semarang article info abstract article history: accepted may 7th, 2019 key words: position; dyspnea; copd chronic obstruction pulmonary disease (copd) is a lung disease that is caused due to an obstruction in a channel the airflow that much happening in indonesia due to the high-risk factor exposure causes the onset of copd as the habit of smoking and an unhealthy environment. blockage in the airway that occurs in patients of copd is usually characterized by shortness of breath. the various ways that can be done to overcome the shortness of breath are with nebulizer therapy. nebulizer therapy action is undertaken in accordance with standard operating procedures (spo) already determined, in the spo mention the position at the time of the nebulizer therapy position fowler or semi fowler. this study aims to know the effectiveness of the grant the position of fowler and semi fowler against the scale of the copd patient shortness of breath while undergoing therapy nebulizer. methode of this study is a quasy experiment in two groups using pre-test and post-test design. the study was conducted in general hospital k.r.m. t wongsonegoro semarang with the total sample as many as 32 patients. the analysis using mann whitney with p-value 0.000 (p < 0.05) so that it can be concluded that there is a difference in the average scale of shortness of breath between fowler and semi fowler while undergoing group therapy nebulizer. the analysis showed that the position of semi fowler is more effective in lowering shortness of breath when compared to the position of fowler while undergoing therapy nebulizer. this study recommended giving the semi-fowler position to reduce dyspnea in copd patients while undergoing nebulizervtherapy. introduction chronic obstruction pulmonary disease (copd) is a disease is not infectious to become a public health problem of the age of life expectancy and the increasing risk factor exposure against, such as unhealthy living habits, pollution the air especially in big cities, industrialization and the smoking habits of thought is closely connected with the incident copd.1 in this current era of not just in adults only even in the case of copd, too many have encountered on the young age groups who are already familiar with the smoke. smoking habit either active or passive smoker is the cause of most important causal and risk factors in associate as the main onset of copd.2 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.1.2019.14-19&domain=pdf&date_stamp=2019-06-23 south east asia nursing research, vol 1 no 1, june 2019/ page 14-19 15 chanif / position of fowler and semi-fowler to reduce of shortness of breath (dyspnea) level while undergoing nebulizer therapy figures for the incidence of copd according to the organisation world health (who) in 2012, the number of copd sufferers reach 274 million and in the estimate increased to 400 million people in 2020, including the country of indonesia. figures for the incidence of copd in indonesia ranks fifth highest in the world, namely 7.8 million people.2 in a preliminary study conducted at the provincial rsud k.r.m. t wongsonegoro semarang in 2016, there are 257 cases of copd patients with the complaint of breathlessness, particularly in internal medicine. although the signs and symptoms of copd vary widely ranging from asymptomatic, symptoms of mild to severe symptoms but the main complaint of the patients perceived is shortness of breath due to a blockage of the airway. shortness of breath (dyspnea) is the subjective feeling of clients due to difficulty breathing. shortness of breath occurs is not just a result of a blockage in the airway but also due to the influence of several factors, one of which is the skeletal muscle function decline. in addition, the copd patient shortness of breath also occurs due to changes in the catalog is encounter on a large airway, small airway, pulmonary and pulmonary vascular. inflammatory cell surface infiltrated the central airway epithelium which resulted in the change of epithelial squamous metaplasia into which causes increased mucus and cells goblet so hypersecretion respiratory tract mucus, as a result, are experiencing clogging and shortness of breath.3 one of the nursing actions that can be done to overcome the obstruction of the respiratory tract such as shortness of breath can be done with nebulizer therapy. nebulizer therapy is a drug generally sniffs into the respiratory tract. nebulizer therapy done because with steam therapy drug particles that enter will be broken down first into small molecules shaped steam, so expect the drug ingested will enter into the respiratory tract to the maximum. in addition to this nebulizer therapy also provides faster onset compared to other therapies as well as giving effect to quickly restore the condition of the bronchi space.4 standard operating procedures (spo) mention that while undergoing therapy in a patient may position the nebulizer on the position of fowler or semi fowler, in the position of fowler will eliminate pressure in the diaphragm that allows the exchange of the larger volume so launch an airway and breathe in the medication that will go to the maximum. as for the semi-fowler position, the position will be going on the withdrawal of the gravitational force of the earth so that the lungs are free to exhale and inhaled medication can enter the maximum respiratory kesaluran.5 the research that's been done before has the result that position semi fowler can stabilize a patient's breath pattern of pulmonary tb.6 the study, entitled effective semi-fowler position against a decline in the scale of breathlessness in patients with asthma to have the result that the position semi fowler can lower a patient's asthma breathlessness.5 other studies also explained that after the client in the supine position, fowler, and his third against influential tripod respiratory function.7 from the explanation of the supine position indicates that fowler, semi fowler, and the influence on respiration and tripod can decrease shortness of breath in many cases unless in combine with nebulizer while undergoing therapy. as for the purpose of the research is to find out the effectiveness of the grant the position of fowler and semi fowler against a decline in the scale of the copd patient shortness of breath while undergoing nebulizer therapy in rsud k.r.m.t wongsonegoro semarang. methods this study is quasy experiment with the design of two group pre-test and post-test, south east asia nursing research, vol 1 no 1, june 2019/ page 14-19 16 chanif / position of fowler and semi-fowler to reduce of shortness of breath (dyspnea) level while undergoing nebulizer therapy with intervention position fowler and semi fowler while undergoing therapy for copd nebulizer in patients who experience shortness of breath. the sample in this research is a copd patient complaining of shortness of breath and getting a nebulizer therapy in rsud k.r.m. t wongsonegoro semarang with a total of 32 respondents, sampling techniques using purposive sampling, namely the respondent on select in accordance with the criteria of inclusion and exclusion that has researchers specify. gauge asphyxiation using mbs (modified borg scale). this research was already through the clearance ethical passed by the commission of bioetik medical research/faculty of medicine sultan agung islamic university in semarang with no. 178/iii/2018 bioetik/commission. the process of research taking place from 4th week of may until the 4th week of june 2018. the data analyzed in univariate, bivariate (test, wilcoxon test, normalcy, and mann whitney test). results table 1 characteristics of copd patient. indicators group fowler semi-fowler age (mean) 57,62 58,19 gender 1. male 37,5% 68,8% 2. female 62,5% 31,3% educational 1. ts 50,0% 56,2% 2. sd 43,8% 43,8% 3. sma 6,2% 0 result fo the study obtained the majority of respondents who experienced shortness of breath in the category after the midaccording to who in the group of fowler average age 57 years and 58 years old semi fowler group, the average gender group fowler more many experienced women amounted to 62.5% and semi fowler group of more experienced by men amounted to 68.8%, with an average education no school of 50% in the group of fowler and 56.2% of the group semi fowler. the results showed the existence of a difference before and after the intervention did position at the time of nebulizer therapy can be seen in table 2 table 2 distribution scale of shortness of breath before and after done action position fowler and semi fowler on when copd nebulizer therapy on patients min-max median sd iqr pre fowler 2-7 3,00 1,365 2 post fowler 0-3 1,00 0,834 3 pre semifowler 2-7 3,50 1,652 1 post semifowler 0-2 0,50 0,629 1 in table 2 it can be known that before a given position of fowler inpergola mean 3.44 and after being given the position of fowler when the nebulizer therapy mean 0.81 while in before given the position of the semi-fowler when the nebulizer therapy obtained the value of the mean 4.06 and after being given the position of the semi-fowler when the nebulizer therapy in acquired mean 0.56. the results of a test of the effectiveness of the average change in the scale of shortness of breath before and after given the position of fowler and semi fowler when the nebulizer therapy can be seen in table 3 table 3 mann whitney test with delta value the effectiveness of average change of scale of shortness of breath on a group of fowler and semi fowler while undergoing therapy in copd nebulizer variable mean rank sum range p fowler group 12,97 207,50 0,024 semifowler group 20,03 320,50 mann whitney test results showed a pvalue 0.000 (p < 0.05) so that it can be concluded that there is a difference in the average scale of shortness of breath between fowler and semi-fowler group's position on the patient's copd nebulizer therapy while undergoing the provincial rsud in k.r.m. t wongsonegoro semarang. the analysis shows that semi fowler is more effective when compared with fowler. this can be proved by the results of the mean rank each of the eight variables where average the biggest changes occurred in the group of semi fowler i.e. of 20.03. south east asia nursing research, vol 1 no 1, june 2019/ page 14-19 17 chanif / position of fowler and semi-fowler to reduce of shortness of breath (dyspnea) level while undergoing nebulizer therapy discussion characteristics of respondents of the results showed that respondents who experienced shortness of breath in the middle age category i.e. age 45 – 59 years. research results can be concluded that patients who suffered shortness of breath are the middle age group. this happens because a person who is experiencing the aging will occur limitations of work on the chest wall caused due to liming rib joints and decreased elasticity of the lung resulting in not being able to work to the maximum.8 it is supported by a lot of statements stated that at the age of 55 years someone will > susceptible of developing various diseases, one of which is lung disease copd, i.e. it is influenced by the declining immunological system when someone gets old. research results on 32 respondents who experienced shortness of breath in both groups noted that most gender is male 17 respondents, whereas the female gender only 15 respondents. it is associated with unhealthy living habits such as smoking which this habit more going in men compared to women.9 in theory, the case of copd is caused due to smoking occur due to dangerous particles or gases from smoking tobacco which triggered an abnormal inflammatory response in the lungs. dialveoli inflammatory response causes damage to lung tissue. exposure to cigarette smoke that is sustainable in a long period of time can cause the onset of copd. research results showed the average education level end 32 respondents who were divided into 2 groups mentioned that most of the respondents 50% i.e. no school on the group semi fowler group and fowler amounted to 56.2%. this associate that education influences the behavior of a person. in this case, someone will behave well will keep his health if the knowledge possessed is also good. it is supported by other research which explains that there is a relationship between knowledge of the behavior of healthy living.6 the difference in the scale of shortness of breath before and after done position fowler while undergoing therapy nebulizer results of research scale shortness of breath before the giving of the nebulizer therapy when fowler's position was 3.44 and after awarding the position of fowler while undergoing therapy nebulizer is 0.81. the results of the average position of fowler when respondents undergo a nebulizer therapy showed decreased 2.63. based on a test of wilcoxon test obtained p-value 0.000 value (p < 0.05) which means that there is a difference of scale shortness of breath before and after the given position of the fowler while undergoing therapy in hospitals k.r.m. nebulizer t wongsonegoro semarang. fowler's position is a position where the head is elevated 900 that can be intervention to patients who suffered shortness of breath because at position fowler will help eliminate pressure in the diaphragm that allows the exchange of the larger volume from the air. what if the position is at the combine with a diaphragm pressure nebulizer therapy there is no particle inhaled medications will ease the most into the respiratory tract (barbara, 2009).10 the difference in the scale of shortness of breath before and after done position while undergoing therapy semi fowler nebulizer results of research scale asphyxiation ratrata prior position semi fowler nebulizer therapy moment are 4.06 and after position semi fowler nebulizer therapy moment is 0.56. the results of the average value of the position of the semi-fowler while undergoing therapy nebulizer demonstrating a decrease of 3.50. south east asia nursing research, vol 1 no 1, june 2019/ page 14-19 18 chanif / position of fowler and semi-fowler to reduce of shortness of breath (dyspnea) level while undergoing nebulizer therapy the semi-fowler position is a position by elevating the head 450, the position is usually given to patients who experience shortness of breath. on the position of the semi, fowler will happen to earth's gravitational force withdrawal draws the diaphragm downwards so that it can degrade o2 consumption and can maximize the pulmonary ekstasis.10 difragma muscles located at the position of 45 degrees will allow the muscles to contract the thoracic cavity volume enlarge by adding the length of its vertical bar. the thoracic cavity is enlarged will create pressure on the thoracic cavity expands and forces the lungs also expands. process vents that increased carbon dioxide will increase spending and increase the oxygen into the alveoli, oxygen inhaled will help attract drug particle respiratory to entry so join the croup can be reduced.11 the effectiveness of position of fowler and semi fowler against the scale of the copd patient shortness of breath while undergoing nebulizer therapy the research shows there is a difference in scale shortness of breath before and after was given the position of the fowler and semi fowler copd patients while undergoing therapy nebulizer. the results of such research give an overview that respondents are in the position the fowler and semi fowler nebulizer therapy can reduce the time scale of the copd patient shortness of breath. nebulizer therapy is therapeutic steam by entering the drug directly into the respiratory tract so that it can reduce shortness of breath. nebulizer therapy action there are two positions that are able to decrease shortness of breath that is the position of fowler and the position of the semi-fowler. the results of research conducted by mann whitney test with delta value retrieved results p-value 0.000 (p < 0.05) which means that there is a difference of position fowler and semi fowler against the scale of the copd patient shortness of breath while undergoing nebulizer therapy in rsud k.r.m. t wongsonegoro semarang. the analysis shows that the position of semi fowler decreases more effective in copd patient shortness of breath while undergoing therapy nebulizer. this is evidenced by the value of the mean rank position semi fowler shows greater value i.e. 20.03. the limitations of the research there are limitations in this study i.e., researchers can not categorize the breathlessness of the respondents based on factors that affect the shortness of breath. researchers simply choose the respondent in accordance with the criteria of inclusion of already defined and concentrates on the respondents who experienced shortness of breath and live the nebulizer therapy. researchers cannot control its homogeneity the age at which respondents age is an important factor which contributed to the scale of shortness of breath. conclusion results of the study are expected to provide information for the hospital and can be intervention to the patients about the best position when giving nebulizer therapy to reduce shortness of breath, have a contribution for the researchers to add science knowledge and apply the knowledge obtained in the learning process, and can add insight and knowledge of the public about the best position can be done to reduce shortness of breath especially patients undergoing therapy nebulizer. conflicts of interest the author declares that none of them had any conflict of interests. south east asia nursing research, vol 1 no 1, june 2019/ page 14-19 19 chanif / position of fowler and semi-fowler to reduce of shortness of breath (dyspnea) level while undergoing nebulizer therapy references 1. perhimpunan dokter paru indonesia p. penyakit paru obstruktif kronik ( ppok ) pedoman diagnosis; penatalaksanaan di indonesia. perhimpunan dokter paru indonesia. jakarta: perhimpunan dokter paru indonesia; 2011. 32 p. 2. who. chronic obstructive pulmonary disease (copd) [internet]. who. 2017 [cited 2018 jun 18]. available from: https://www.who.int/en/news-room/factsheets/detail/chronic-obstructive-pulmonarydisease-(copd) 3. fahy j v, dickey bf. airway mucus function and dysfunction. n engl j med [internet]. 2010 dec 2 [cited 2019 jun 18];363(23):2233–47. available from: http://www.ncbi.nlm.nih.gov/pubmed/21121 836 4. sudarsini. fisioterapi [internet]. malang: penerbit gunung samudera; 2017 [cited 2019 jun 18]. 140 p. available from: https://books.google.co.id/books?id=m4aodw aaqbaj&printsec=frontcover&hl=id#v=onepa ge&q&f=false 5. safitri r, andriyani a. keefektifan pemberian posisi semi-fowler terhadap penurunan sesak nafas pada pasien asma di ruang rawat inap kelas iii rsud dr. moewardi surakarta. gaster j kesehat [internet]. 2012 aug 7 [cited 2019 jun 18];8(2):783–92. available from: http://www.jurnal.stikesaisyiyah.ac.id/index.php/gaster/article/view/ 29 6. majampoh ab, rondonuwu r, onibala f. pengaruh pemberian posisi semi fowler terhadap kestabilan pola napas pada pasien tb paru di irina c5 rsup prof dr. rd kandou manado. j keperawatan. 2015;3(1). 7. costa r, almeida n, ribeiro f. body position influences the maximum inspiratory and expiratory mouth pressures of young healthy subjects. physiotherapy [internet]. 2015 jun 1 [cited 2019 jun 18];101(2):239–41. available from: https://www.sciencedirect.com/science/articl e/abs/pii/s0031940614000820 8. ionescu c, jabłonski i. nonstandardized lung function tests. lung funct test 21st century [internet]. 2019 jan 1 [cited 2019 jun 18];49– 80. available from: https://www.sciencedirect.com/science/articl e/pii/b978012814612500004x 9. sarwani d, sri n. merokok dan tuberkulosis paru, studi kasus di rs margono soekarjo purwokerto. fkm unsoed purwokerto. 2012; 10. kozier b. fundamentals of nursing: concepts, process and practice [internet]. pearson education, limited; 2011. available from: https://books.google.co.id/books?id=nbzfna eacaaj 11. potter, p. a., perry, a. g., stockert, p., & hall a. fundamentals of nursing-e-book. elsevier h. 2011. factors related the job satisfaction among migrant nurses in qatar corresponding author: saiful uddin saifindo@yahoo.com south east asia nursing research, vol 1 no 1, june 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.1.2019.1-6 original article factors related the job satisfaction among migrant nurses in qatar saiful uddin1 1 messaieed medical center qatar petroleum article info abstract article history: accepted may 7th, 2019 key words: job satisfaction; nurse; working time arrangements indonesian nurses migrated out of the country with various motifs, for instance, to earn a better income, enhancing the experience, personal development, and improvement of nursing ability. the phenomenon where nurses turn over from their job can also be caused by job dissatisfaction. nurses job’s satisfaction needs serious attention since the nurses are spearheading the implementation of services. the objective of this study to get an idea of the level of job satisfaction and to identify factors affecting job satisfaction in indonesian migrants nurse in qatar. the research method is a descriptive analytic using cross-sectional approach. the research’s sample represents a total sample of 39 indonesian nurses who work in an outpatient clinic in qatar in february 2012. the results showed that indonesian migrant nurses working in qatar are satisfied with the work of 51.3%. the results of the analysis showed no correlation between length of service and working time arrangements with job satisfaction, whereas there was no correlation between age, education degree and family status with job satisfaction. the recommendations can be given to health care management in qatar are to further improve the promotion system and nurses self-development and to increase incentives for nurses who do shift duty. nurses are advised to increase the level of education and improve the performance of work. introduction qatar is a rich country with high economic growth due to oil and natural gas. the rapid development and development that is taking place in qatar will automatically provide extensive employment opportunities including the health sector. there are opportunities that is one reason that indonesian nurses migrated to qatar in hopes of getting a better life. with the increasing number of indonesian migrant nurses in qatar, there is a phenomenon and dynamics of the lives of nurses abroad. mingling with the international community with a variety of cultural backgrounds, customs, beliefs, and different languages gives rise to their own stories and impressions. discrimination with native qatari including work and salary amounts contribute to making indonesian nurses satisfied or not at work, which also relates to feeling comfortable and at home abroad. https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.1.2019.1-6&domain=pdf&date_stamp=2019-06-23 south east asia nursing research, vol 1 no 1, june 2019/ page 1-6 2 saiful uddin / factors related the job satisfaction among migrant nurses in qatar job satisfaction is an expression of one's feelings and expressions when he can or cannot fulfill the expectations of the work process and its performance. job satisfaction is not a single dimension concept, but rather a multifaceted concept which means that job satisfaction is influenced by a number of factors. in addition to salary problems, many other factors influence nurse job satisfaction. the factors that can affect an employee's job satisfaction are the contents of work, appearance, actual work assignments and as control of work, supervision, organization and management, opportunities for advancement, salaries and other financial benefits such as incentives, work colleagues, and work conditions.1 whereas according to demographic characteristics also affect job satisfaction.2 other research declares that there is no relationship between nurse job satisfaction and age, and there is no relationship between job satisfaction and the length of employment of nurses.3 meanwhile, setiawan's (2007) study states that there is a relationship between age, and marital status with nurse job satisfaction and the absence of a relationship between sex, work period and level of education with nurse job satisfaction.4 an interview with several nurses working in qatar showed data that most felt comfortable working in qatar. other data shows that for 4 years from 2007 to 2011, out of 53 nurses working in one health care institution, only 1 nurse (1.8%) resigned and returned to indonesia, with a 0% turnover rate. in fact, the number is increasing with the arrival of new nurses and those who are still in the process of recruitment. this phenomenon is very different from the experience of working for 6 years in the uae (united arab emirates), in the first 2 years almost half of the women who resigned. hardy (2010) also stated that the resignation of indonesian nurses significantly occurred in kuwait, saudi and uae. in accordance with the other study that resignation can be related to job satisfaction.1,5 nurse job satisfaction needs to get serious attention from the management and nurses themselves because nurses are the spearhead of implementing services and personnel who interact directly with patients and families of patients. the image of a health institution is influenced by the services provided by nurses. besides for the institution, job satisfaction is also beneficial for the nurse's own health. the level of job satisfaction and health can be mutually reinforcing so that an increase from one can increase the other and vice versa a decline has a negative effect on the other.6 job satisfaction problems can have a big impact on productivity, performance, service, absenteeism, turnover and so on. achievement of nurse job satisfaction can provide many benefits for the nurse herself and the institution where she works, and of course the client or community at large recipient of nursing services. for indonesian migrant nurses in qatar, job satisfaction gives a deeper meaning. far from home and far from relatives, job satisfaction is expected to provide more benefits, such as increasing support for nurses to survive overseas. conversely, a low level of job satisfaction will affect behavior and personal life that is less comfortable, which in turn can encourage high levels of resignation and turnover. based on the above things, it is interesting to study and examine what factors are related to the job satisfaction of indonesian migrant nurses in qatar. methods the type of research used is descriptive analytic research to make a picture of the analysis of the relationship between two variables in a situation or group of subjects. the research design used is a crosssouth east asia nursing research, vol 1 no 1, june 2019/ page 1-6 3 saiful uddin / factors related the job satisfaction among migrant nurses in qatar sectional approach considering the assessment of a nurse's perception of feelings towards his work can only be done for a moment because a person's perception is likely to change at any time. the sample in this study was taken by purposive sampling technique. the total sample of all indonesian migrant nurses in qatar amounted to 39 people who were in accordance with the criteria of inclusion and research exclusion. this research was conducted in qatar in the span of time from 15 february 2012 to 29 february 2012. tools for collecting data using questionnaires that have been tested for validity and reliability. the questionnaire consists of 2 sets, namely questionnaires to assess the characteristics of respondents and questionnaires to determine the level of job satisfaction of respondents. data were analyzed univariately to see the frequency and distribution of respondents based on demographic characteristics and job characteristics and to know the level of job satisfaction of respondents. then bivariate analysis to see the relationship between the independent variable and the dependent variable using the chi-square correlation and rank spearman test. results the results of the study on 39 respondents showed that the age of the respondents was at an average age of 37.7 years with the age of the youngest 31 years and the oldest 46 years. judging from other demographic characteristics, it can be seen that indonesian nurses in qatar are mostly male sex 87.2%. the working period is between 1 and 10 years. the majority of nurses live with families in qatar and work in shifts. the education level of the majority of indonesian migrant nurses in qatar is diploma graduates which are equal to 56.4%, then senior high school (spk) as many as 12 people (30.8%) and those who hold nursing degrees both s1 and s2 are 5 (12%). in general indonesian nurses working in qatar were satisfied with their work (51.3%). there is no relationship between age and job satisfaction of indonesian migrant nurses in qatar. there is a relationship between the tenure and the job satisfaction of indonesian migrant nurses in qatar. there is no relationship between the level of education and the job satisfaction of indonesian migrant nurses in qatar. there is no relationship between marital status and job satisfaction of indonesian migrant nurses in qatar. job satisfaction factors for indonesian migrant nurses in qatar, which are statistically proven to be related to overall job satisfaction are work periods and work time arrangements. table 1 distribution of indonesian migrant nurses in qatar based on the level of job satisfaction level of job satisfaction f % satisfied 20 51,3 not satisfied 19 48,7 amount 39 100 table 2 distribution of indonesian migrant nurses in qatar based on age, employment rates and job satisfaction bivariate correlation variable coefficient correlation p-value spearman's rho age vs job satisfaction .359* 0.025 working period vs. job satisfaction .359* 0.025 table 3 distribution of indonesian migrant nurses in qatar based on education, family status level, and job satisfaction level of education job satisfaction p satisfied not satisfied f % f % senior high school 7 58,3 5 41,7 0,738 diploma 10 45,5 12 54,5 bachelor and master 3 60 2 40 marry (live with family) 14 48,3 15 51,7 0,522 single (live alone) 6 60 4 40 south east asia nursing research, vol 1 no 1, june 2019/ page 1-6 4 saiful uddin / factors related the job satisfaction among migrant nurses in qatar table 4 distribution of indonesian migrant nurses in qatar based on work time arrangements and job satisfaction working time settings job satisfaction or (95% ci) p satisfied not satisfied f % f % shift 11 39,3 17 60,7 0,144 0,017 not shift 9 81,8 2 18,2 discussion based on the characteristics of the demographics of indonesian nurses in qatar, most of them are male, mature, live with family and are educated by the nursing academy. whereas based on the characteristics of its work, most of the work period in qatar is relatively long, namely 5 years and above and working shifts. the age of indonesian migrant nurses in qatar is in the range of 31 to 46 years, showing a relatively long maturity and possible work experience. the age group that is mostly over 36 years is 25 people. satisfaction in the aspect of work for indonesian migrant nurses in qatar seen from the age factor can be used as evidence because age over 35 years can lead to feelings of satisfaction with work.6,7 the results of this study also show that the working period of indonesian migrant nurses working in qatar is relatively long, namely 5 years and over as many as 27 people. because the majority of the working period is longer than the new, the level of job satisfaction of indonesian migrant nurses working in qatar is high, this is consistent with the long working period will stimulate increased job satisfaction.8 the education level of indonesian migrant nurses who work in qatar is mostly nursing graduates with 56.4%. although in this study the education level of indonesian migrant nurses working in qatar was not statistically related to job satisfaction, nurses were required to improve their abilities and education to face the era of globalization. most indonesian migrant nurses working in qatar live in qatar together with their families (74.4%). because indeed most nurses get family status facilities from companies or hospitals where they take shelter so they can invite families to stay in qatar. the tendency to feel satisfied with the work of nurses who live with family is higher than the nurse who lives single. this is based on the fact that nurses who live with spouses and children of wives will feel more calm and comfortable. indonesian migrant nurses who work in qatar, mostly shift work. nurses involved in the rotation shift system will change their working time which is usually morning, evening and evening, according to the specified rotation shift system. besides having a positive aspect of maximizing existing resources, work shifts will have risks and affect workers socially, physically and psychologically such as dissatisfaction and irritation. in general, job satisfaction assessments by nurses of indonesian migrant nurses in qatar are balanced between those who value being satisfied with those who are dissatisfied. the number of satisfied nurses as many as 21 people against the dissatisfied there are 18 people. job satisfaction is a condition felt by someone who is the result of comparing the appearance or outcome (product) that is felt in relation to one's expectations.9 judging from the results of the research answers the questions with the highest percentage of satisfaction is in the questions about work facilities and infrastructure, environmental hygiene, information and support/assistance of superiors to nurses in completing nursing tasks. while the aspects that cause the highest dissatisfaction are opportunities south east asia nursing research, vol 1 no 1, june 2019/ page 1-6 5 saiful uddin / factors related the job satisfaction among migrant nurses in qatar for promotion and self-development, as much as 30.8%. based on the results of the study it was found that there was no relationship between age and job satisfaction of indonesian migrant nurses working in qatar. analysis of researchers, this result is supported by the fact that the age of most indonesian migrant nurses in qatar is included in the adult group and has worked in other places so that they have a comparison of the main factors of work. the results of this study contradict the theory which states that age has an effect on job satisfaction and the older the employee, the higher the level of satisfaction.5,6 this is supported by a number of reasons including the further age of a person, the more difficult it is to start a new career in a new place, an established lifestyle, and an inner bond and friendship between those who are friends in the organization, on the contrary easy to guess for employees who are more young, the desire to move is greater.9 the results of rank spearman analysis showed that p = 0.025 (p <0.05) or there was a relationship between years of service and job satisfaction of indonesian migrant nurses in qatar. nurses whose work period is more than 5 years give a satisfied rating of 18 people (66.7%), while nurses who have a working period of 4 years and under there are 3 people or (25.0%) who claim to be satisfied with their work. this is in line with the statement that stated that the working period was consistently associated negatively with the entry and exit of employees and was stated as one of the best single forecasters for job satisfaction when viewed from the entry and exit of employees or nurses.8 the test results using chi-square showed that p = 0.738 (p> 0.05) or there was no relationship between the level of education and the job satisfaction of indonesian migrant nurse nurses in qatar. this is not in accordance with the statement of another study who concluded that employees with advanced education felt very satisfied with the work they did.7 the absence of a statistical relationship between the level of education and the job satisfaction of indonesian nurses in qatar can be caused because there is no difference in the types of employment contracts, staffing, salaries/incentives and benefits between employees who have low or high levels of education family status or residence whether or not someone is with the family will affect a person's behavior in organizational life, including expectations and demands on work/company organization. the test results using chi-square show that there is no relationship between family status and indonesian migrant nurse's job satisfaction in qatar because the p-value obtained is 0.522 (p> 0.05). progress in the field of communication that makes it easy for people to connect long distances both through sound and image/video may be one of the factors that cause the absence of a relationship between nurses who live with family and those who live alone in qatar. another factor is for single nurses (alone) can take twice a year leave plus tickets. the results showed that there was a relationship between setting work time and job satisfaction for indonesian migrant nurses in qatar. from the result, there is a significant (very large) difference between non-shift nurses and shift workers in answering job satisfaction in qatar. most non-shift nurses or 81.8% said they were satisfied with their work, while shift work nurses were only 42.9% who expressed satisfaction with their work. the existence of a statistical relationship between the regulation of work time and job satisfaction, in line with the statement that shift work is related to social, physical and psychological problems including job satisfaction and stress.1,6,7 even so, the south east asia nursing research, vol 1 no 1, june 2019/ page 1-6 6 saiful uddin / factors related the job satisfaction among migrant nurses in qatar rotation shift work system has a positive aspect, namely empowering existing resources optimally. looking at the effects of shift work which affects many aspects including job satisfaction, it is appropriate for management to provide special incentives for nurses who carry out shift work. conclusion the results of the study were conducted on indonesian migrant nurses in qatar with 39 respondents working in outpatient clinics. variables studied included job satisfaction, age, years of service, education level, family status and division of work time. the results of the test of job satisfaction analysis for indonesian migrant nurses in qatar showed 51.3%. while the correlation between age, education level and family status with job satisfaction are not related. conversely, there is a meaningful relationship between years of work and work time arrangements with job satisfaction. this research is useful as information and evaluation of implementation and obstacles in achieving nurse job satisfaction abroad, especially in qatar, so the authors expect nurses in qatar and those who will go abroad to prepare themselves both physically and mentally, with additional training and increase their education level. recognizing local customs and culture as well as work-related factors will also help nurses to better adapt to the workplace and work well so that they can achieve job satisfaction as expected. conflicts of interest the author declares that none of him had any conflict of interests. references 1. rivai v. manajemen sumber daya manusia untuk perusahaan : dari teori ke praktik [internet]. banjarmasin: rajawali pers; 2009 [cited 2010 jun 21]. 1087 p. available from: https://books.google.co.id/books?id=rb7qzw eacaaj&dq=manajemen+sumber+daya+manu sia+untuk+perusahaan+dari+teori+ke+praktik &hl=id&sa=x&ved=0ahukewjc4pay0_niahxex fkkhbpybmqq6aeikdaa 2. cummings gg, olson k, hayduk l, bakker d, fitch m, green e, et al. the relationship between nursing leadership and nurses’ job satisfaction in canadian oncology work environments. j nurs manag [internet]. 2008 jul 1 [cited 2019 jun 21];16(5):508–18. available from: http://doi.wiley.com/10.1111/j.13652834.2008.00897.x 3. gustian y. hubungan stres kerja dengan kinerja perawat pelaksana dalam melaksanakan asuhan keperawatandi ruang rawat inap rsud pasaman barat tahun 2010. 2010 oct 21 [cited 2017 jun 21]; available from: http://repo.unand.ac.id/398/ 4. teguh setiawan 6450402559. hubungan antara karakteristik individudengan kepuasan kerja perawat pelaksana di rsbanyumanik. 2007 mar 30 [cited 2019 jun 21]; available from: https://lib.unnes.ac.id/1118/ 5. riani al. manajemen sumber daya manusia masa kini. edisi pert. yogyakarta: graha ilmu; 2013. 6. munandar as. psikologi industri dan organisasi. jakarta: ui-press; 2008. 7. waluyo m. psikologi teknik industri. in: edisi 1. yogyakarta: graha ilmu; 2009. 8. robbins sp, judge t. organizational behavior. edition 16. boston: pearson; 2015. xxxiii, 709 pages. 9. siagian sp. kiat meningkatkan produktivitas kerja. jakarta: rineka cipta; 2009. change of consciousness through oxygen supply in head injury corresponding author: khoiriyah khoiriyah@unimus.ac.id south east asia nursing research, vol 1 no 2, september 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.2.2019.76-82 original research change of consciousness through oxygen supply in head injury khoiriyah khoiriyah1, hendi ardiananto2 1 university of muhamadiyah semarang 2 dr. kariadi hospital semarang article info abstract article history: accepted september 30th, 2019 key words: consciousness level; head injury; simple mask; head elevation head injury is one of the main causes of death and disability in the productive age group and most occur due to traffic accidents. patients with a head injury can experience permanent damage to brain tissue or secondary injuries such as brain ischemia due to hypoxia, hypercapnia, hyperglycemia or electrolyte imbalance, even respiratory failure and heart failure. the head injury patients are initially examined using a standardized scoring system to assess the consciousness level of patients with impaired consciousness, namely the glasgow coma scale (gcs). one of the possible treatments for decreasing intracranial pressure (icp) and cerebral perfusion managements to position the patients with a head elevation of 15˚-30˚. this treatment aimed to increase venous drainage from the head and to reduce systemic blood pressure that may be compromised by cerebral perfusion pressure. this study aimed to determine the effect of giving oxygen through a simple mask and the 30˚ head elevation position to the changes of the consciousness level for the patients witha head injury in the emergency department at dr. kariadi hospital, semarang. this study was quasi-experimental research without control with pre-test and post-test one-group design with used a sample of 23 respondents. the instrument used an observation sheet containing the gcs examination results and analyzed using the wilcoxon test. based on the results of the bivariate analysis using the wilcoxon correlation test, a p-value of 0,000 <0,05 was obtained so it could be concluded that the h0 is accepted. therefore, giving oxygen through simple masks and patient positioning with 30˚ head elevation affect the consciousness level of head injury patients at dr. kariadi hospital, semarang. introduction head injury is a series of pathophysiologic events that occur after head trauma which involve severe head component, ranging from the scalp, bones, and brain tissue or a combination. head injury is one of the leading causes of death and disability in the productive age group and most of it occurs due to traffic accidents.1poorly treated head injury patients tend to have a secondary brain injury in addition to primary brain injury which will result in brain ischemia.2 patients with a head injury can experience permanent damage to brain tissue or secondary injuries such as brain ischemia due to hypoxia, hypercapnia, hyperglycemia https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.2.2019.76-82&domain=pdf&date_stamp=2019-09-30 south east asia nursing research, vol 1 no 2, september 2019/ page 76-82 77 khoiriyah / change of consciousness through oxygen supply in head injury or electrolyte imbalance, or even respiratory failure and heart failure.3 as a result of trauma, the patient experiences physical and psychological changes. severe head injury often resulting in secondary brain injury, cerebral edema, airway obstruction, increased intracranial pressure, vasopasm, hydrocephalus, metabolic disorders, infections, and seizures.4 patients who experience decreased consciousness generally experience airway disorders, respiratory problems and circulatory disorders.5 the brain is a vital organ for all activities and functions of the body, because there are various control centers such as physical, intellectual, emotional, social, and skill control in it. eventhough the brain is in a closed space and protected by strong bones, it can also experience damage. one of the causes is a head injury that can cause damage to brain structure that leads to disruption of brain function. normally, the brain requires 30-40% oxygen of the total body's oxygen needs. since the brain does not have oxygen reserves, the incoming oxygen supply will be used up. to maintain adequate brain oxygenation, a balance is needed between oxygen supply and brain oxygen demand. brain oxygen balance is affected by cerebral blood flow, which ranges from 15-20% of cardiac output. good management of head injury must begin from the scene of injury, during patient transportation, at the emergency department until definitive therapy is performed. correct and proper management will affect the patient outcomes. the initial examination performed on patients with head injury using the glasgow coma scale (gcs) which is a standardized assessment system used to assess the level of awareness in patients with impaired consciousness. it includes the numerical calculation of cognitive, behavioral, and neurological functions. the results can be used to measure the level of awareness of head trauma patients, which is one of the components used as a reference for treatment and the basis for general clinical decision making for patients.6 based on the results of the riset kesehatan dasar (riskesdas) in 2013, from 1,027,758 people of all ages, there were 84,774 injured respondents and 942,984 people not injured. the national injury prevalence is 8.2% and the prevalence of head injury in central java is 8.3%. the highest injury prevalence based on the characteristics of respondents is in the age group of 15-24 years (11.7%), and in men (10.1%).8 based on the data from rsup dr. kariadi semarang in 2017, there were 189 patients who suffered a head injury. the data from the general hospital dr. kariadi semarang showed that there were 168 patients with a head injury from 612 case of traffic accidents recorded from january to august 2018. every time an accident occurs and the victim experiences a collision in the head, especially if it causes the patient to become unconscious, must be considered a serious and dangerous accident with the suspicion of brain concussion. likewise, every victim who is fainted and thought to have suffered a head injury must be treated carefully.3 in the study conducted by febriyanti, et al (2017), which used paired t test sao2 before and after the first 10 minutes, pvalue = 0.000 <α 0.05 were obtained in the first 10 minutes and the second 10 minutes tests. the tests between the second 10 minutes and the third 10 results in p-values = 0.005 <α 0.05 and repeated anova tests. these results showed that there is an influence of prong nasal oxygenation therapy on the changes in oxygen saturation of head injury patients in the emergency department of prof. rsup dr. r. d. kandou manado. a preliminary study was carried out on 28 september2018 at dr. kariadi semarang within the period of january august 2018.there were 150 head injury patients and head injury were the most common south east asia nursing research, vol 1 no 2, september 2019/ page 76-82 78 khoiriyah / change of consciousness through oxygen supply in head injury diagnosed case in the surgery. head injury will provide a more complex disorder when compared to the trauma on other body organs. this is due to the anatomic and physiological structure of the skull contents, which are brain fluid, brain membranes, nerve tissue, blood vessels and bones, having the consistency of liquid, soft solid and dense solid. patients with head injury require early diagnosis so that therapeutic measures can be taken immediately to produce a precise, accurate and systematic prognosis. because of the high number of head injury incidents, the writeris interested in researching about changes in signs of increased intracranial with the title "the effect of oxygen administration through simple masks and 30º head position to the changes in awareness levels of the patients with mild and moderate head injury. methods this study uses the quantitative research methods with quasi-experiment research. the research design used was pre-test and post-test one group design. the subjects were head injury patients in the er of rsup dr. kariadi semarang with a total sample of 23 respondents using purposive sampling. data collection was done by observation and using the consciousness level. it is used to assess the patient's level of consciousness and neurological status. data analysis was performed using univariate analysis, normality test and bivariate analysis (nonparametric test i.e.willcoxon test). the inclusion criteria in this sample were all head injury patients recorded in the medical record, head injury patients who had been examined for consciousness level, patients with injury classification. severe head injury, moderate head injury and mild head injury. the research process includes selecting head injury patients used glasgow coma scale (gcs) score results by looking at inclusion and exclusion criteria, taking gcs assessment data for subjects that have the inclusion criteria, providing oxygen through a simple mask for 6 hours and head elevation position 30˚ for 2 hours, and reevaluating the subjects gcs assessment results after the treatment. results the result of this study shows that the majority of e values (eye) with a score of 3 are 17 people (73.9%), v values (verbal) with a score of 5 are 8 people (34.8%), m scores (motoric) with a score of 5 are 11 people (47.8%). based on table 1, most of the e (eye) scores with a score of 4 were 14 people (60.9%), v (verbal) with a score of 5 were 13 people (56.5%), m (motorik) with a score of 6 a total of 16 people (69.6%). tabel 1 gcs assesment distribution before and after intrevention indicator score f % before intervention eye 1 2 3 4 1 4 17 1 4,3 17,4 73,9 4,3 verbal 1 2 3 4 5 1 6 1 7 8 4,3 26,1 4,3 30,4 34,8 motorik 2 4 5 6 1 1 11 10 4,3 4,3 47,8 43,5 after intervention eye 2 3 4 1 8 14 4,3 34,8 60,9 verbal 2 3 4 5 1 4 5 13 4,3 17,4 21,7 56,5 motorik 3 5 6 1 6 16 4,3 26,1 69,6 based on the analysis using the wilcoxon correlation test (table 2), a p-value of 0,000 <0.05 was obtained so that it can be concluded that the h0 was accepted. this means that there is a significant difference in the level of awareness between before and after administering oxygen through a simple mask and 30˚ head elevation south east asia nursing research, vol 1 no 2, september 2019/ page 76-82 79 khoiriyah / change of consciousness through oxygen supply in head injury position in the head injury patient in the emergency room (er) of rsup dr. kariadi semarang. table 2 theawareness level before and after oxygen administration through simple mask and 30o head elevation position of head injury patient in the er of rsup dr. kariadi semarang (n= 23) indicators pre intervention post intervention p gcs levels, mean(sd) 11.70 (2.54) 13.57 (1.92) 0,000* min-max 6-14 9-15 *wilcoxon test discussion based on the results of the study, we found the average size of the gcs score before being given oxygen through a simple mask and 30˚ head elevation position was 11.70, while the average size of the gcs score after being given oxygen through a simple mask and 30˚ head elevation position was 13,57. from the test results using the wilcoxon test, the p value of 0,000 <0.05 was obtained so that it can be concluded that h0 is accepted. this means that there is an influence of oxygen delivery through simple masks and 30˚ head elevation position to changes in the level of consciousness in head injury patients in the er of dr kariadi hospital semarang. head injury is damage to the head that is neither congenital nor degenerative, but is caused by an attack or physical impact from the out side which can reduce or change in consciousness and causing damage to cognitive abilities and physical function. a head injury can occur as a result of collisions on the head in 3 types of conditions,which are a stationary head being hit by a moving object, a moving head hit by a stationary object, and a head that cannot move because it rests on another object hit by a moving object. based on the severity of head injury, it can be classified into mild head injury(gcs 13-15, amnesia less than 30 minutes), moderate head injury (gcs 9-12, loss of consciousness 30 minutes 24 hours), and severe head injury (gcs 3-8, a decrease in consciousness of more than 24 hours to days).10 an increase in icp is an emergency that must be dealt with immediately. when the pressure rises, the brain substance is suppressed. secondary phenomena are caused by circulatory disorders and edema can cause death. intracranial enhancement occurs when the value of intracranial pressure is more than 15 mmhg which is characterized by clinical syndromes indicated by an increase in blood pressure, decreased pulse, changes in respiration and changes in pupils. the impact of increased intracranial pressure on cerebral circulation will cause an increase in intracranial pressure and decreases cerebral blood flow resulting in ischemia. 35 minutes of ischemia will cause irreversible brain damage so that it stimulates the vasomotor center and systemic pressure increases to maintain the blood flow such that the pulse slows, breathing becomes irregular and blood pressureincreases.12 head up sleeping position allows the chest cavity to develop widely and increase the lung complaints. this condition will cause oxygen intake (oxygenation) to improve and the respiration process returns to normal. positioning the patient with a slight head elevationof 30˚ to increase venous drainage from the head and head elevation can cause a decrease in systemic blood pressure which may be compromised by cerebral perfusion pressure. head up sleeping position arrangement allows the chest cavity to expand widely and increase lung complaints. this condition will cause oxygen intake (oxygenation) to improve so that the respiration process returns to normal.39 this is related to low gcs which is a predictor of death in head injury patients. measuring gcs is an important intervention that must bed one by nurses in the er room when providing nursing care to patients south east asia nursing research, vol 1 no 2, september 2019/ page 76-82 80 khoiriyah / change of consciousness through oxygen supply in head injury with a head injury. in severe head injury, gcs values tend to be quickly decreased due to the compensation mechanism of the human body when the reisan increase in intra-cranial pressure. head injury patients require adequate oxygen supply to meet the brain's metabolic needs. oxygen saturation observation is carried out to prevent and recognize the risk of tissue hypoxia. tissue hypoxia will cause a risk of secondary trauma to brain tissue which will result in the death of the patient. peripheral oxygen saturation below 90% indicates hypoxemia condition.14 low oxygen saturation significantly increases the risk of death, patients with the saturation <80% have a threefold increased risk of death. hypoxia is a predictor of poor outcomes in patients with a moderate and severe head injury as a result of the additional risk of secondary brain injury experienced by the patient.as much as 2755% recorded hypoxia can originate from the scene, in the ambulance / when transportation, or upon arrival at the emergency department. the level of awareness of head injury patients assessed by the gcs score is a measure of the clinical condition of the head injury patients examined when the patient arrives at er. the level of awareness evaluated with gcs score has a strong influence on the life chances and recovery of the head injury patients. the gcs score is one of the mandatory examinations in patients with head injury at the time of hospital admission. a low initial gcs score indicates a severe disturbance in the brain function associated with the risk of the death of the patient. brain disorders that continue with brain tissue death are important, because the nature of brain tissue tends to be irreversible in the event of death.40 disorders and damages that occur in the brain will disrupt the work of the body vital systems, such as breathing and cardiovascular, systems, and result in the threat of death. attention to the patient's family must also be given to provide emotional and spiritual support. the treatment for the head injury patients with low gcs will get a priority, this is indicated by the use of the level of awareness as a component in triage that serves to prioritize patient management. patients with low awareness will fall into the first priority category. priority is done to prevent worse complications and even death in patients.39 the main focus of head injury patient’s management is to prevent secondary brain injury. providing oxygenation and maintaining good and adequate blood pressure to fulfill brain perfusion is the most important factor, especially to prevent and limit the occurrence of secondary brain injury which will ultimately improve the patient's end result. this is in accordance with patria (2012) that head injury patients should be given oxygen therapy using masks or reservoir masks with oxygen concentrations of 40-80%.16 hypoxia is a condition inadequate tissue oxygenation at the tissue level which occurs due to deficiency of oxygen delivery or the use of dicellular oxygen. oxygenation is the most basic human needs. the existence of oxygen is a component of gas and a vital element in the metabolic process and to maintain the survival of all body cells. maslow's hierarchy theory is a theory that nurses can use to understand the relationship between basic human needs when providing care. physiological needs are important for survival, one of which is oxygenation needs. christopher etal. (2012) concluded that the oxygenation of brain tissue is closely related to several parameters of patient outcome and prognosis. the application of intervention therapy to maintain oxygenation of brain tissue above a certain threshold can improve mortality and neurological outcomes in the head injury patients. head elevation based on physiological response is a change in position to increase blood flow to the brain and prevent an increase of icp. south east asia nursing research, vol 1 no 2, september 2019/ page 76-82 81 khoiriyah / change of consciousness through oxygen supply in head injury some clinic nurses perform bedrest with a head elevation not more than 30 °, rationally preventing the increased risk of decreasing cerebral perfusion pressure and further worsening cerebral ischemia if vasospasm is present.43 this is in line with the research conducted by lesko (2012) which states that the total gcs score is a good predictor of death for head injury patients. gcs is related to a disturbance in brain structure or tissue. according to maas, engel, and lingsma (2011), there are several studies that showed an association between lower scores on gcs and worse outcomes. in patients with severe head injury, the motor component of gcs has the greatest predictive value because eye and verbal responses are generally absent in patients. the gcs score in this study uses an interval scale, with a middle value of 10, a minimum value of 6 and a maximum value of 15. the results of this study are consistent with research conducted by emery, durward and fieldman (2003) who found that the head position up to 15˚ significantly reduced the intracranial increase which is due to the effects of jugular venous system pressure and there was a decrease in heart rate from 0.76% to 5.6%. another similar research was conducted by setterval, souza and silva (2011) where gcs scores were assessed three times during 72 hours after injury. the findings of this study showed that gcs has a relationship with the outcome of head injury patients. research conducted by duward et al. and lee et al. also states that a head up position of 15 to 30 head was progressively reducing arterial pressure and decreasing cvp (p <0.05) within the ranges of 0.12 to 1.8 cm. conclusion the result of this research describe that there is an influence of oxygen supply through simple masks and the 30⁰ head elevation position to the changes in the awareness level of head injury patients at dr kariadi hospital semarang. acknowledgements we wish to express our appreciation to all patients who participated in this study and to the dr. kariadi general hospital semarang for valuable assistance during data collection. conflicts of interest neither of the authors have any conflicts of interests that would bias the findings presented here. references 1. price, s. a, & wilson, l, m. 2012. patofisiologi : konsep klinis proses – proses penyakit, edisi 6, volume 2. jakarta : egc. 2. soemitro d.w a , (2011). sipnopsis ilmu bedah saraf, jakarta : cv sagung seto 3. arifin, m. z. 2013. cedera kepala : teori dan penanganan. jakarta : sagung seto. 4. haddad, s. h., &arabi, y. m. 2012. critical care management of severe traumatic brain injury in adults. scand j trauma resuc emergency med 20 (12) : 1 – 15. 5. muttaqin, a. 2012. pengantar asuhan keperawatan klien dengan gangguan sistem persarafan. jakarta : egc. 6. ricard, et.al.(2010). journalassessingtheneurological status ofpatientswithheadinjury. 7. simon m, andrew b, mark cb. (2006). intensive care, 2nd ed, elsievier churcill livingstone. 8. badan penelitian dan pengembangan kesehatan kementrian kesehatan ri. (2013). riset kesehatan dasar 2013. http://www.depkes.go.id/resources /download/general/hasil%20riske sdas%202013.pdf (diakses 30 september 2018). 9. potter dan perry.(2005). buku ajar fundamental keperawatan.penerbitbukukedokteran.egc. jakarta. 10. krisanty. dkk. 2009. asuhan keperawatan gawat darurat, jakarta : trans info medika. south east asia nursing research, vol 1 no 2, september 2019/ page 76-82 82 khoiriyah / change of consciousness through oxygen supply in head injury 11. smeltzer, s. c. and bare, b. g, 2006. buku ajar keperawatan medikal bedah brunner&suddarth, edisi 8 volume 2. alih bahasa h. y. kuncara, monica ester, yasmin asih, jakarta : egc. 12. mansjoer, arif. 2008. kapita selekta kedokteran. jakarta : egc buku kedokteran. 13. jackson, d. (2014). keperawatan medikal bedah edisi 1. yogyakarta, rapha pubishing. 14. reeves, charlene j. 2006. buku satu keperawatan medikal bedah. jakarta : salemba medika. 15. carperito, l j. 2006. diagnosa keperawatan aplikasi pada praktek klinik edisi 6. jakarta egc. 16. patricia a. potter&pery, anne g. (2011). fundamental ofnursing : fundamental keperawatan buku 3 edisi 7. jakarta : egc. factors that related to cancer related fatigue corresponding author: santoso tri nugroho santrinug01@gmail.com south east asia nursing research, vol 1 no 1, june 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.1.2019.20-26 literature review factors that related to cancer related fatigue santoso tri nugroho1 1 pekalongan university article info abstract article history: accepted may 7th, 2019 key words: fatigue; cancer; nursing about 40% to 100% of cancer patients complaint of fatigue. cancer related fatigue is the most disturbing symptom compared to another symptom, like nausea and vomiting. persistent cancer-related fatigue can impact on patient quality of life because the patient becoming too tired to involve in the activity. need study to recognize factors that related to fatigue so that as a nurse we can choose accurate nursing intervention to overcome cancer-related fatigue. objective: to identify factors related to cancerrelated fatigue. methods: literature were searched via google scholar and google search with keyword: fatigue, cancer, and nursing. literature were in full text and published by the year 1999-2016. literature that was in inclusion criteria than be analyzed. result: from 6 kinds of literature that were analyzed we found out factors that are related to cancer-related fatigue. that is characteristic (age, sex), sociodemography (economic status), stadium cancer, exercise, pain, depression, and sleep quality. but the factor that most related to cancer-related fatigue remains unclear. conclusion: age, sex, economic status, stadium, exercise, pain, depression and sleep quality are factors that can be used as predictor fatigue. introduction fatigue is a feeling of fatigue that includes physical, mental and emotional, described as feeling helpless or lacking in energy to do something we want or need we.1 fatigue in cancer-related fatigue is a very common symptom and sign occurs in cancer patients and is different from fatigue experienced by healthy individuals in daily life.1,2 in normal individuals, fatigue will disappear with adequate rest and sleep, while fatigue in cancer patients is not.2 as many as 40% to 100% of cancer sufferers experience fatigue. fatigue in cancer patients is a symptom and a sign that is most disturbing compared to other symptoms and signs, such as pain, nausea and vomiting.3 continuous fatigue conditions can affect quality client's life because the client becomes too tired to get involved in daily activities.4 given these conditions, there is a need for appropriate nursing intervention to overcome fatigue in cancer clients. nurses as scientists, in providing nursing care must be based on an evidence base. the nursing intervention carried out must focus on the factors that are the cause of fatigue itself, so that the nursing https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.1.2019.20-26&domain=pdf&date_stamp=2019-06-23 south east asia nursing research, vol 1 no 1, june 2019/ page 20-26 21 santoso tri nugroho / factors that related to cancer related fatigue interventions provided are truly effective in overcoming fatigue. based on this background, the authors feel the need for a study to find out the factors that are related to fatigue to determine appropriate nursing interventions to overcome fatigue in cancer clients. the objective of this review is writing this literature study aims to identify what factors are associated with fatigue in cancer clients. methods design of article tracking in this literature study through google scholar and google search, with keywords fatigue, cancer, nursing. the literature used was dated 1999–2016, full-text form and design used observational study, prospective controlled study, 1-year longitudinal study, longitudinal study with repeated measures and systematic review. articles that have met the criteria then analyzed narratively. results 1. the study was conducted on 374 respondents namely gastric cancer survivor. kuisener was in the form of a brief fatigue inventory, a beck depression inventory, a european organization for research, a qlq-c30 treatment of cancer and a qlq-sto22 gastric module that was sent by mail. it also contains questionnaires about sociodemography and characteristics of symptoms and signs. then the data is analyzed by regression logistic model to find out the relationship between independent and dependent variables. the results showed that nearly half of gastric cancer survivors who experienced fatigue were associated with female sex, poor economic status, living in rural areas, active smokers, early-stage tumors, being depressed, and poorly performing. depression and strong poor appearance are associated with fatigue. while the tumor stage (initial) and type of surgery contribute to worsening fatigue conditions. 2. meta-analysis with search methods through electronic databases including pubmed, cinahl, psychinfo, proquest, and sports discus on journals and articles that are in accordance with the research subjects. a total of 16 results were obtained which represented 1426 respondents (exercise, 759; control, 667). furthermore, a meta-analysis was prepared using the fixed-effects model. the results of the analysis found that aerobic exercise and musculoskeletal strength exercises were known to provide significant development to overcome fatigue in cancer patients. 3. observational analytic research design with a cross-sectional approach. the survey was conducted, 1933 respondents filled out questionnaires sent by letter consisting of questionnaires about brief fatigue inventory, beck depression inventory, european organization for research and treatment of cancer qlq-c30, and qlq-br23. also includes data on sociodemography, clinics, and characteristics of symptoms. data analysis using multivariate logistic regression. the results showed that 66.1% of mammary ca survivors had moderate to severe fatigue and 24.9% had moderate to severe depression. both fatigue and depression are both more influenced by sociodemographic factors, comorbidity, and characteristics of symptoms and signs, than cancer and cancer treatment itself. 4. study design prospective controlled cross-sectional study. the study was conducted by means of advanced cancer patients treated in 3 palliative care units included as respondents. the exclusion criteria were: patients underwent radiotherapy or chemotherapy in the last 4 weeks, south east asia nursing research, vol 1 no 1, june 2019/ page 20-26 22 santoso tri nugroho / factors that related to cancer related fatigue experienced clinical anxiety, lack of english language skills, helplessness, non-dominant hand pain, and prognosis of patients who died less than 2 weeks. the working procedure is that the researcher visits the 3 treatment units each week and approaches the identified patients can be used as research respondents. recruitment was stopped when researchers were on vacation, or sick. controls were subjects of the same age and sex as respondents but did not suffer from cancer, with the inclusion criteria and exclusions being the same as patients. after informed consent, patients and controls were given the same assessment, except for blood tests not performed on controls. after 2 weeks, the assessment was repeated both for the patient and the controls. the research tool consisted of fatigue severity scale (fss) to measure fatigue levels, the european organization for research and treatment of cancer quality of life questionnaire (eortc qlq core 30) to measure quality of life, hospital anxiety and depression scale (hads) to measure anxiety levels and depression, three visual analog scales (vas) to measure fatigue and weakness and ability to concentrate, the body mass index (bmi) and the mid arm muscle circumference (mamc) to measure nutritional status. patients (not done in the control), blood cell count, routine biochemistry, and prostate cancer patients were tested for testosterone, luteinizing hormone (lh) and hormone sex binding globulin (shbg). spearman rank correlation coefficient was used to determine the relationship of each variable. mann-whitney u-test was used to compare each group and multiple regression analysis was used to identify factors that independently predicted fatigue. the results showed that fatigue was not related to age, sex, diagnosis, the metastatic process, anemia, nutritional status, muscle function, or emotional condition. fatigue is significantly associated with pain and dyspnea in patients and is associated with anxiety and depression in controls. 5. the study design was a 1-year longitudinal study, with the sampling technique of 107 women newly diagnosed with stage i-iii mammary cesarean and scheduled to get at least 4 cycles of chemotherapy then selected according to the specified inclusion criteria. from the selection process, 68 people were included in the study. control was women who did not have cancer included in the study as a comparison. furthermore, each respondent (cancer sufferer) was asked to choose one of their friends to be controlled, if the respondent did not have friends, volunteers would be chosen to become control. each friend (control) must be the same as the cancer patient in terms of age (± 5 years), ethnicity, and education. from the selection process, there were 60 people as "normal" controls. exclusion criteria (cancer patients) are: pregnant, in a spinal cord transplant, undergoing radiotherapy, metastatic cesarean section, suffering from other diseases, anemia, and experiencing physical and psychological deterioration. while the exclusion criteria for normal controls are ever diagnosed with cancer (all types). the data collection procedure was: after respondents filled out informed consent, respondents and controls were asked to fill out questionnaires to measure the quality of sleep, fatigue, depression, and qol. data collection was done 3 times: before chemotherapy, at the end of 4 cycles of chemotherapy, and 1 year after chemotherapy. the time of data collection varies depending on when the patient starts chemotherapy, but always at least 3 days before chemotherapy. descriptive analysis (mean, standard deviation, and error standard) was carried out on all south east asia nursing research, vol 1 no 1, june 2019/ page 20-26 23 santoso tri nugroho / factors that related to cancer related fatigue outcomes from the 3 measurements. ttests and chi-square or fisher's exact tests were used to measure differences in demographic characteristics between the two groups. chi-square tests or fisher's exact tests were used to examine possible differences in medical comorbidities and average dropout. the pearson correlation is applied between variables and age and body mass index. the results showed that compared to the control group, cancer patients had longer napping times, worse sleep quality, more fatigue, more depression, more disturbed routine ratification and worse qol (p-value <0.05). when administering 4 cycles of therapy: cancer patients showed sleep quality, fatigue, depression, and routine activity were worse than the group at the baseline level and in those without cancer (control) (p values <0.05). after 1 year, fatigue, depression, and qol in cancer patients returned to baseline levels but remained worse than the control group. while for naping time and routine activities it is no different from the control group. 6. the design of the study is longitudinal design with repeated measures, with the sampling technique of ca mammary patients visiting the medical-surgical oncology clinic selected to be used as the study sample. the inclusion criteria of this study included women diagnosed with mammary cancer (0-8 weeks), being in stage 0-iii, aged> 18 years, able to provide informed consent, being able to fill out questionnaires every 3-6 months up to 4 years after treatment active ends, can read and write, can speak english, and has no mental disorders. from the selection process, a sample of 150 people was obtained. the research tool used is the distress thermometer problem list, used for self-reporting about stress conditions around cancer he suffered and the psychological status of the respondent. the brief pain inventory is used to measure the incidence, location, and intensity of pain. the brief fatigue inventory is used to measure the level of fatigue of respondents. the patient health questionnaire (phq9), is used to independently measure client depressive conditions. generalized anxiety disorder (gad7), is used to measure the respondents' anxiety level. data analysis using univariate, bivariate and multivariate analysis. the results of the analysis showed that desperation, pain, and sleep disorders were significant predictors individually and collectively on fatigue (p <0.00). sleep disturbance was the most significant predictor of fatigue in the first year of patients with cesarean section. south east asia nursing research, vol 1 no 1, june 2019/ page 20-26 24 santoso tri nugroho / factors that related to cancer related fatigue table 1. characteristics of articles (n = 6) no title author (year) method results 1 factors related to clinically relevant fatigue in diseasefree stomach cancer survivors and expectationoutcome consistency.5 hwang ic et.al (2014) observational, cross-sectional fatigue in cancer clients is related to the female sex, poor economic status, living in rural areas, active smokers, early stages, and depression, strong depression is associated with fatigue, compounded if the client is in the early stages. 2 exercise is an effective treatment modality for reducing cancer-related fatigue and improving physical capacity in cancer patients and survivors.6 elliott m. mcmillan and ian j. newhouse, (2011) meta-analysis. exercise is related to fatigue in cancer clients. exercise (aerobic and musculoskeletal strength) is effective in overcoming fatigue in cancer clients. 3 fatigue and depression in disease-free breast cancer survivors: prevalence, correlates, and association with quality of life.7 kim, s.h; son, b.h; hwang, s.y; han, w; yang, j.h; lee, s; yun, y.h. (2008) the survey, cross-sectional fatigue and depression are more influenced by sociodemographic factors, comorbidity, and characteristics of respondents. 4 fatigue in advanced cancer: a prospective controlled crosssectional study.8 p stone, j hardy, k broadley, aj tookman, a kurowska and r a’hern (1999) prospective controlled crosssectional study. fatigue is not related to age, sex, diagnosis, the process of metastasis, anemia, nutritional status, muscle function, or emotional condition. fatigue is significantly associated with pain and dyspnea in patients and is associated with anxiety and depression in controls. 5 sleep, fatigue, depression, and circadian activity rhythms in women with breast cancer before and after treatment: a 1-year longitudinal study.9 israel, s.a ; liu l ; rissling, m ; loki natarajan, l ; neikrug, a.b ; palmer, b.w ; paul j; mills, p.j ; barbara a. parker, b.a ; georgia robins sadler, g.r ; and maglione, j. (2014) a 1-year longitudinal study compared to the control group, cancer patients have longer napping times, worse sleep quality, more fatigue, more depression, more disturbed routine ratification and worse qol (p values <0.05) when administering 4 cycles of therapy: cancer patients showed sleep quality, fatigue, depression, and routine activity were worse than the group at the baseline level and in those without cancer (control) (p values <0.05) after 1 year, fatigue, depression, and qol in cancer patients returned to baseline levels but remained worse than the control group. while for naping time and routine activities it is no different from the control group. http://www.ncbi.nlm.nih.gov/pubmed/?term=kim%20sh%5bauthor%5d&cauthor=true&cauthor_uid=18358687 http://www.ncbi.nlm.nih.gov/pubmed/?term=son%20bh%5bauthor%5d&cauthor=true&cauthor_uid=18358687 http://www.ncbi.nlm.nih.gov/pubmed/?term=hwang%20sy%5bauthor%5d&cauthor=true&cauthor_uid=18358687 http://www.ncbi.nlm.nih.gov/pubmed/?term=han%20w%5bauthor%5d&cauthor=true&cauthor_uid=18358687 http://www.ncbi.nlm.nih.gov/pubmed/?term=han%20w%5bauthor%5d&cauthor=true&cauthor_uid=18358687 http://www.ncbi.nlm.nih.gov/pubmed/?term=yang%20jh%5bauthor%5d&cauthor=true&cauthor_uid=18358687 http://www.ncbi.nlm.nih.gov/pubmed/?term=lee%20s%5bauthor%5d&cauthor=true&cauthor_uid=18358687 http://www.ncbi.nlm.nih.gov/pubmed/?term=lee%20s%5bauthor%5d&cauthor=true&cauthor_uid=18358687 http://www.ncbi.nlm.nih.gov/pubmed/?term=yun%20yh%5bauthor%5d&cauthor=true&cauthor_uid=18358687 south east asia nursing research, vol 1 no 1, june 2019/ page 20-26 25 santoso tri nugroho / factors that related to cancer related fatigue no title author (year) method results 6 factors that affect fatigue in breast cancer survivors.10 ingham, jaclyn ( 2015) a longitudinal design with repeated measures depression, pain and sleep disturbance were significant predictors of individual and collective fatigue (p <0.00). sleep disturbance was the most significant predictor of fatigue in the first year of patients with cesarean section. discussion based on the search results it was found that there were several factors that could be used as predictors of fatigue in cancer clients, namely characteristics (age, sex), sociodemography (economic status), stage of the disease, exercise, pain, depression, and sleep quality. the first study found that strong depression was associated with the onset of fatigue, and the condition was exacerbated if the client was in the early stages of cancer. the results of the first study were strengthened by fifth research which can be concluded that the more depressed the client, the more fatigued he will be. depression is an emotional reaction in response to a sense of loss that is indicated by losing interest, difficulty concentrating and feeling hopeless to feel useless and interesting again. this condition is referred to as negative cognitive tread, this belief is seen as a basic symptom of depression, wherein it also includes somatic disorders (such as sleep disorders), motivational disorders, and affective disorders which will ultimately affect the physical condition and manifest as fatigue. the results of the second study (systematic review) found that exercise (aerobic and muscle strengthening exercises) can reduce fatigue levels in cancer clients. this condition reinforces the notion that with increased physical activity it will provide great benefits psychologically and increase physical abilities so as to reduce the level of fatigue. the third study was found that both fatigue and depression were both more influenced by sociodemographic factors, comorbidity, and characteristics of symptoms and signs, than cancer and cancer treatment itself. this is not in accordance with the fourth study which states that fatigue is not related to characteristics (age, sex) but is more related to pain. pain is actually common in cancer patients, but this factor is not alone causing fatigue but is interrelated with one another. complaints of pain that are felt continuously can cause patients to become less active, not appetite, sleep disorders, and cause patients to be depressed and depressed, all of which can cause fatigue. this can be seen in the seventh study where the results state that desperation, pain, and sleep disorders are significant predictors both alone and collectively towards fatigue. conclusion by looking at the 6 literature we have not been able to deduce what is actually the main factor that causes fatigue in cancer clients because the results of the research are different and there are mutually reinforcing studies between one another. the main causes of fatigue in cancer clients are still unclear. however, based on these studies we know what factors might be predictors of fatigue in cancer clients, so we as nurses can focus on these factors to determine appropriate nursing interventions to overcome fatigue in cancer clients. south east asia nursing research, vol 1 no 1, june 2019/ page 20-26 26 santoso tri nugroho / factors that related to cancer related fatigue conflicts of interest the author declares that none of him had any conflict of interests. references 1. berger am, mooney k, alvarez-perez a, breitbart ws, carpenter km, cella d, et al. cancer-related fatigue. off j natl compr cancer netw [internet]. 2015 [cited 2016 jun 20];13(8):1012. available from: https://jnccn.org/abstract/journals/jnccn/13/ 8/article-p1012.xml 2. howell d, keller-olaman s, oliver tk, hack tf, broadfield l, biggs k, et al. a pan-canadian practice guideline and algorithm: screening, assessment, and supportive care of adults with cancer-related fatigue. curr oncol [internet]. 2013 jun [cited 2019 jun 20];20(3):e233-46. available from: http://www.ncbi.nlm.nih.gov/pubmed/23737 693 3. hinds ps, quargnenti a, bush aj, pratt c, fairclough d, rissmiller g, et al. an evaluation of the impact of a self-care coping intervention on psychological and clinical outcomes in adolescents with newly diagnosed cancer. eur j oncol nurs [internet]. 2000 mar [cited 2019 jun 20];4(1):6–17. available from: http://www.ncbi.nlm.nih.gov/pubmed/12849 624 4. janda m, gerstner n, obermair a, fuerst a, wachter s, dieckmann k, et al. quality of life changes during conformal radiation therapy for prostate carcinoma. cancer [internet]. 2000 sep 15 [cited 2019 jun 20];89(6):1322–8. available from: http://www.ncbi.nlm.nih.gov/pubmed/11002 229 5. hwang ic, yun yh, kim y-w, ryu kw, kim ya, kim s, et al. factors related to clinically relevant fatigue in disease-free stomach cancer survivors and expectation-outcome consistency. support care cancer [internet]. 2014 jun 9 [cited 2019 jun 20];22(6):1453–60. available from: http://link.springer.com/10.1007/s00520013-2110-2 6. mcmillan em, newhouse ij. exercise is an effective treatment modality for reducing cancer-related fatigue and improving physical capacity in cancer patients and survivors: a meta-analysis. appl physiol nutr metab [internet]. 2011 dec [cited 2019 jun 20];36(6):892–903. available from: http://www.nrcresearchpress.com/doi/10.11 39/h11-082 7. kim sh, son bh, hwang sy, han w, yang j-h, lee s, et al. fatigue and depression in diseasefree breast cancer survivors: prevalence, correlates, and association with quality of life. j pain symptom manage [internet]. 2008 jun [cited 2019 jun 20];35(6):644–55. available from: https://linkinghub.elsevier.com/retrieve/pii/s 0885392408000614 8. stone p, hardy j, broadley k, tookman aj, kurowska a, a’hern r. fatigue in advanced cancer: a prospective controlled crosssectional study. br j cancer [internet]. 1999 mar 26 [cited 2019 jun 20];79(9–10):1479–86. available from: http://www.ncbi.nlm.nih.gov/pubmed/10188 894 9. ancoli-israel s, liu l, rissling m, natarajan l, neikrug ab, palmer bw, et al. sleep, fatigue, depression, and circadian activity rhythms in women with breast cancer before and after treatment: a 1-year longitudinal study. support care cancer [internet]. 2014 sep 15 [cited 2019 jun 20];22(9):2535–45. available from: http://link.springer.com/10.1007/s00520014-2204-5 10. ingham j. factors that may predict fatigue in women with newly-diagnosed breast. 2015 [cited 2019 jun 20]; available from: https://kb.osu.edu/handle/1811/68732 metacarpal acupressure reduced pain in the first stage of labor corresponding author: sri rejeki srirejeki@unimus.ac.id south east asia nursing research, vol 1 no 3, december 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.3.2019.148-153 original research metacarpal acupressure reduced pain in the first stage of labor sri rejeki1, tri hartiti1, achmad sulichan1, machmudah machmudah 1 1 university of muhammadiyah semarang, indonesia article info abstract article history: accepted december 30th, 2019 keywords: acupressure metacarpal; pain of stage labor; the spouses pain during labor will cause psychological disorders for mothers, such as 87% of postpartum blues, 10% of depression and 3% of psychosis. therefore, intervention to relieve pain level is necessary to prevent complications for mother and fetus during the process and after delivery. one of the simple methods to relieve the pain level of childbirth is metacarpal acupressure. the application of this method is usually only done by health workers, although a spouse or other family member can conduct it. this study aimed to describe the application of metacarpal acupressure by the husband to relieve pain level in first delivery women. the study used a descriptive-analytic design. the population was 40 husbands, who were waiting for their wives at the first stage of labor. the husbands have been trained about acupressure methods. the sampling method used a consecutive sampling method. the results of the study revealed 75% of husbands did well for practicing acupressure methods, 60% of women claimed they got pain relief after given acupressure by their husband. the recommendation of this study is the importance of a spouse's presence in first stage labor for reducing the pain of mothers in childbirth. introduction most deliveries (90%) is always accompanied by pain while in labor pain is a common thing to happen, the pain of labor is a physiological and psychological process.1,2 reported from 2,700 women giving birth only 15% of births take place with mild pain, 35% with moderate pain, 30% with severe pain and 20% of deliveries with severe pain.3,4 health statistics of central java obtained deliveries by skilled health personnel is not a maximum 82.75%, and in particular, the county kendal obtained 64.71% figure means about 35% of deliveries are handled by other than medical personnel.5 moreover, likely deliveries take a patient's own home. labor pain can stimulate the release of chemical mediators including prostaglandins, leukotrienes, thromboxane, histamine, bradykinin, substance, and serotonin, which will result in the secretion of stress hormones like catecholamine cause and steroids with consequent vasoconstriction of the blood vessels to weaken intestinal contractions.6 excessive secretion of these hormones will cause uteroplacental interference circulation resulting in fetal hypoxia. from the research, pain in childbirth causes women to experience psychological disorders, 87% postpartum blues that occur from 2 weeks to 1 year https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.3.2019.148-153&domain=pdf&date_stamp=2019-12-30 south east asia nursing research, vol 1 no 3, december 2019/ page 148-154 149 sri rejeki / metacarpal acupressure reduced pain in the first stage of labor postpartum, 10% and 3% depression with psychosis.7 labor pain is not unbearable encourage maternal looking for some alternatives to treat pain, including use of pain medications such as analgesics and sedatives.4 while these drugs can give adverse side effects include fetal hypoxia, the risk of neonatal respiratory depression, decreased heart rate and increased maternal body temperature and may cause changes in the fetus.4,8 therefore, interventions reduce labor pain is necessary to reduce complications in the mother and fetus during the process and after delivery. many kinds of methods performed by health workers to reduce pain in childbirth. nonpharmacologic intervention reduces pain, among others, hypnosis, acupressure, yoga, hydrotherapy, acupuncture, acupressure breathing, and relaxation techniques.9 acupressure metacarpal proven to reduce labor pain but not much done. this method is relatively easy to do by the health worker and his family, especially her husband to help her to reduce the level of labor pain. the importance of the role of the family, especially the husband in a decrease in the level of pain in labor should be recognized as an appropriate strategy because her husband and can act as a psychological support to the wife in labor, so as to reduce morbidity and maternal mortality rates are not directly impact on reducing vulnerability and addressing the impact of the disease. therefore, the present study aims to describe how her husband practices after getting training methods of metacarpal acupressure to reduce pain in first stage labor.10–12 labor pain is a pain felt by the mother in labor. from the research, pain in childbirth causes women to experience psychological disorders, 87% of postpartum blues that occur from 2 weeks to 1 year postpartum, 10% and 3% depression with psychosis.3 therefore, it is necessary to find a solution to the labor pain that is cheap and practically can be used by mothers to reduce pain in first stage labor. the contribution from the research includes a) providing information about one of the alternatives to reduce labor pain in a nonpharmacologic. b) inform the husband's role in the practice of counter-pressure method to reduce pain levels in the mother during the birth process first stage c) provide information support the importance of family, especially the husband (spouse) in nursing care in labor.4 the delivery process begins with uterine contractions that cause pain and discomfort in women who give birth.5 physiological factors pain: paths pain starts from the nerve endings (receptors) on the site of tissue damage then formed trajectory spinal afferents to the spinal ganglion in the posterior spinal cord radik, then delivered to the pathways/ tracts ascending to the pain center of the central nervous system. psychological factors of pain: past experiences, value systems associated with pain, family expectations, environment, emotions, culture. signal reception and transmission of pain. excitatory nerve pain in the air-channeled myelin faster than nonpainful stimuli to the nerve myelin. the nerve fibers are divided into several groups: 1) air-myelin nerve fibers receptors are mechanosensitive nerve conduction quickly, respond to mechanical stimuli, such as by the pressure and touch. 2) air-myelin nerve fibers a mechanothermal nerve receptors that respond to the rapid conduction of mechanical stimuli, such as pressure, touch, and heat. 3) c nerve fibers are not air-poly-modal nociceptor myelin, nerve conduction is slow to respond to some stimulus.13 distribution of pain signals from the spinal cord to the distributed network through radik posterior spinal nerves stayed in the dorsal horn of the spinal cord and continues to form a complex connection. this is what often makes it difficult to determine which pain is felt, especially in visceral pain. then the pain signal is delivered to the pain centers in the central nervous system via south east asia nursing research, vol 1 no 3, december 2019/ page 148-154 150 sri rejeki / metacarpal acupressure reduced pain in the first stage of labor pathways spinothalamic pathway before reaching the center of the pain is in the brain stem and then stayed the thalamus. after the thalamus and then the sensation of pain distributed to several somatosensory cortexes of the brain. when the pain signal reaches the brain, the signal does not stop proceeding in which multiple signals to the motor cortex and then down through the spinal cord to the motor nerves. this impulse causes muscle contractions experienced a painful stimulus.13 descending inhibition of pain begins at the somatosensory cortex to the thalamus and hypothalamus channeled. derived from the thalamus to the mesencephalon then form a synapse with ascending pain pathways in the medulla oblongata and medulla spinally, and inhibit nerve signals ascending. this led to the formation of the body's natural painkillers caused by stimulation neurotransmitter opioids (such as endorphins, dynorphinandenkephalin).6,13 pain signals can be attributed by the autonomic nervous system and the current through the medulla oblongata can cause increased heart rate, increased blood pressure, increased respiratory rate and sweat production. this reaction depends on the intensity of the pain and can lead to depression centers in the cortex.13 the transduction process produces a magnification of pain impulses and intransmission by pain pathways to the spinal cord dorsal horn. in the cornu of the spinal cord impulse modulation of the pain experience, which can be enlarged or reduced. it assists modulation of nerve fibers running nociceptive impulses from the periphery toward the center, and finally accepted the brain as a sensation/perception of pain.6,13 ronald melzack and patrick wall explain the mind and emotions can influence the perception of pain and through the mechanism of the gate control cornus posterior spinal cord. small nerve fibers and large fibers in the cell synapsed projector (p) which is going through the spinothalamic tract leading to the pain centers of the brain, and also synapsed interneurons inhibitors. these relationships determine when a painful stimulus is channeled to the brain by several mechanisms as follows. when there is no input of pain, the nerve fibers inhibitors prevent the projector from delivering signals to the brain (gate closes).6,13 2) normal somatic sensation when there is stimulation of the larger fibers or just stimulation of large nerve fibers and nerve, the nerve inhibitors projector will be stimulated, but the neural inhibitor prevents nerve signals to the brain projector channel (gate closes). 3) acceptance of nociceptive pain occurred when the smaller fibers stimulated. this causes the inactivation of the nerves and nerve inhibitors projectors to deliver pain signals to the brain (gate open).6 most women will experience pain during labor. the pain of labor is individualized. each individual will perceive pain differently to the same stimulus depending on its pain threshold. pain in childbirth is fundamentally different from the pain experienced by individuals in general. the difference lies in: a) the labor pain is a physiological process, b) women can know that he will experience pain during childbirth so it can be anticipated, c) adequate knowledge of the birth process will help women to cope with labor pain that is intermittent (periodically), d) the concentration of women in the baby to be born will make it more tolerant to the pain felt during labor.3 factors that affect pain include age, gender, culture, understanding pain, concern, anxiety, fatigue, past experiences, coping patterns, family and social support. acupressure is one of the techniques that can be used to reduce labor pain. metacarpal acupressure consists of a fixed given a strong impetus to the point in the south east asia nursing research, vol 1 no 3, december 2019/ page 148-154 151 sri rejeki / metacarpal acupressure reduced pain in the first stage of labor metacarpal during contractions. acupressure is given in the areas of pain or discomfort when the contractions started. acupressure is usually performed at metacarpal. gate control theory can give reasons why this action is successful. gate control theory of melzack and wall, 1965 said the pain impulses could be regulated or even inhibited by the defense mechanism along with the central nervous system.10 defense mechanisms can be found in the cells of the substantial gelatinosa in the dorsal horn of the spinal cord, the thalamus, and the limbic system. this theory says the pain impulse is delivered when an impulse inhibited defense opened and closed when a defense. efforts to close the defense is a basic pain relief therapy.14 caplan in friedman explains the family has some support functions namely; a). informational support: the support is the provision of materials that can provide direct assistance such as the provision of money, the provision of goods, food, and services. this form can reduce stress because individuals can solve problems that relate directly to the material. b) support the assessment. the form of this support involves the award of the information, suggestions or feedback on the individual circumstances. this type of information can help individuals to identify and solve problems easily. c) support the instrumental. the support is a source of practical and concrete help, such as the health of people in terms of the need to overcome the pain, eating and drinking, resting, avoiding sufferers of fatigue. d) emotional support. the form of this support has made people comfortable feeling, sure, cared for and loved by the family so that individuals can face problems with either. this support is very important in the face of a state that cannot be controlled. methods the method used is descriptive which gives an overview of the practice of husbands to reduce maternal pain in the first stage of labor by using an acupressure. the population in this study were all women giving birth by normal delivery at the first stage and as a whole, the maternal sample is the normal delivery at the first stage of which is in the kendal hospital, with a sample that meets the criteria watchman husband and wife, the first wife. consecutive sampling technique sampling. data collection was started by selecting respondents based on criteria, then trained counter-pressure method. the instrument in this study is a set of tools in the form of instruments action steps that are used to guide him into doing acupressure and set of tools for measuring instruments that have been validated, pain respondents. applied research ethics approval or informed consent i.e., anonymity with no name, give the patient the freedom to provide flexibility patient rights. result and discussion factors that affect reproductive health support to her husband, that knowledge about pregnancy and childbirth, experience, marital status, and socioeconomic status.5 from the research data obtained 35% of elementary school-educated husbands and 85% of workers are husband's job as a factory worker, shop workers, and other workers. this suggests that the husband's education level and family income is low relatively low. as seen in table 1, the husband's support is very important in the delivery process. because at the time of delivery occurs physiologically severe pain interferes with the mother. from the results, the husband's behavior when trained counter-pressure is 77% of this kind of behavior shows their husband's attention when obtaining information relating to the wife in the delivery process is very large. the behavior of a good husband provides convenience in receiving information in the training of counter-pressure. this is consistent with south east asia nursing research, vol 1 no 3, december 2019/ page 148-154 152 sri rejeki / metacarpal acupressure reduced pain in the first stage of labor the findings that 80% of men can perform actions acupressure 3 times correctly. in general, from the results, the practice of the husband to perform acupressure is good (75%) it shows no concern in giving support to the wife in labor. in the face of labor required consultation and support from family, especially her husband. age is one indicator that can reflect the maturity of someone in the act, including in decision-making. the average age of the husband is 32 years old; it shows the average husband belonged to a young adult. young adults can show positive behavior in preparing for the future, including in preparing a generation descendant of the family, especially the reproductive, developmental tasks. minimum age is 18 years old husband (7.5%) of this age is still part of adolescence to early adulthood is possible to still less mature in the decision included in the act of doing spousal support (included in the delivery process). from the research data obtained there is still 23% less good husband in training acupressure and 25% less well in practice acupressure. this is possible because the husband is still there under the age of 20 years. table 1. characteristic behavior while training on counter pressure on the respondent (husband) in soewondo hospitals, kendal, 2015 spouse behavior while training do not done f % f % husband listens to the goals acupressure method 26 60 14 40 husband listens to the way action reduces labor pain with acupressuresuami 36 90 4 10 active husband asked as an explanation 20 50 20 50 the husband can take action to correct the acupressure least 3 x while training 32 80 8 20 a husband willing to act acupressure when the wife felt pain in the first stage of labor 40 10 0 0 0 age also affects a person responds to pain. judging from the average age of the respondent (wife) is 28 years showed a majority in the age group 20-30 years, in addition to the average of the respondents were in the productive age, as well as physiologically possible still withstand labor pain. however, in addition to individual pain response, pain is influenced by many things such as the environment, race, certain actions and also the pattern of one's coping in the face of pain. table 2. characteristics of pain to reduction measures by the respondent (spouse) to acupressure practice in soewondo hospitals kendal, 2014 acupressure action do not done f % f % husband tells wife acupressure measures to reduce labor pain 38 95 2 5 husband gives a wife a position as comfortable as possible on the felt labor pain 20 50 20 50 the husband gave t comfort position before the action of pressure 28 70 12 30 fourth husband looking for the right spot to apply pressure with acupressure to reduce the pain of his wife 32 80 8 20 husband doing a strong push at the point in the metacarpal during contraction using the heel of the hand 36 90 4 10 husband doing a strong push at the point in the metacarpal the contraction of the thumb 24 60 16 40 the husband asked his wife whether the pain is reduced when performed acupressure 36 90 4 10 husband always do acupressure when the wife felt pain during childbirth 28 70 12 30 south east asia nursing research, vol 1 no 3, december 2019/ page 148-154 153 sri rejeki / metacarpal acupressure reduced pain in the first stage of labor the result showed that 22% of mothers who received acupressure measures were primigravida and has had second thoughts, it means the mother has had previous experience of overcoming pain. the results of the study mothers pain after counterpressure is reduced pain by her husband as much as 60% of mothers and only a small proportion is 12.5% said the pain increased after the acupressure by the husband, and 27.5% of mothers said there are no changes in their pain even after given counterpressure by their husbands. individual labor pain and many other factors are influential.11 table 3 table frequency of pain after doing acupressure by husband in soewondo hospitals kendal, 2014 level of pain f % reduced 24 60 not reduced 11 27,5 increased 5 12,5 total 40 100 conclusion metacarpal acupressure action performed by the spouses can reduce the pain of a mother in first stage childbirth. from these results, it is suggested that health workers involving husband's birth attendants in the delivery process especially in reducing labor pain. acknowledgments thank you to all of the respondents who have helped this research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. lowdermilk dl, perry se, cashion k, alden kr, olshansky ef. maternity & women’s health care. 11th editi. elsevier; 2016. 2. lowdermilk dl, perry se, cashion k. maternity nursing. 8th editio. mosby/elsevier; 2014. 3. whitburn ly, jones le, davey ma, mcdonald s. the nature of labour pain: an updated review of the literature. women and birth. 2019;32(1):28-38. doi:10.1016/j.wombi.2018.03.004 4. hensley jg, collins mr, leezer cl. pain management in obstetrics. crit care nurs clin north am. 2017;29(4):471-485. doi:10.1016/j.cnc.2017.08.007 5. dinas kesehatan. profil kesehatan kota semarang 2017. published online 2017:4849. doi:10.2307/1942600 6. ballestas hc, caico c. pathophysiology of nursing.; 2014. 7. kacperczyk-bartnik j, bartnik p, symonides a, sroka-ostrowska n, dobrowolska-redo a, romejko-wolniewicz e. association between antenatal classes attendance and perceived fear and pain during labour. taiwan j obstet gynecol. 2019;58(4):492-496. doi:10.1016/j.tjog.2019.05.011 8. chou r, gordon db, de leon-casasola oa, et al. management of postoperative pain: a clinical practice guideline from the american pain society, the american society of regional anesthesia and pain medicine, and the american society of anesthesiologists’ committee on regional anesthesia, executive commi. j pain. 2016;17(2):131-157. doi:10.1016/j.jpain.2015.12.008 9. molsberger af, schneider t, gotthardt h, drabik a. german randomized acupuncture trial for chronic shoulder pain (grasp) a pragmatic, controlled, patient-blinded, multicentre trial in an outpatient care environment. pain. 2010;151(1):146-154. doi:10.1016/j.pain.2010.06.036 10. klafke n, mahler c, von hagens c, blaser g, bentner m, joos s. developing and implementing a complex complementary and alternative (cam) nursing intervention for breast and gynecologic cancer patients undergoing chemotherapy--report from the congo (complementary nursing in gynecologic oncology) study. support care cancer. 2016;24(5):2341-2350. doi:10.1007/s00520-015-3038-5 11. hajiamini z, masoud sn, ebadi a, mahboubh a, matin aa. comparing the effects of ice massage and acupressure on labor pain reduction. complement ther clin pract. 2012;18(3):169-172. doi:10.1016/j.ctcp.2012.05.003 12. rejeki s, hartiti t. tingkat nyeri persalinan melalui terapi acupressure metacarpal dan south east asia nursing research, vol 1 no 3, december 2019/ page 148-154 154 sri rejeki / metacarpal acupressure reduced pain in the first stage of labor counter-pressure regiosakralis ibu persalinan kala i. in: prosiding seminar nasional & internasional. vol 1. ; 2017. 13. rodriguez l. pathophysiology of pain: implications for perioperative nursing. aorn j. 2015;101(3):338-344. doi:10.1016/j.aorn.2014.12.008 14. melzack r, kinch r, dobkin p, lebrun m, taenzer p. severity of labour pain: influence of physical as well as psychologic variables. can med assoc j. 1984;130(5):579-584. accessed january 20, 2020. http://www.ncbi.nlm.nih.gov/pubmed/669 7268 analysis of factors adherence to safe injection practice procedures among nurses healthcare center qatar corresponding author: sobur setiaman soburs@gmail.com south east asia nursing research, vol 1 no 2, september 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.2.2019.61-66 original research analysis of factors adherence to safe injection practice procedures among nurses healthcare center qatar sobur setiaman1, syahfirin abdullah2, kholil kholil3, kohar sulistyadi4 1 messaieed medical center qatar petroleum, qatar 2,3,4 post graduate school, sahid university jakarta article info abstract article history: accepted september 30th, 2019 key words: nurses; safe injection practice; nurses behavior injection practices was common medical procedure done by nurses according doctor’s prescription. in nursing process, injection practice is part of nursing intervention, but injection practices was risky for the health care workers. needle stick injury was happened to the nurses, 18% due disposal of the needle, and 15% while draw the blood for laboratory study. adherence to the work procedure influence by few behavior factors. aim of research of the research were to finding out of the factors influence of adherence to safe injection practice among the nurses at healthcare center x qatar. type of the research was observational analytic quantities of the analytic description, using cross sectional approach. 9 variable latent with 56 variable indicator. size of sample were 114 nurses. data analytic with using pls-sem. tstatistic value on variable culture 2.94; environment 1.99; work procedure 3.81 and supervisory 3.10. t-statistic of individual characteristic, work facility, attitude, and knowledge bellow 1.96. r2 variable adherence were showed 96.05% with q2 87.07%. culture, environment, work procedure and supervisory influenced of the adherence safe injection practice among the nurses. (96.05%) variable independent influence of the adherence safe injection practice among the nurses, within 87.07% showed good predicted. introduction injection practices was common medical procedure done by nurses according doctor’s prescription. doenges m.e., moorhouse m.f., murr a.c., (2014) stated in nursing process, injection practice is part of nursing intervention, but injection practices was risky for the health care workers. mandal j., (2013) reported needle stick injury was happened to the nurses, 18% due disposal of the needle, and 15% while draw the blood for laboratory study. gholami, et al., (2013) result studied at iran, 32% health care worker had experience with the needle stick injury, 45% experience more than twice. 9.7% needle stick injury had reported to the supervisor, with odd ratio 2.4 within shift duty. if the incident of needle stick injury not reportable, will be miss to be investigation and monitoring and also the hepatitis b and hiv exposed from the needle could not be follow up. some reasons why the incident of needle stick injury not reported due to work fatigue and high workload among nurses. https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.2.2019.61-66&domain=pdf&date_stamp=2019-09-30 south east asia nursing research, vol 1 no 2, september 2019/ page 61-66 62 sobur setiaman / analysis of factors adherence to safe injection practice procedures among nurses healthcare center qatar amira c.o., and awobusuyi j.o., (2014) reported at nigeria, incident needle stick injury 24.5%/years. causes of the needle stick i injury due recapping of the needle (45%), while disposed of the needle (30%), and while inserted the intravenous infusion (27.5%). needle stick injury reported to the superior (37%). study reported by kaphle, et al.,(2014) at the nepal, 30.5% nurses had training of safe injection practice, had vaccination anti hepatitis b (76,8%), awareness to the needle stick injury (57,7%), had experience needle stick injury (71,8%), needle stick injury (55,1%), while recapping the needle (94,1%). conclusion from there studied needle stick injury incident due of lack of awareness, lack of skill on the safe injection practice. study reported done by holla, et al., (2014) incident rate needle stick injury at india 71.9% (n 136), correlated to the long hour duty. long hour duty can be caused of the fatigue, fatigue had rick of the needle stick injury. reported by jahangiri, et al., (2016) needle stick injury in iran, (76%) to the nurses, while dealing with the needle before the injection procedure (85.5%), recapping the needle (41.4%), and not reported (46,7%), significant due long hours duty and shift work. reported by gyawali, et al., (2016) at nepal 75.6% nurse’s rural hospital, 39.2% nurses city hospital had developed with the sign and symptom of hepatitis. 13.3% nurses at city hospital had hepatitis b positive, 37.3% nurses from rural hospital had hepatitis b positive. 33.3% rural nurses, 21.6% nurses for the city hospital had needle stick injury. dc (2013), predicted health care worker has no hepatitis b vaccination, exposed by hepatitis b 6%-30%, hepatitis c 1.8% and exposed by hiv 0.3%. papadakis m., and mcphee, sj., (2015), stated that hepatitis b is infectious disease at the liver by the virus of hepatitis type b. dafaalla m.d., et al., (2016) reported that sudani nurses, 2.3% not wearing hand glove while injection procedure, 95.9% believed inf had needle stick injury will hepatitis infected, 99% believed needle stick injury high risk hiv infected, 83% nurse feeling worry exposed by hiv and hepatitis if had needle stick injury, 77.8% hand wash when had needle stick injury, 36.5% stated sharp box not enough stock, 31.8% believe needle stick can be prevented. bijani, et al., (2017) reported the impact the safe injection practice training for nurses, incident needle stick injury reduced from 15% became 10% with significant (p=0,002). conclusion these study, safe injection practice training can be prevent of incident of needle stick injury among the nurses. according strank, j., (2013) adherence to the work procedure influence by behavior factors, component the behavior included: 1. attitude; 2. motivation; 3. perception; 4. memory of procedure; 5. individual characteristics; and 6. social background. based on the theory of lawrence green cite by dafaalla, et al., (2016), and diclemente, et al., (2013), behavior influence by 3 factors: 1. predisposition factor such as attitude, skill, culture, believe and individual characteristics; 2. enabling factor such as facility, and work environment; 3. reinforcing factor such as rule and supervisory from the management, and written procedure have to in place. injection procedure is high risk become needle stick injury. when needle stick injury is happen, may infectious disease transmitted or exposed to the nurses. nursing safe injection practice been implementation, but the incident of needle stick injury still happening. lack of knowledge, negative attitude and unsafe behavior may influence to adherence to the safe injection practice. according the theory of infection prevention and control and also data empiric needle stick injury, what is contributing factors influence to adherence safe injection practice among nurses in healthcare facility qatar? south east asia nursing research, vol 1 no 2, september 2019/ page 61-66 63 sobur setiaman / analysis of factors adherence to safe injection practice procedures among nurses healthcare center qatar methods type of the research were used the quantitative observational analytics, within cross sectional approach. venue of the research were the healthcare center qatar, since march 1st up to september 1st 2019. number of population of the nurses were there working at the ras laffan city 91 nurses, messahed city 35 nurses, dan dukhan city 26 nurses within total 152 nurses, only 114 nurses were an acceptable to participated as responder in this research. questionnaire as the instrument to collecting data regarding of the characteristic individual, knowledge, attitude, culture, facility, supervisory, work environment, work procedure and adherence safe injection practice. respondent will choose the answer following a likert scale: 5=strongly agree, 4=agree, 3=neutral, 2=disagree, 1=strongly disagree. instrument validity a proof following convergent and discriminant of validity. cut off the validity used were the loading factor value above 0.5 and the discriminant validity used were the average variance extracted (ave) value above 0.5. (j. f. hair, g.t.m. hult, c.m. ringle, m. sarstedt, 2017). cronbach alpha used for the check the reliability of the construct. good reliability of the construct must above the 0.7 (n.k avkiran, c.m. ringle 2018). analysis these data, we using the technic of partial least square structural equation model (pls-sem). steps of technic pls-sem following steps bellows: 1. first steps: designing the model of structural (inner model). 2. second steps: designing the model of measurement (outer model). 3. third steps: construct the path diagram. 4. fourth steps: converse of the path diagram to the equation model: outer model as the outer relation or the measurement model and the inner model, as the relation between the variable latent or structural model. 5. fifth steps: do estimation of the parameter. 6. six step: goodness of fit analysis. 7. seven step: hypothesis test results and discussion research had been completely at healthcare center qatar supporting oil and gas operation. research conducted since may 1st 2019 up to september 1st with number of responder were 114 nurses. purpose of this research were to find out of factors influence adherence safe injection practice among nurses at healthcare qatar. safe injection practice procedure been implemented in this healthcare to make sure all nurses, patient and community safe from the needle hazard. safe injection practice procedure will guide the nurses to do prevention and control of exposure from the cross infection and prevention of needle stick injury among nurses and minimize abuse of needle by community. table 1 showed, most of the responder is male (83.3%). it is typical nurses hired by company were the male. male nurses easy going to response any emergency at the site plant or inside industrial area. healthcare in industrial area had the ambulance unit, an also sometime the occupational nurse will visit to the workplace to make sure the workplace were healthy condition. table 1 showed the level education of responder, majority were graduated from bachelor degree (52,6%). 43% still hold diploma level. according new policy from state of qatar, minimal qualification for healthcare worker must be graduated from bachelor level. bachelor level had ability to make decision with professionalism. south east asia nursing research, vol 1 no 2, september 2019/ page 61-66 64 sobur setiaman / analysis of factors adherence to safe injection practice procedures among nurses healthcare center qatar table 1 distribution frequency sex responder (n114) indicators f % sex female 19 17 male 95 83 education diploma 49 43,0 bachelor degree 60 52,6 master degree 5 4,4 table 2 showed, age level of the responder, variation from 44.9 years old up to 60 years. age above 30 years old had long enough exposed by work experience as the professionalism. the average of work experience were 21.3 year as nurses, 63% above 21 year experience. minimal experience as nurse in this healthcare facility are 2 years. table 2 distribution frequency age level of responder (n114) indicators mean (sd) min-max age level 44.99 (4.831) 31-60 work experience 21.28 (4.898) 9-31 validity and reliability result result of study showed the result of the validity testes mostly above 70%, only the individual characteristics showed ave value 0.51 but the cronbach’s alpha showed 61.56%. according some researcher mention if ave between 0.4 up to 0.7, make sure the validity test above 50% will consider accepted. significant level result table 6 showed the significant test showed if value t-statistic above 1.96 with alpha 0.5 we can conclusion this on significant level. from table no 6 we can see the variable work culture, supervisory, environment and work procedure showed the t-statistic above 1.96, we conclude these variables were significant influence to the adherence safe injection practice. t-statistic individual characteristic, knowledge, attitude and work facility were not significant (bellow 1.96). determinant level work procedure contributed positive to adherence safe injection practice 57.04% (r2 05704, t-value 3.81), safety culture contributed positive to adherence safe injection practice 44,88% (r2 0,4488 tvalue 2.95), supervisory contributed to adherence safe injection practice 26,09% (r2 0,2609 t-value 3.10), work environment contributed negative to adherence safe injection factor 24,56% (r2 0,2456 t-value 1.99). characteristic individual, knowledge, attitude and facility not significant contributed ( t-value < 1.96). r2 variable adherence were showed 96.05% with q2 87.07%. 96.05% variable of culture, environment, supervisory, and work procedure were influenced of the adherence safe injection practice among the nurses within predictive relative 87.07%. conclusion conclusion of this research had been proof, those variable work culture, supervisory, environment and work procedure showed the t-statistic above 1.96 we conclude these variables were significant influence to the adherence safe injection practice. variable individual characteristic, knowledge, attitude and work facility were not significant influence to adherence of safe injection practice. acknowledgements we wish to express our appreciation to all respondents who participated in this study for valuable assistance during data collection. conflicts of interest neither of the authors have any conflicts of interests that would bias the findings presented here. south east asia nursing research, vol 1 no 2, september 2019/ page 61-66 65 sobur setiaman / analysis of factors adherence to safe injection practice procedures among nurses healthcare center qatar references 1. amira c.o., dan awobusuyi j.o., (2014). needlestick injury among health care workers in hemodialysis units in nigeria: a multi-center study. int j occup environ med 2014;5:1-8. 2. ajzen, i., (2015). consumer attitudes and behavior: the theory of planned behavior applied to food consumption decisions. rivista di economia agraria, anno lxx, n. 2, 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(2013) needle stick injury: a major occupational hazards among the health care workers in nepal. nepal: international journal of occupational safety and health, 3(1), 22 – 25. 26. motaarefi h., mahmoudi h., mohammadi e., dehkordi a.h., (2016) factors associated with needle stick injuries in health care occupations: a systematic review. j clin diagn res. 2016 aug; 10(8): ie01–ie04. 27. moller n., hansson s.o., holmberg j.e., rollenhagen c., (2018). handbook of safety principles. new jersey, usa: published by john wiley & sons, inc., 111 river street, hoboken. 28. n.k. avkiran, c.m. ringle (2018). pls-sem recent advances in banking and finance. international series in operations research and management. swiss:springer 29. nurses association of new brunswick (2014). standards for infection prevention and control revised october 2014 (2/15), canada: nurses association of new brunswick. 30. osha, (2015). osha safety and health program management guidelines. http://www.osha.gov 31. royal college of nursing (2017). essential practice for infection prevention and control guidance for nursing staff. londond: published by the royal college of nursing, 20 cavendish square, london. 32. who dan ilo (2018). occupational safety and health in public health emergencies: a manual for protecting health workers and responders. geneva: copyright © international labour organization. 33. who (2016). best practices in patient safety 2nd global ministerial summit on patient safety. geneva: copyright © international labour organization. dimensions supporting and inhibiting pregnant women in using “sayang bunda” application corresponding author: tiwuk puji rahayu tiwp01@yahoo.co.id south east asia nursing research, vol 1 no 3, december 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.3.2019.112-119 original research dimensions supporting and inhibiting pregnant women in using “sayang bunda” application tiwuk puji rahayu1, farid agushybana2, bagoes widjanarko3 1 student of master of health promotion of diponegoro university, indonesia 2 department of biostatistics and demographics of universitas diponegoro, indonesia 3 public health study program of universitas diponegoro, indonesia article info abstract article history: accepted december 21st, 2019 keywords: smartphone; supporting; inhibiting the maternal and neonatal health surveillance officer and the public health center of purwoyoso build the android application. this application aims to help pregnant women recognize their pregnancy health thereby can improve the pregnant women’s four-visit antenatal care coverage. this case study described the dimensions supporting and inhibiting pregnant women in the puskesmas purwoyoso work area conducted on august-november 2019. the informants of the research consisted of 42 pregnant women. data collection was conducted using interviews and observation techniques. the instrument used was an interview guide, recorder, and observation sheet. the result of the research showed the factors supporting healthcare service in semarang area, semarang health office always monitoring the condition of pregnant women through the result of examination on pregnant women facilitation in the application, updating pregnancy article, making innovation of application to facilitate pregnant women in accessing and using the application. puskesmas purwoyoso promotes the application when pregnant women have their pregnancy examined in puskesmas and the implementation of pregnant women class. the maternal and neonatal health surveillance officer promotes the application when visiting the pregnant women’s house for facilitating the pregnant women. this application has an advantage over other pregnancy application so that pregnant women puskesmas purwoyoso work area can get many benefits. inhibiting factor includes the highland condition of residence, pregnant women having no android smartphone and memory data of smartphone android of pregnant women has been full. introduction information and communication technology (ict) can be enjoyed by everyone. the development of ict contributes to the community, including the health sector, either positively or negatively. the positive contributions of ict to the health sector are: accelerating the public service, facilitating the data’s accessibility, facilitating communication between health workers, facilitating data checking, and saving place. the negative contributions (weaknesses) of it are: resulting in health disorders such as eye disorder, depending on the electric power https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.3.2019.112-119&domain=pdf&date_stamp=2019-12-30 south east asia nursing research, vol 1 no 3, december 2019/ page 112-119 113 tiwuk puji rahayu / dimensions supporting and inhibiting pregnant women in using “sayang bunda” application supply, health workers depending on the application used, its use needs special practice.1 a variety of healthcare applications have been developed by the republic of indonesia’s ministry of health, sehatpedia, indonesia health facility finder (iheff), e-sign, e-postorder alkes pkrt,2 program indonesia sehat with a family approach.3 visit schedule and information about women pregnancy health is contained in the design of an android-based pregnancy visit application.4 the cloud computing-based pregnant women application gives some benefits: consultation with obstetrician and sharing experience between pregnant women.5 the use of an android-based pregnant women application increases the proportion of antenatal care with good quality.6 “sayang bunda” application is the android-based pregnancy application launched by semarang health office on july 2019 aiming to help pregnant women find out their pregnancy health, so that it is expected to improve the four-visit antenatal coverage of pregnant women. content or menu contained in “sayang bunda” android-based application is the facilitation of pregnant women's health, online consultation with gasurkes kia officers, pregnancy article, date of delivery estimation, proximate healthcare center, and general information. “sayang bunda” android-based mobile application is a new product in puskesmas semarang’s work area because it is marketed simultaneously to pregnant women on july 2019.7 semarang health office’s data shows that the four-visit antenatal care coverage in semarang is 97.57% (28,060 visits) and lower than the target specified.8 this data also shows that the four-visit antenatal care coverage of puskermas purwoyoso is 73.1% and does not meet the target of the program; it is the one with the lowest fourvisit antenatal care coverage in semarang.9 the four-visit antenatal care coverage is used to find out the coverage of antenatal care comprehensively (meeting the standard service and using the time specified) as the representation of pregnancy women protection level and the sustainability of maternal and neonatal health program. inadequate antenatal care visit of pregnant women can be hazardous to mother and fetus she has.10,11 pregnant women with less than four-pregnancy visits has maternal death risk of 4.57 times higher than those with 4-visit anc or more regularly.12 in the implementation of semarang’s local regulation number 2 of 2015 about maternal and neonatal safety, the “sayang bunda” android-based mobile application is expected to help pregnant women maximally in puskesmas purwoyoso’s work area, semarang, in monitoring their pregnancy so that their 4-visit antenatal care coverage can improve. considering the result of a preliminary study on gasurkes kia in puskesmas purwoyoso, it can be seen that the acceptability and use of the “sayang bunda” application are still low in puskesmas purwoyoso, only 12 out of all pregnant women targeted to use the “sayang bunda” application. this research employed rogers’ diffusion innovation theory and anderson’s satisfaction theory. in using “sayang bunda” android-based application in pregnant women, there are supporting and inhibiting dimensions that should be recognized. methods the research method employed in this study was qualitative analysis one with a case study research type to obtain an indepth description of dimensions supporting and inhibiting pregnant women in the application use. this research was conducted from august to november 2019. this research was conducted in puskesmas purwoyoso’s work area because the 4-visit antenatal care (anc) coverage in this work south east asia nursing research, vol 1 no 3, december 2019/ page 112-119 114 tiwuk puji rahayu / dimensions supporting and inhibiting pregnant women in using “sayang bunda” application does not achieve the target and is the lowest coverage throughout semarang. informants of the research consisted of 42 pregnant women. data collection was carried out using interviews and observation techniques. the instruments used were interview guide, recorder, and observation sheet. the variables were supporting and inhibiting factors of pregnant women in puskesmas purwoyoso’s work area. the method of analyzing data used was descriptive analysis one. to validate the data of research, source and triangulation techniques were used. source triangulation was obtained from the public health division of health office responsible for the “sayang bunda” application and gasurkes kia as the facilitator of pregnant women. technique triangulation was conducted by observing the result of the interview with respondents. results “sayang bunda” application has been created semarang health office aiming to help pregnant women recognize their pregnancy health, thereby expectedly improving their 4-visit antenatal care (anc) coverage and it has been trialed in three puskesmas (public health centers) on june 2019: puskesmas gayamsari, tlogosari wetan, and puskesmas kedungmundu. the result shows that some constraints were still found in its operation: pregnant women still found difficulty in logging into the application, some gasurkes kia have not used the application yet, and many pregnant women still decline to use the “sayang bunda” application. this “sayang bunda” android application can be obtained by downloading it for free through play store on an android smartphone. figure 1. login “sayang bunda” application menu of “sayang bunda”-android application includes pregnant women facilitation, birth consultation, proximate healthcare center, pregnancy article, date of delivery calculator, and general information. figure 2. menu of “sayang bunda” application characteristics of informants the result of research on the characteristic of informants is presented in table 1. that showed that nearly all of the pregnant women (92.86%) are 20-35 years old. most (54.76%) of pregnant women are housewives. almost all pregnant women (80.95%) have secondary education level. most of them (76.19%) have medium income. all (100%) of pregnant women are muslims. all (100%) of them live in a plain south east asia nursing research, vol 1 no 3, december 2019/ page 112-119 115 tiwuk puji rahayu / dimensions supporting and inhibiting pregnant women in using “sayang bunda” application area. less than half (35.73%) of them are in the second-trimester gestation. most (71.43%) of them are multigravida. most (73.81%) of them have plain joe's lifestyle. almost all (92.86%) of them show rational consumer behavior. table 1. characteristics of pregnant women in puskesmas purwoyoso’s work area, semarang (n=42) characteristics category total f % age <20 years 20-35 years ‘> 35 years 0 39 3 0 92.86 7.14 occupation merchant labor/farmer civil servant tni/polri (army/police) retired entrepreneur private housewife 0 0 0 0 0 2 17 23 0 0 0 0 0 4.76 40.48 54.76 education primary/low secondary high 3 34 5 7.14 80.95 11.91 income low medium high very high 0 32 6 4 0 76.19 14.29 9.52 religion islam christian catholic hindu buddha konghucu belief in god 42 0 0 0 0 0 0 100 0 0 0 0 0 0 residence area coastal village/kelurahan non-coastal village/kelurahan slope/peak village/kelurahan valley village/kelurahan plain village/kelurahan 0 0 0 0 42 0 0 0 0 100 pregnancy trimester i trimester ii trimester iii 14 15 13 33.33 35.72 30.95 pregnant status primigravida multigravida 12 30 28.57 71.43 lifestyle kelompok swingers kelompok seekers kelompok plain joes 2 9 31 4.76 21.43 73.81 consumer behavior rational consumer behavior irrational consumer behavior 39 3 92.86 7.14 supporting dimension the result of the interview with informants shows that the “sayang bunda” application is marketed simultaneously to pregnant women in all work areas of puskesmas throughout semarang in july 2019. pregnant women can access this application by means of downloading it for free in play store on the android smartphone; this application has content/menu different from other pregnancy applications do. the difference lies on a menu of pregnant women facilitation displaying the women’s result of pregnancy examination in gasurkes kia south east asia nursing research, vol 1 no 3, december 2019/ page 112-119 116 tiwuk puji rahayu / dimensions supporting and inhibiting pregnant women in using “sayang bunda” application visit including weight, blood pressure, forearm circle, fundus uterine height, complaint, pregnancy risk, and etc. the online consultation menu contains the phone number of gasurkes kia (health worker) facilitating the pregnant women. the healthcare facility menu contains all healthcare services available in each subdistrict existing in semarang. the date of the delivery calculator menu enables us to get an estimation of the due date by entering the first day of the last menstruation and monthly menstruation cycle into it. the pregnancy article menu contains many articles on pregnancy and neonatal health. the general information menu contains any general information on health in semarang. the content/menu of the “sayang bunda” application will be filled in by gasurkes kia based on the women’s result of pregnancy examination during home visit. the menu of pregnancy articles is always updated by the public health division of semarang health office. puskesmas purwoyoso and gasurkes kia promote the “sayang bunda” application since its launching. promotion is conducted at any time when the officer sees pregnant women, both during the examination in the puskesmas or in the implementation of pregnant women class and during the home visit for facilitating pregnant women. “sayang bunda” application connects pregnant women online to the public health division of semarang health office so that their health condition can be monitored by the public health division of semarang health office. generally, “sayang bunda” application has some advantages over other pregnancy applications: pregnant women can know their pregnancy health condition and can tell it to others by opening “sayang bunda” application on their own smartphone, pregnant women can acquire knowledge on pregnancy and fetal health, baby, postpartum, and health advise to maximize maternal and fetal health, pregnant women can access easily the result of pregnancy examination facilitation conducted in this application, pregnant women know their pregnancy condition routinely and periodically, it establishes closer relationship between pregnant women and gasurkes kia officers, pregnant women should not pay to get this application as it is given for free by downloading it, pregnant women can consult online with gasurkes kia officer, this application is simple, complete, and usable and operable, and this application is portable as it is inherent to pregnant women’s smartphone. inhibiting dimension “sayang bunda” application is still new as it has just been launched in july 2019 by semarang health office; thus many pregnant women have not known the application yet. the result of current research shows that not all pregnant women existing in puskesmas purwoyoso have android smartphones. some pregnant women or their families have no android smartphone. some others have it but it is brought by their husband or child, while the pregnant women do not have it. it inhibits the use and the access to “sayang bunda” application. pregnant women’s residence location is high land so that the android smartphone signal is poor. only some pregnant women’s houses subscribe to wifi. it makes pregnant women accessing the “sayang bunda” application difficultly. android smartphone has some limitation in the term of application that can be downloaded. pregnant women in puskesmas purwoyoso’s work area have their own need in accessing the application in their android smartphone so that android smartphone often encounters application overload. it inhibits access to other applications, including the “sayang bunda” application. south east asia nursing research, vol 1 no 3, december 2019/ page 112-119 117 tiwuk puji rahayu / dimensions supporting and inhibiting pregnant women in using “sayang bunda” application some pregnancy applications have been available on the internet and can be accessed in pregnant women’s android smartphone easily and for free. pregnant women consider them more important than the “sayang bunda” application so that they decline to use the “sayang bunda” application during their pregnancy. discussion the satisfaction with healthcare service access can be achieved when the healthcare service can be distributed well based on geographic location, social-economic condition, and people’s demand.13 a developing country has varying demographic characteristics including plain, hill, swamp, jungle, and coast.14 pregnant women with higher education levels are aware of their and their family’s health.15 those with lower education levels have limited language use. the health workers can explain with the reverse sheet containing supporting images or other visual aids.16 the working women have no time to have their pregnancy examined. housewives also consider their chores like washing and taking care of children as the constraint in accessing anc service.17 the accessibility of information on pregnancy in various media can be obtained by pregnant women with high economic status.16 more knowledge, comprehension, and experience related to pregnancy and its complications are acquired in older pregnant women so that the frequency of anc visits in this age group is higher than that in younger pregnant women.18 primigravida women have not had experience with pregnancy risk and complication. therefore, pregnant women utilize anc visits to acquire information.19 supporting dimension pregnancy application evidently improves pregnant women’s knowledge, attitude, and behavior effectively related to the prevention of pregnancy and birth complications.20 health education or pregnancy article and technical service on smartphone applications for pregnant women trigger the change of behavior and improve the quality of antenatal care (anc).21 health worker’s support affects pregnant women’s knowledge, attitude, and behavior to pregnancy application and anc visit.22 health workers affect positively the successful promotion of healthcare service to the community.23 inhibiting dimension technology advance is something inevitable today; therefore it can be utilized to create innovation, one of which is by utilizing the android operating systembased cellular phone.24 data indonesian internet service provider association (data asosiasi penyelenggara jasa internet indonesia or apjii)’s data shows that nearly half (48.57%) of internet penetration occurs in female users in indonesia. the penetration of internet users by ware ownership indicates that half (50.08%) of internet users use smartphones/tablets. the utilization rate of the internet for the health sector includes 51.06% for searching for information on health and 14.05% for consulting with health professionals. the service accessed mostly (89.35%) is chatting one.25 in her study entitled health care and social media: building relationships via social network, brittany a. hackworth from morehead state university, found that healthcare service providers in the united states of america use internet in marketing their healthcare service to communicate actively with their patients, by developing (patientslikeme and south east asia nursing research, vol 1 no 3, december 2019/ page 112-119 118 tiwuk puji rahayu / dimensions supporting and inhibiting pregnant women in using “sayang bunda” application inspire) application and utilizing social media (facebook, twitter, facebook).26 pregnant women’s residence location is high land so that the android smartphone signal is poor. only some pregnant women’s houses subscribe to wifi. it makes pregnant women accessing the “sayang bunda” application difficultly. android smartphone has some limitation in the term of application that can be downloaded. pregnant women in puskesmas purwoyoso’s work area have their own need in accessing the application in their android smartphone so that android smartphone often encounters application overload. it inhibits access to other applications, including the “sayang bunda” application. some pregnancy applications have been available on the internet and can be accessed in pregnant women’s android smartphone easily and for free. conclusion the advantages of the “sayang bunda” application and the support coming from gasurkes kia, puskesmas purwoyoso, and semarang health office can be used as an alternative to support the pregnant women to access and to use “sayang bunda” application. the presence of supporting dimensions from many parties is expected to deal with the inhibiting ones in the use of “sayang bunda” application, and thereby many more pregnant women in puskesmas purwoyoso’s work area will access and use the application and it can improve the 4visit antenatal care coverage in puskesmas purwoyoso. acknowledgments the authors would like to express their gratitude to the health office of semarang city, and puskesmas purwoyoso for their support in the use of the “sayang bunda” application. they also thank gasurkes kia, pregnant women and post-partum women for participating in supporting the application. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. reynold. cerdas dan terampil teknologi informasi dan komunikasi. jakarta; 2010. 2. kementerian kesehatan republik indonesia. kemenkes luncurkan 4 aplikasi bidang kesehatan. 2018. 3. kementerian kesehatan republik indonesia. pedoman umum program indonesia sehat dengan pendekatan keluarga. jakarta; 2016. 4. apriyani me, qodir a. perancangan aplikasi kunjungan kehamilan. batam: jurusan teknik informatika, politeknik negeri batam; 2014. 5. wibowo a. perancangan aplikasi konsultasi ibu hamil berbasis cloud computing. 2018;ix(1):18. 6. farhati n, husin f. penerapan aplikasi sahabat ibu hamil ( asih ) terhadap peningkatan kualitas pelayanan antenatal di pedesaan. 2018;9(november):352-359. 7. semarang dkk. dinas kesehatan kota semarang luncurkan empat sistem aplikasi terbaru untuk mengoptimalkan pelayanan. 2019:1. 8. dinas kesehatan. profil kesehatan kota semarang 2017. 2017:48-49. doi:10.2307/1942600 9. semarang dkk. profil dinas kesehatan kota semarang. 2012. 10. kementerian kesehatan ri. profile kesehatan indonesia tahun 2017. minist heal indones. 2018:107-108. doi:10.1002/qj 11. drife jo. maternal mortality. curr obstet gynaecol. 2002;12(6):314-321. doi:10.1054/cuog.2002.0286 south east asia nursing research, vol 1 no 3, december 2019/ page 112-119 119 tiwuk puji rahayu / dimensions supporting and inhibiting pregnant women in using “sayang bunda” application 12. noor h. analisis faktor resiko terhadap kematian maternal di kabupaten bulukamba. media kebidanan poltekkes makasar. 2010;2(2):47-55. 13. idris h. ekuitas terhadap akses pelayanan kesehatan : equity of access to health care : theory & aplication in research. j ilmu kesehat masy. 2016;7(2):73-80. https://www.neliti.com/publications/58014/ equity-of-access-to-health-care-theoryaplication-in-research. 14. haque a, dash sk, abdul m, chowdhury b. maternal health care seeking behavior : the case of haor ( wetland ) in bangladesh. bmc public health. 2016:1-9. doi:10.1186/s12889-0163296-2 15. awasthi ms, awasthi kr, thapa hs, saud b, pradhan s, khatry ra. utilization of antenatal care services in dalit communities in gorkha , nepal : a cross-sectional study. 2018;2018. 16. kim kh, choi jw, oh j, moon j. what are the barriers to antenatal care utilization in rufisque district , senegal ?: a bottleneck analysis. 2019;34(7):1-19. 17. chi pc. a qualitative study exploring the determinants of maternal health service uptake in post-conflict burundi and northern uganda. 2015;(april). doi:10.1186/s12884-015-0449-8 18. ayalew tw, nigatu am. focused antenatal care utilization and associated factors in debre tabor town , northwest ethiopia , 2017. bmc res notes. 2018:1-6. doi:10.1186/s13104-0183928-y 19. yeneneh a, alemu k, dadi af, alamirrew a. spatial distribution of antenatal care utilization and associated factors in ethiopia : evidence from ethiopian demographic health surveys. 2018;(december). doi:10.1186/s12884-0181874-2 20. fratidhina y, nursyirwan s, machmud r, duarsa ab. pengembangan model yudhia sebagai pendekatan persalinan berbasis aset dan partisipasi masyarakat. 2017. 21. mcnabb m, chukwu e, ojo o, shekhar n. assessment of the quality of antenatal care services provided by health workers using a mobile phone decision support application in northern nigeria : a pre / post-intervention study. 2015:1-12. doi:10.1371/journal.pone.0123940 22. nirmala. hubungan pengetahuan dukungan suami dan dukungan suami dan dukungan tenaga kesehatan dengan kunjungan antenatal. 2014;3(april):97-102. 23. sabati mr. peran petugas kesehatan terhadap keberhasilan pemberian asi eksklusif. 2015:121. 24. wikipedia. android ( operating system ). 2015:1-39. 25. apji. penetrasi & perilaku pengguna internet indonesia. apjii. 2017;2018(31 august 2018):hasil survey. 26. hackworth ba, kunz mb. health care and social media: bulding relationships via social networks. acad heal care manag j. 2010;6(1):55-68. analysis relationship family support and health cadre with elderly hypertension practice in controlling health at primary health care mranggen demak corresponding author: ninin irani nininirani.ni@gmail.com south east asia nursing research, vol 1 no 1, june 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.1.2019.7-13 original article analysis relationship family support and health cadre with elderly hypertension practice in controlling health at primary health care mranggen demak ninin irani1 1 primary health care of mraggen demak article info abstract article history: accepted may 7th, 2019 key words: practice; elderly; health control; hypertension hypertension is a major risk factor for cardiovascular disease which is the leading cause of death in indonesia. data research department of health in 2005, showed hypertension and cardiovascular disease is still quite high and even tends to increase with the lifestyle that much of the behavior of healthy and clean life, high cost of treatment of hypertension, erroneous perception of the public accompanied by a lack of safety facilities hypertension , hypertension is actually a disease that can be prevented if the risk factors can be controlled and healthy behaviors (healthy behavior) which practices or activities related to efforts to maintain, control and improve health. data from demak district health department, the incidence of hypertension has increased within the last three years. the aim of this study was to determine the relationship of family support and cadres with elderly hypertension practices in controlling health in puskesmas mranggen, demak by using a cross-sectional study with a quantitative approach. the sample size for a quantitative approach is 285 respondents (total sampling). the data were analyzed using univariate, bivariate with chi-square. the results showed an association between family support for elderly people who suffer from hypertension with the practice of elderly hypertension in controlling health (p = 0.048), there is a relationship between support for health workers to the elderly who suffer from hypertension with practice elderly hypertension in controlling health (p = 0.049). advice to the puskesmas officers in order to improve the quality of health care, home visits, provide health education particularly on controlling health benefits for elderly hypertension and cross-sectoral cooperation in the implementation of an integrated program of coaching post (posbindu) elderly. introduction hypertension is a major risk factor for cardiovascular disease which is the leading cause of death in indonesia. data research department of health in 2005, showed hypertension and cardiovascular disease is still quite high and even tends to increase with the lifestyle that is far from healthy and hygienic behavior, high cost of treatment of hypertension, accompanied by a lack of safety facilities hypertension. if https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.1.2019.7-13&domain=pdf&date_stamp=2019-06-23 south east asia nursing research, vol 1 no 1, june 2019/ page 7-13 8 ninin irani / analysis relationship family support and health cadre with elderly hypertension practice in controlling health at primary health care mranggen demak left untreated hypertension, the blood pressure will continue to increase gradually, resulting in the excessive workload of the heart.1 the excessive workload of the heart that will someday result in serious damage to the blood vessels and organs such as the heart, kidneys, eyes, and even rupture of capillaries in the brain, or better known by the name of a stroke. hypertension, also known as a heterogeneous group of diseases, which can affect anyone of various age groups, the elderly are the age group most susceptible to hypertension, as well as the social economy. the tendency of changing lifestyles as a result of urbanization, modernization, and globalization led to a number of risk factors that may increase morbidity hypertension.2 38.8% of the elderly who suffer from hypertension, only 50% were treated regularly (controlled hypertension) and only half of the control well. that is, of all people with hypertension in indonesia that is wellcontrolled amount below 10%.3,4 it is easy to understand because it does not give symptoms of hypertension. such conditions appropriate to the nature of hypertension as the silent killer (silent killers), because many people do not pay attention to a disease that is sometimes taken lightly by them, without knowing if the disease is dangerous from a variety of disorders that more fatal for example, abnormal blood vessels, heart (cardiovascular) and kidney problems and many patients who come for treatment when already severe vascular damage.5 hypertension is actually a disease that can be prevented if the risk factors can be controlled and healthy behaviors (healthy behavior) that the conduct or activities related to efforts to maintain and improve health. those efforts include monitoring blood pressure regularly, healthy living programs without smoke, increased physical activity/exercise, a healthy diet with caloric balance through the consumption of high-fiber, low-fat and lowsalt, it is a combination of independent efforts by individuals / communities and supported by the existing health care program and should be done as early as possible, in hypertensive patients require regular maintenance in order to know their blood pressure. patients with hypertension should perform routine checks that hypertension in misery can be controlled well.2 data from demak district health offices, the incidence of hypertension has increased within the last three years, in 2011 was 889 cases (13.6%), the year 2012 amounted to 1 235 cases (16.5%) and the year 2013 by 2173 (17, 8%) and ranked first 10 elderly diseases. data in demak mranggen health center in the last 3 years, in 2011 was 935 cases (12%), in 2012 as many as 1150 cases (14.5%) and in 2013 amounted to 1 325 cases (16.3%) and is the second highest after joint disease of 1570 cases (21%). based on reporting records of posyandu elderly source healthy kale village, turns hypertension in the elderly was ranked first in the amount of 64% (130 people), joint disease 20% (41 people) of 203 elderly who are registered as members of posyandu. of hypertensive patients is only 32% (42 people) who carry out regular inspections of each month, the rest do not do on a regular basis.1 from the report the practice of nursing care performed s1 students of nursing, the university of muhammadiyah semarang in puskesmas mranggen in january-march 2014, of 318 elderly with hypertension, 145 (46%) perform a routine check on health services, the rest do not conduct regular inspections, it is because the reason does not have money for treatment, felt bad for being a burden his family, no escort because they live alone, considers the disease is a mild disease that does not need to be checked regularly. in a society often found misconceptions about the illness. many members of the south east asia nursing research, vol 1 no 1, june 2019/ page 7-13 9 ninin irani / analysis relationship family support and health cadre with elderly hypertension practice in controlling health at primary health care mranggen demak public when they are already sick can not work or is not able to get out of bed. communities affected by the disease but do not feel pain (disease but no illness) will not act anything against the disease, but if they are affected by the disease and also feel pain then there will be a business and kinds of behavior, ie no action (no action), acting treat yourself (self-treatment) and seek traditional treatment started (traditional remedy), up to modern medical facilities organized by practitioners (private modern medicine).6 someone will take preventive action is influenced by demographic variables (education, knowledge, age, and occupation) of individuals as well as for instructions to behave (cues to action) alleged right to start the process of behavior, which is derived from information or advice on the health problems of hypertension. health behaviors someone starts that behavior is a function of one's intention to act (behavior intention), social support from family and the surrounding community (social support), lack of access to health services (accessibility of health care), personal autonomy of people concerned in terms of taking the actions or decisions (personal autonomy) as well as the situation allows it to act (action situation). 7 methods this type of research is explanatory research using a cross-sectional approach. the population in this study were all elderly with hypertension, aged ≥ 60 years or older and live in the region puskesmas mranggen demak between the months of june to december 2014. the sample size in this study is total sampling that all the elderly who suffer from hypertension, aged ≥ 60 years or older and live in the region puskesmas mranggen demak, as many as 285 people. measuring tool used to obtain quantitative data in this study is a questionnaire in the form of written questions to uncover the independent and dependent variables. to prove the validity of the questionnaire used in this study has been tested for validity and reliability, the trial questionnaires in puskesmas karangawen demak with the number of respondents 30 elderly. validity test conducted with product moment correlation test, while the reliability test using cronbach alpha statistic test. independent variables: family support, and support health workers while the dependent variable was the practice in controlling hypertension elderly health. once the data is collected, then processed by examining the questionnaire, editing, coding, scoring and tabulating the data analyzed. data analysis aimed to determine the relationship between independent variables with the dependent variable. in addition, the analysis was also used to test the research hypothesis. analysis techniques used include: univariate, is used to analyze the variables variables that exist in descriptive by calculating the frequency distribution and proportion. the bivariate analysis consists of: (1) cross tabulation analysis is used to summarize, determine the distribution of data and can also be used to analyze descriptively. (2) the comparative analysis (correlation test) as the basis for testing the research hypothesis. this analysis using chi-square test with α = 0.05. results practice in controlling health elderly average practices committed by the respondent in controlling health was 5.47 ± 1.721 with a minimum of 2 and a maximum value of 8. practice elderly hypertension in controlling health have largely been good, that is 69.1% and less by 30.9 %, but there are about 59.6% do not exercise regularly, 44.2% were still smoking and a diet as recommended by 35.1% and 33.7% still consume alcoholic beverages. south east asia nursing research, vol 1 no 1, june 2019/ page 7-13 10 ninin irani / analysis relationship family support and health cadre with elderly hypertension practice in controlling health at primary health care mranggen demak family support average family support against the respondent was 9.04 ± 1.959 with a minimum of 2 and a maximum value of 11. the highest level of support from family is good support and the support of 88.1% less as much as 11.9%. most of the respondents have the support of the family, but in practice control the health of the respondents did not receive full support from the family, it is pointed out there are still 26.3% of families do not take the time to the respondents, 24.9% of respondents did not want to deliver to check the health stewardship , 21.8% of families do not support all the activities of the respondents and 18.6% of families do not bear all the costs of treatment responders. support health cadre average support cadres of the respondents were 2.86 ± 2.152 with a minimum value of 1 and a maximum of 7. the level of support from most health cadres is good support at 51.2% and less support as much as 48.8%. respondents who have the support of a cadre of good health and a lack of support is quite balanced, this is indicated approximately 58.2% health worker gives advice about the disease that affects the elderly, 55.1% of health volunteers reminded to conduct periodic examinations, 53 , 3% taught how to care and 52.3% were advised to rest, while support health volunteers demonstrated less than 87% volunteer health worker to deliver health services, 79.3% did not teach gymnastics, and 67.4% are not health workers organize posyandu elderly. from the analysis of the relationship between health workers to support the elderly who suffer from hypertension in the elderly hypertension practice in controlling health showed that there were 98 (75.4%) of respondents who have less support health cadres to practice good health control. while respondents who have the support of good health cadres there are 99 (63.9%) who practice good health control, and that there are as many as 32 (24.6%) of respondents who have less support health cadres to practice controlling ill health. while respondents who have the support of good health cadres there were 56 (36.1%) who practice controlling ill health. the results of the statistical test chi-square test obtained by value p = 0,049 with an error rate of 5%, it can be concluded that there is a relationship between health workers to support the elderly who suffer from hypertension in the elderly hypertension practice in controlling health discussion the support given by the family of the elderly with hypertension who control practices in good health, is they have been warned to want to check, reminded to take his medication regularly, delivering check, help with the cost check, remind to reduce salt, adequate rest, quitting smoking, advise many worships and pray, while the family of advanced age is not doing well health control practices revealed that they have made efforts reminded to check, recommends to check, eat right, do a heavy work the size of the support provided by the family is also closely linked to the family's understanding of the perception of vulnerability, perceived severity, perceived benefits, perceived barriers, and access to health services. from the analysis of the relationship between family support for elderly people who suffer from hypertension in elderly hypertensive practices in controlling health showed that there were 18 (52.9%) of respondents who have less family support practices with good control of their health. while respondents who have good family support there were 179 (71.3%) who practice good health control, and that there are as many as 16 (47.1%) of respondents south east asia nursing research, vol 1 no 1, june 2019/ page 7-13 11 ninin irani / analysis relationship family support and health cadre with elderly hypertension practice in controlling health at primary health care mranggen demak who have less family support practice controlling ill health. while respondents who have good family support there were 72 (28.7%) who practice controlling ill health. the results of the statistical test chi-square test obtained by value p = 0,048 with an error rate of 5%, it can be concluded that there is a relationship between family support for elderly people who suffer from hypertension in elderly hypertensive practices in controlling health. humans as social beings can not live alone without the help of others. physical needs (clothing, food, housing), social needs (association, recognition, school, work) and psychological needs including curiosity, a sense of security, feelings of religiosity, not be fulfilled without the help of others.8 especially if the person is facing problems, whether mild or severe. at moments like that, someone would seek social support from the people around him, so he feels valued, cared for and loved. social support can be regarded as something beneficial situation, providing assistance for individuals obtained from another person who can be trusted and as the availability and willingness of those means, which can be trusted to assist, encourage, receive, and keep individual. from these circumstances, the individual will know that other people pay attention, respect, and love. the family is a source of social support for family relationships to create a relationship of mutual trust. the individual as a member of the family will make the family as a collection of hope, a story, ask, and issuing complaints when the individual is experiencing problems.9 according to green's theory that social support is one factor that strengthens a person to perform a specific behavior.7 family support can include emotional support, instrumental, information, and assessments.10 emotional support involves the physical strength and the desire to believe in others so that the individuals concerned became convinced that others are able to provide love and affection to him, support instrumental, such as the provision of means to facilitate or help others as an example is the equipment, supplies, and other supporting facilities and including providing a timely opportunity. informative support for the provision of information to resolve personal problems, namely the provision of advice, guidance, and other information required by the individuals concerned as well as support for assessment in the form of social roles that include feedback, social comparison, and affirmation (approval). giving support to the elderly requires an understanding of the family about the perception of vulnerability, perceived severity, perceived benefits, perceived barriers, access to health services and presence (availability) as well as the accuracy / appropriateness (adequacy) of such assistance for the elderly, so as not to cause social support given misunderstood and not well targeted. if the elderly (for various reasons) are no longer able to understand the significance of social support, it is necessary not only social support or maintenance service but socially (social care) completely.11 support has been done by the families in this study were mostly families have made efforts observing condition/disease state, suggesting to pray, remind to always obey the doctor's advice, suggesting to adequate rest, and provide information about the disease. results cross check with the family of respondents indicated that the majority of families of respondents have understood recurrence risk factors, complications may occur, along with the health benefits of exercise control obstacles that may occur as well as access gained in an effort to control the practice of health of elderly hypertensive. the support provided by the family tried to remind to want to check, reminded to take his medication regularly, south east asia nursing research, vol 1 no 1, june 2019/ page 7-13 12 ninin irani / analysis relationship family support and health cadre with elderly hypertension practice in controlling health at primary health care mranggen demak delivering the check, help with the cost check, remind to reduce salt, adequate rest, smoking cessation, suggesting to many worships and pray. this suggests that with good family support would encourage elderly hypertensive to practice good health control anyway. social support has an important role to prevent health threats,10 high social support would make the elderly more optimistic in the face of today's life and future, more skilled in meeting the psychological needs and have a higher system, as well as lower levels of anxiety, enhance interpersonal skills, have the ability to achieve what they want and be able to guide the elderly to adapt to stress that health problems are being encountered can be resolved properly and is able to perform optimal health control practices. social support for the elderly is very necessary for the elderly themselves are still able to understand the meaning of social support such as a supporter/sustainer of life, but the life of the elderly is often found that not all elderly people are able to understand the social support from others, so even though he had received social support but still just indicate dissatisfaction, which is shown by way grumble, disappointed, upset and so forth. this can happen because of the support provided is not sufficient, the elderly feel no need to be assisted or worry too much emotionally that do not pay attention to the support provided, the support provided is not in accordance with what is required of elderly, a source of support for setting a bad example for the elderly, as do suggest unhealthy behaviors and to maintain or support the elderly in doing anything it wants. this situation can disrupt health control practices should be done by the elderly and causes the elderly to become dependent on others. in this study support given by health workers include: remind the elderly to carry out checks at regular intervals, suggesting to many breaks, dropping to health services, provide advice about the disease, the elderly posyandu organize, teach gymnastics elderly and teach how to care. there is some support for health cadres perceived by the respondents is not optimal they are escorted to health care, teaching gymnastics elderly and organizing posyandu, this is due to the limited number of health volunteers are active in every village, most of the implementation of posyandu still join the posyandu toddler, while the results of cross-checking with the families of the respondents about the support given to elderly hypertensive cadres showed the majority of respondents said that family health volunteers have held posyandu, gymnastics, giving advice about the disease, and taught to live a healthy life. meanwhile, in the opinion of its own health workers, they have been warned to check, suggesting to many breaks, advise, encourage and teach you how to care to posyandu. thus, the better support health volunteers to elderly hypertension will increase efforts to elderly hypertension to control their health and supported by a good understanding of the factors that are at risk of recurrence, complications may occur, the benefits to control health along with the obstacles that may occur and access gained in an effort to control the practice of health of elderly hypertension is the ability to provide support to elderly hypertensive to practice health control will also increase. conclusion from the results of the study showed that 69.1% of respondents have good health control practices and the remaining 30.9% had less health control practices, among others: there are about 59.6% do not exercise regularly, 44.2% still smoke and not on a diet as recommended by 35.1% and 33.7% still consume alcoholic beverages. 88.1% of respondents get good south east asia nursing research, vol 1 no 1, june 2019/ page 7-13 13 ninin irani / analysis relationship family support and health cadre with elderly hypertension practice in controlling health at primary health care mranggen demak family support and the remaining 11.9% have less family support. 51.2% of respondents have the support of good health cadres and the remaining 48.8% less to get the support of the health cadres. 71.9% of respondents get access to good health services and 28.1% had less access to health services. there is a relationship between family support for elderly people who suffer from hypertension in elderly hypertensive practices in controlling health. less family support, health management practices will be less as well. there is a relationship between health cadre support for elderly people who suffer from hypertension in elderly hypertension practices in controlling health. support cadre ill health, health management practices will be less as well. conflicts of interest the author declare that none of her had any conflict of interests. references 1. kemenkes. profil kesehatan jawa tengah tahun 2015. tengah dkpj, editor. semarang: dinas kesehatan provinsi jawa tengah; 2015. 2. rahajeng e, tuminah s. prevalensi hipertensi dan determinannya di indonesia. maj kedokt indones. 2009;59(12):580–7. 3. whelton pk, he j, muntner p. prevalence, awareness, treatment and control of hypertension in north america, north africa and asia. j hum hypertens [internet]. 2004 aug 22;18(8):545–51. available from: http://www.nature.com/articles/1001701 4. julius s. current trends in the treatment of hypertension: a mixed picture. am j hypertens [internet]. 1997 dec 1;10(12):300s-305s. available from: https://academic.oup.com/ajh/articlelookup/doi/10.1016/s0895-7061(97)00389-0 5. hoel d, howard rb, gifford rw. hypertension. postgrad med [internet]. 1997 feb;101(2):116–21. available from: http://www.tandfonline.com/doi/full/10.381 0/pgm.1997.02.155 6. notoatmodjo s. promosi kesehatan: teori dan aplikasi. jakarta: pt. asdi mahasatya; 2005. 7. notoatmodjo s. ilmu kesehatan masyarakat prinsip-prinsip dasar. jakarta: pt. rineka cipta; 2003. 8. potter, p. a., perry, a. g., stockert, p., & hall a. fundamental of nursing e-book. elsevier; 2016. 9. nasrudin e. psikologi manajemen. bandung: pustaka setia; 2010. 10. budiman na, istiarti t, bm s. faktor-faktor yang berhubungan dengan praktik wanita pekerja seks (wps) jalanan dalam upaya pencegahan ims dan hiv/aids di sekitar alun-alun dan candi prambanan kabupaten klaten. j promosi kesehat indones [internet]. 2008;3(2):120–6. available from: https://ejournal.undip.ac.id/index.php/jpki/ar ticle/view/2542 11. mahanani n. faktor-faktor yang berhubungan dengan perawatan diri kusta pada penderita kusta di puskesmas kunduran kecamatan kunduran kabupaten blora tahun 2011. 2013; available from: https://lib.unnes.ac.id/18240/ factors affecting indonesian nurse behavior in applying universal precaution corresponding author: wansuzusino wansuzusino@gmail.com south east asia nursing research, vol 1 no 2, september 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.2.2019.88-94 original research factors affecting indonesian nurse behavior in applying universal precaution wansuzusino wansuzusino1 1 messaieed medical center qatar petroleum article info abstract article history: accepted september 30th, 2019 key words: universal precaution; behavior; nurse professional nurses in carrying out their roles and functions on a daily basis, are always at risk of contacting various diseases. transmission of the disease can occur via direct or indirect contact, transmission can be through droplet transmission, and airborne transmission (cdc). universal precautions are one of the strategies that have been recommended by the centers for disease control and prevention (cdc) in efforts to control infection and disease transmission in health facilities, such as hospitals, doctors' practices, and other health care centers. the purpose of the study was to determine the factors that influence the behavior of indonesian nurses in implementing universal precaution in the center for health services in qatar. the research process was carried out in october 2011 in qatar with a total sampling method, a total sample of 52 respondents. the results showed that most indonesian nurses in qatar with a diploma in nursing, had work experience of more than 6 years. placed in various locations such as; ambulance services, company clinics and hospitals. there was no significant relationship between knowledge and nurses behavior in applying universal precaution (p <0.05). there was no significant relationship between attitude and behavior of indonesian nurses in implementing universal precaution (p <0.05). there was no significant relationship between motivation and the behavior of indonesian nurses in implementing universal precaution (p <0.05). there was a significant relationship (p <0.05) between the means and the behavior of indonesian nurses in implementing universal precaution. based on these results it is necessary to maintain the consistency of nurses to always apply universal precaution appropriately according to the patient's condition at hand introduction universal precautions are one of the strategies that have been recommended by the centers for disease control and prevention (cdc) in efforts to control infections and transmit diseases in health facilities, such as hospitals, clinical clinics, and other health care centers. standard precaution can prevent transmission of disease / microorganisms (duerink, et al. 2006). the principle of universal precautions is to assume all patients are affected or infected by microorganisms, with or without signs and symptoms so that a uniform level of prevention must be https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.2.2019.88-94&domain=pdf&date_stamp=2019-09-30 south east asia nursing research, vol 1 no 2, september 2019/ page 88-94 89 wansuzusino / factors affecting indonesian nurse behavior in applying universal precaution used in treating all patients (smeltzer, et al, 2009). universal precaution (up) ie. a way of handling that must be applied by health workers to minimize exposure to blood and body fluids from all patients who are sources of infection regardless of diagnosis or infection status (icn, 2009). this method was first introduced by the centers for disease control and prevention in the united states in 1987, one of its main objectives is to protect health care workers from disease transmission in health facilities by stressing the importance of treating all patients as potential contagious infections so that steps need to be taken adequate prevention (isa, 2006, from khairudin 2007). health workers have the potential to be exposed to blood during their duties and therefore they have the risk of being infected with diseases caused by pathogenic germs, such as hiv, hepatitis c virus, and hepatitis b virus. blood exposure can occur through percutaneous injury (needling or other sharp objects) ), mucocutaneous incidents (splashes of blood or body fluid mixed with blood on the eyes, nose or mouth) or blood contact with normal skin (kermode, et al, 2005). who (2002) estimates that among 35 million health workers worldwide, around three million have experienced percutaneous exposure to blood-borne viruses each year (two million hvb, 900,000 hcv and 300,000 hiv). this incident is estimated to result in infection of 16,000 hepatitis c, 66,0000 hepatitis b and 200 5000 hiv. more than 90% of these infections occur in low-income countries and whereas in developed countries can be prevented (kermode, et al., 2005) according to nopriadi, et al. (2004), hospital staff who have a high risk of getting nosocomial infections include: doctors, nurses, midwives and laboratory workers, given that these officers always check and make direct contact with patients. as health workers who are in the front lines of each health service center, nurses are always exposed to various cases of illness, this is very risky to the health of the health workers themselves. research conducted by anwar (2005) shows that universal precautionary procedures are still often ignored, influencing factors are lack of knowledge and lack of funds needed to support the implementation of universal precautionary procedures (khoirudin, 2007). according to harris, nicolai and richmond (2010), that almost all emergency medical service sites make a report if they are exposed to blood and body fluids, and they are aware of the risk of hepatitis and hiv. in addition ems officials were found to be inconsistent in applying the precaution standard when treating patients or when using syringes, such as not wearing gloves 17% and not removing contaminated objects (19%), including needles (87%) at any time. there were also reported cases of 40% needle recapping, 1.4% lanceolate, and 4.5% needle puncture. officers in the emergency room have a high risk of occupational infections by pathogenic germs through the blood, but unfortunately, according to evanoff, et al (1999) reported that adherence to the application of universal precaution is still low in clinical high-risk settings. compliance with the use of ppe is influenced by knowledge, attitudes, perceptions of risk, and organizational climate. in addition, the availability of ppe and convenient or easy use also have an effect. differences in the level of adherence to ppe observed between different work groups indicate that interventions designed for certain groups may be needed for changes in effects in the use of ppe and other precautions against blood-borne disease transmission. south east asia nursing research, vol 1 no 2, september 2019/ page 88-94 90 wansuzusino / factors affecting indonesian nurse behavior in applying universal precaution the procedure of universal precaution must absolutely be implemented in all health care centers, such as in emergency rooms, action rooms, triage rooms, observation rooms and laboratories, as well as in ambulances. various nursing procedures, both invasive and noninvasive, allow nurses to be exposed to germs that come from patients through blood and bodily fluids that contain blood. all nurses must apply universal precautionary procedures that are appropriate and consistent, at all times carrying out nursing actions for all patients, because in addition to selfprotection, also to prevent cross infection to patients or colleagues. universal precautions require nurses' abilities as executors, supported by facilities and infrastructure, as well as standard operating procedures that regulate universal precautions. health workers must get protection from the risk of contracting the disease in order to work optimally (mahardani, 2010). the purpose of this study is to determine the factors that influence the behavior of indonesian nurses in implementing universal precaution in the health service center in qatar. methods the study was conducted with a descriptive correlation method which is a study conducted to analyze the relationship between two research variables, namely between the independent variable and the dependent variable (nursalam, 2008). the design used is the cross sectional approach. the sample in this study were all indonesian nurses in qatar, amounting to 65 people (inna qatar, 2011). this research was conducted at the indonesian nurses community in qatar, the qatar indonesian national nurse association (ppni), which was carried out in october 2011. data collection tools with questionnaires and observation sheets. data were analyzed univariately, bivariately (pearson product moment correlation, spearman rank. kolmogorovsmirnov test). results the results obtained by indonesian nurses who work in qatar are mostly men, aged less than 40 years and have a diii education. in general they have ample work experience> 10 years. indonesian nurses working in qatar health care centers are scattered in several work locations, such as; in ambulances, in company clinics, and hospitals, and there are also those who work in ambulances and clinics. most indonesian nurses, have a positive attitude, and have high motivation, and expressed supportive means for the implementation of universal precaution. indonesian nurses mostly have positive behavior towards the implementation of universal precaution. normality test results for knowledge, means and behavior variables, the significance value is less than 0.05, then the data is not normally distributed, while the normality test for attitude and motivation variables, the significance value is greater than 0.05, then the data is normally distributed. obtained results there is no significant relationship between behavior with knowledge nurses, between attitudes with nurses' behavior, between motivation and behavior (table 1). table 1 correlation of knowledge, attitudes and motivation with nurse behavior in implementing universal precaution indicator correlation coefficient p nurse knowledge -0.260 0.063 the attitude of the nurse 0.037 0.797 nurse motivation 0.159 0.260 there is a meaningful relationship between facilities and infrastructure with behavior (table 2). south east asia nursing research, vol 1 no 2, september 2019/ page 88-94 91 wansuzusino / factors affecting indonesian nurse behavior in applying universal precaution table 2 correlation of facilities and infrastructure with nurse behavior in applying universal precaution indicator correlation coefficient p facilities and infrastructure available 0.458 0.001 discussion indonesian nurses working in qatar, mostly aged between 30 39 years old. characteristics of indonesian nurses working in qatar are mostly in the early adult phase so they have emotional maturity and can make the right decisions in carrying out their roles and functions as professional nurses . according to berg (1996) age is the age of the nurse who outlines an indicator in the maturity of each decision-making that refers to each of his experiences (rozulaina, 2007). indonesian nurses who work in qatar, in general, have had enough previous experience, where most respondents have a tenure of> 10 years before working in qatar, they have worked in company clinics in indonesia, and in hospitals, both in indonesia and abroad. siagian (1995) states, one's service life in the organization needs to be known, because tenure is one indicator of productivity and work motivation. furthermore siagian assumes that the longer a person works in an organization the higher the productivity, because he is more experienced and has high skills in completing tasks, but it is not impossible the opposite happens, that people who have long worked in the organization will show symptoms of decreased motivation and productivity work. if someone gets a good work experience in the past, it will also have a good effect in the new workplace, but conversely if the experience of something less certainly will affect the new work environment. the study described that male respondents were more dominant because the nurses' admission system from indonesia in qatar at this time was still dominated by male nurses, while female nurses were generally local. gender is the respondent's identity that is used to distinguish male or female nurses. siagian, (1995) states that there are certain types of work that are suitable for women or men. and the nursing profession is seen as a female profession, but it is also possible for men to enter the profession, but in small numbers. the study explained that indonesian nurses in qatar, most of them were nursing academy graduates. which means that most indonesian nurses are still at the level of semi-professional (vocational) nurses. low education level, but have a long working experience, will affect the behavior of nurses. the higher level of nurse education can influence nurses' behavior in applying universal precaution appropriately and correctly. the results of research on indonesian nurses have a high level of knowledge about universal precaution. high knowledge about universal precaution can encourage someone to behave according to the expected standard. knowledge of how diseases are transmitted and their prevention can encourage nurses to apply universal precaution appropriately and correctly. the study showed that most indonesian nurses had a positive attitude towards the adoption of universal precaution. a positive attitude of nurses can encourage nurses to behave positively towards the application of universal precaution to prevent transmission of disease, from patient to nurse and vice versa from nurse to other patients. the results showed that most indonesian nurses were highly motivated. motivation can arise from within an individual or come from the environment for someone and what gives direction to their activities south east asia nursing research, vol 1 no 2, september 2019/ page 88-94 92 wansuzusino / factors affecting indonesian nurse behavior in applying universal precaution the results of research on indonesian nurses showed that the majority of respondents stated the means of support. the availability of facilities at work is one of the factors that influence the formation of compliance and includes enabling factors (green, 2000). if the facilities and facilities are insufficient in the working environment, it is certainly difficult to achieve the goals of an organization. the availability of facilities and infrastructure has a very important role among other factors that influence the behavior of nurses in the application of universal precaution, because without the means and infrastructure, standard precaution cannot be applied precisely and consistently. the results obtained by the relationship between knowledge and behavior of nurses that are not significant (p <0.05) these results are in line with the study of regina, et al (2001) in hong kong, which showed no significant relationship between nurse knowledge and compliance with universal precaution and it is recommended that universal precaution training programs need to be considered to be combined with empirical knowledge. but this is different from the results of research conducted by karmode, et al (2005), which states that some actions that need to be emphasized to improve the compliance of health workers in the application of universal precaution, not only their knowledge and understanding, but also the importance of creating a safe environment by the organization that hired him. according to the results of research conducted by ndikom and onibokum (2007) there is a significant relationship between knowledge and behavior in hiv prevention among health workers in nigeria. according to the authors knowledge of how disease transmission and prevention can encourage nurses to apply universal precaution appropriately and correctly. however, high knowledge about universal precaution must also be supported by facilities / facilities available at the workplace agency. the results obtained by the correlation between attitude and behavior of nurses were not significant at (p <0.05). research conducted by oliviera, et al (2009) states that despite the fact that staff have adequate knowledge about universal precaution, they fail to behave appropriately in their actions to reduce the risk of spreading infectious agents and causes of work accidents. although there are still some respondents who are negative about universal precaution, it does not prevent them from continuing to apply universal precaution that is true and right in the workplace. whereas askarian, et al (2005) conclude that strong support for the achievement of the implementation of the standard precaution guidelines depends on several factors such as optimal awareness and positive attitudes each health worker has, and this goal cannot be achieved without continuing training by quality staff, as often mentioned in various literature. according to researchers a positive attitude needs to get support from other factors so nurses can behave optimally in applying universal precaution. the results obtained by the correlation between attitude and behavior of nurses were not significant at (p <0.05). these results are not in line with the results of research conducted by khairudin (2010) which concluded that there is a significant relationship between nurses' motivation in implementing universal prevention. mark cole, (2005) states that a motivational teaching approach is needed in changing the behavior of health workers to increase the level of compliance in applying hand washing before and after taking medical action. the author assumes that nurses' motivation in behavior in the application of universal precaution is not always consistent, because motivation can be influenced by factors of encouragement from within the individual, as well as outside the individual. the results obtained by the correlation between attitude and nurse behavior were south east asia nursing research, vol 1 no 2, september 2019/ page 88-94 93 wansuzusino / factors affecting indonesian nurse behavior in applying universal precaution significant at (p <0.05). this is in line with the results of research conducted by efstathiou et al (2011), stating that one of the inhibiting factors of health workers in implementing universal precaution is the unavailability of appropriate facilities and infrastructure when they need it. while the results of research conducted by ndikom and onibokum (2007) state that the facilities and infrastructure needed in practice must always be available, and so also the workplace environment must be sufficiently conducive to the application of universal precaution. these facilities and facilities essentially support or enable the realization of a behavior, so it is called a supporting factor or enabling factor (green, 2000). facilities and infrastructure in the nurse's workplace environment have the greatest influence on the application of universal precaution, because without adequate facilities and infrastructure, it is not possible for a nurse to apply universal precaution that is appropriate and consistent. limitations that exist in this study include the use of the study correlation approach method so that the relationship determined from the independent variable and the dependent variable is not a causal relationship, because the study was conducted at the same time and without any follow-up. and the absence of controlling factors in this study. with the limited number of respondents available, so that if this study is conducted with a larger number of samples, it will certainly produce better results. and there are still other factors that can be used as independent variables in this study, such as level of education, length of work experience, perceptions, sources of funds and others. data collection using a questionnaire has a very subjective impact so that the truth of the data depends on the honesty of the respondents. researchers have not found the standard standard questionnaire so that the instrument is based on the understanding and experience of the researchers themselves, which of course is still limited as a beginner researcher. the questionnaire was used for the first time although the results of the validity and reliability tests were quite good but only one research site was limited. appropriate and consistent application of universal precaution is very important for a nurse to provide nursing care to the clients. conclusion the results of the study of the factors influencing the behavior of indonesian nurses in implementing universal precaution at the qatar health service center, namely: the majority of indonesian nurses working in qatar are male, aged less than 40 years old, have a diii education, already have considerable work experience , spread across several work locations, such as; in ambulances, in company clinics, in hospitals, while most work in ambulances and clinics. there is a relationship between the availability of facilities and infrastructure with the behavior of indonesian nurses in carrying out universal preventive action procedures in the work environment. there is no relationship between the level of knowledge, attitudes and motivation of nurses on the behavior of indonesian nurses in carrying out universal preventive action procedures in health care centers. acknowledgements we wish to express our appreciation to all respondents who participated in this study for valuable assistance during data collection. conflicts of interest neither of the authors have any conflicts of interests that would bias the findings presented here. south east asia nursing research, vol 1 no 2, september 2019/ page 88-94 94 wansuzusino / factors affecting indonesian nurse behavior in applying universal precaution references 1. asmadi. 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(2000). health promotion planning an educational and environmental approach. (2nd ed.). mountain view: mayfield publishing company. 7. harris, s.a, nicolai, l.a. (2010). occupational exposures in emergency medical service providers and knowledge of and compliance with universal precautions. usa, apice, publikasi oleh elsevier inc. (american journal infection control 2010: 38. 86-94) 8. icn. (2009). nursing matter: infection control. fact sheet. jenewa, swiss 9. kermode, m et.al (2005). compliance with universal precaution among health care workers in rural india. australia. association for professional in infection control and epidemiology, inc. 10. khoirudin, a (2010). faktor-faktor yang mempengaruhi perilaku perawat dalam menerapkan prosedur tindakan pencegahan universal di instalasi bedah sentral rsup dr. karyadi semarang.unimus (skripsi) tidak dipublikasikan. 11. kusnanto. (2003). profesi dan praktik keperawatan profesional. jakarta. egc 12. mahardani, r. 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(2004). psikologi untuk keperawatan. jakarta egc history of low birth weight and exclusive breastfeeding on the incidence of acute respiratory infection in children under five years corresponding author: ni wayan wiwin asthiningsih nww131@umkt.ac.id south east asia nursing research, vol 4 no 4, dec 2022 issn:2685-032x doi: https://doi.org/10.26714/seanr.4.4.2022.18-24 original research history of low birth weight and exclusive breastfeeding on the incidence of acute respiratory infection in children under five years ni wayan wiwin asthiningsih1, milkhatun milkhatun1, alfi ari fakhrur rizal1 1 faculty of nursing, universitas muhammadiyah kalimantan timur, indonesia article info abstract article history: submitted: oct 1st 2022 accepted: nov 30th 2022 published: dec 15th 2022 keywords: exclusive breastfeeding; ari; low birth weight acute respiratory infections (ari) are one of the main causes of infectious disease morbidity and mortality worldwide. acute respiratory infection (ari) is a health problem that often occurs in children, and the group most at risk is children under five years. this study aimed to determine the relationship between nutritional status and exclusive breastfeeding on the incidence of ari in the working area of the loa bakung public health center, samarinda. this type of research is quantitative research using a crosssectional approach. the samples in this study were parents of children under five who visited the posyandu in the working area of the loa bakung public health center, samarinda. the sampling technique used was purposive sampling with a total sample of 181 respondents. the analytical test used in this research is chi-square. the chi-square test results on the history of lbw obtained a p-value = 0.373 and exclusive breastfeeding with a p-value = 0.440. this shows no relationship between a history of lbw and exclusive breastfeeding on the incidence of ari at the loa bakung public health center, samarinda. the incidence of ari in children under five years at the loa bakung public health center, samarinda, is not influenced by a history of lbw and exclusive breastfeeding. still, other factors could have influenced the incident that was not carried out in this study. the role of parents is very important in maintaining the health of their children under five years to prevent the occurrence of ari in their children under five years. introduction infants and children under five years are a group of people who are vulnerable to various diseases, especially infectious diseases. one of these infectious diseases is acute respiratory infection (ari). acute respiratory infection (ari) is an infectious disease that attacks one or more parts of the respiratory tract, from the nose (upper tract) to the alveoli (lower tract), including adnexa tissue, such as sinuses, middle ear cavity, and pleura. ari is a respiratory tract infection that lasts for 14 days.1 acute respiratory infection (ari) in indonesia is a disease that often occurs in children. according to who (world health organization) data, it is estimated that the incidence of ari in developing countries with under-five mortality rates above 40 per 1000 live births is 15-20% per year in the under-five age group.2 southeast asia has a prevalence that ranks first in the https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.4.4.2022.18-24&domain=pdf&date_stamp=2022-12-15 south east asia nursing research, vol 4 no 4, dec 2022/ page 18-24 19 ni wayan wiwin asthiningsih / history of low birth weight and exclusive breastfeeding on the incidence of acute respiratory infection in children under five years incidence of ari, estimated to be more than 80%. indonesia's health profile data in 2018 shows the incidence of ari in indonesia according to the results of the 2018 basic health research (riskesdas) of 20.06%, almost the same as the previous year's data of 20.56%.3 ari is one of the main causes of patient visits at the puskesmas (40%-60%) from year to year and always ranks first as the cause of infant or toddler mortality and is always on the list of the 10 most common diseases every year in health facilities, such as community health centers. report 4 states that cases of ari among children under five in the city of samarinda rank the highest, with 378 cases (18.01%). most cases of ari among children under five in samarinda city occurred at 12 23 months, with 387 cases (19.3%). several factors that can increase the risk of acute respiratory infection are divided into two factors, namely intrinsic factors and extrinsic factors. intrinsic factors include age, exclusive breastfeeding, immunization status, and birth weight. extrinsic factors include the mother's knowledge, home environmental conditions, socioeconomic conditions, and parents' occupations. birth weight is one of the intrinsic factors that influence the incidence of ari. the main causes of death in lbw are asphyxia, respiratory distress syndrome, infection, hypothermia complications in lbw infants, the formation of anti-pneumonic substances, and other respiratory tract diseases.5 one of the other intrinsic factors influencing the incidence of ari is exclusive breastfeeding. the world health organization (who) revealed that exclusive breastfeeding could reduce infant mortality due to acute respiratory infections (ari). the results of a preliminary study conducted in the working area of the loa bakung public health center, samarinda city, still found phenomena or health problems found in the community, especially in children aged 0-5 years, namely ari that had not been resolved. this is evidenced by the incidence of ari, which always occupies the list of the top 10 monthly and annual diseases at the loa bakung public health center for 2020. the publications focused more on the history of lbw and exclusive breastfeeding with the incidence of ari in children under five years. this makes the researchers want to prove whether there is a similar phenomenon where a history of low birth weight and exclusive breastfeeding influence the incidence of ari in children under five years in the working area of loa bakung public health center, samarinda city. methods this research is a type of quantitative research with a cross-sectional design. the study was conducted on 64 sample children aged 12-59 months who visited and registered at the loa bakung public health center. this research was carried out at the loa bakung public health center for 13 days, starting on may 11 23, 2020. the population in this study was all children aged 12-59 months who visited and registered (recorded in the child register book) at the loa bakung public health center in april 2020, with as many as 181 children under five years. the study was conducted on 64 samples by taking samples by accidental sampling or by chance being met by the researcher if deemed suitable as a data source. determination of the sample size is determined using the slovin formula. the research instrument used was a questionnaire sheet. other instruments used are mch books, medical records, or patient cards. primary data were obtained directly from respondents by using a questionnaire sheet. the primary data collected were the characteristics of the mother respondents, the characteristics of children under five years, and exclusive breastfeeding. secondary data in this study south east asia nursing research, vol 4 no 4, dec 2022/ page 18-24 20 ni wayan wiwin asthiningsih / history of low birth weight and exclusive breastfeeding on the incidence of acute respiratory infection in children under five years is data collected related to the purpose of the study, such as the baby's birth weight obtained from the mch book records and the results of the ari examination obtained from medical records. after all the data is collected, the data will be verified, after which data analysis is carried out. hypothesis testing using the chi-square test with a significance value of p < 0.05. this research has received ethical approval from the health research ethics commission, the universitas muhammadiyah kalimantan timur, with the number 003/kepk-umkt/2020. results table 1 describes the characteristics of respondents based on maternal age, mostly in the age range of 21-30 years (59.4), the majority of mothers' education is high school (70.3), mothers mostly work as housewives (62.5%), ages under five the majority were 36-47 months (32.8%), most of the respondents under five were female (68.8%). table 2 describes the characteristics of the variables; the data obtained are children who are exclusively breastfed (56.2%) and not exclusively breastfed (43.8), children under five years with a history of low birth weight (34.4%), and children under five years who experience ari (35, 9%). table 3 shows the results of calculations using chi-square analysis with a significant = 5% in 64 respondents under five, p-value = 0.008 <0.05 so that h0 is accepted, and ha is rejected, which means that there is a relationship between exclusive breastfeeding and the incidence of ari in children under five years at the loa bakung public health center, samarinda. in addition, for the analysis of the history of lbw with the incidence of ari, p-value = 0.007 < 0.05, which means that there is a relationship between a history of lbw and the incidence of ari in children under five at the loa bakung public health center, samarinda. table 1 characteristics of respondent (n=64) indicator f % mother’s age ≤ 20 years 1 1,6 21 30 years 38 59,4 31 40 years 25 39,1 mother’s education elementary 6 9,4 junior high 4 6,3 senior high 45 70,3 undergraduate 9 14,1 mother’s occupation housewife 40 62,5 private employees 23 35,9 government employees 1 1,6 toddler’s age 12 23 months 11 17,2 24 35 months 17 26,6 36 47 months 21 32,8 48 59 months 15 23,4 gender male 20 31,3 female 44 68,8 table 2 characteristics of variable (n=64) indicator f % lbw history normal 42 65,6 lbw 22 34,4 exclusive breastfeeding exclusive breastfeeding 36 56,2 not exclusive breastfeeding 28 43,8 ari incident ari 23 35,9 no ari 41 64,1 south east asia nursing research, vol 4 no 4, dec 2022/ page 18-24 21 ni wayan wiwin asthiningsih / history of low birth weight and exclusive breastfeeding on the incidence of acute respiratory infection in children under five years table 3 analysis of the relationship between a history of lbw and exclusive breastfeeding with the incidence of ari in children under five years variable ispa incident p ispa no ari f % f % lbw history normal 20 31,3 22 34,4 0,007 lbw 3 4,7 19 29,7 exclusive breastfeeding exclusive breastfeeding 18 28,1 18 28,1 0,008 not exclusive breastfeeding 5 7,8 23 35,9 discussion based on the results of the study, it is known that as many as 20 (31.3%) respondents with a history of normal birth and 3 (4.7%) respondents with a history of lbw who experienced ari, while as many as 22 (34.4%) respondents had a history of normal birth and 19 (29,7%) respondents with a history of lbw who did not experience ari at the loa bakung public health center, samarinda.6 said that premature infants, in particular, those born before 32 weeks' gestation suffered significantly more respiratory morbidity due to pulmonary immaturity at birth. in addition, they also suffer from relatively poor breastfeeding as they will not be strong enough to receive sufficient nutrition by mouth to gain weight before 37 weeks. this is in line with study 7, which showed that as many as 15 (11%) children with a history of lbw were at risk of experiencing ari. low birth weight is associated with a markedly increased risk of lri mortality among all racial groups. birth weight determines physical and mental growth and development in infancy. according to other research, lbw is very easy to be infected with diseases, especially ari, because during pregnancy, the mother has poor nutritional status, does not check her womb regularly to the posyandu or doctor, and does not maintain the cleanliness of the surrounding environment, and lacks adequate rest (for working mothers) so that the baby is in good health. contents can be infected with the disease.8 this is in line with study, which showed that low birth weight was one of the risk factors for the occurrence of ari with a p-value = 0.0005, which is very significant, about 3 times the proportion of the case group was higher with less birth weight, which was < 2500 grams. low birth weight in term infants is a surrogate marker of intrauterine growth restriction.9 this presents a high risk of ari due to structural deformation that endangers lung health and impaired immune competence. the same study was also conducted by other research who said the effect of lbw on ari showed significant results, namely with a p-value of 0.04 with an rr value of 1.15 times (95% ci 1.00 1.31) which means that children under five years with lbw are at risk 1.15 times to experience ari when compared to children under five years with normal birth weight.10 this study also found that 19 children under five years with a history of lbw did not experience ari. this is in line with research, which showed that out of 48 children under five years with lbw birth weight, 28 children under five years (58.3%) had ari while 20 children under five years (41.7%) did not experience ari because actually viral infection is a self-limiting disease, so if babies with lbw given exclusive breastfeeding and complete immunization will have the body's defenses like children with normal birth weight. 11 the same study was also conducted by other research, which showed that p = 0.008 (p> 0.05), so there was a significant relationship between birth weight and a history of ari.12 the theory states that low birth weight is a baby born <2500 grams. low birth weight can cause impaired growth, maturation of tools and organs of the body that are not yet perfect, immunity to infectious diseases is very weak, as a result of low birth weight can experience fatal infections and complications in infants and can even cause mortality.13 south east asia nursing research, vol 4 no 4, dec 2022/ page 18-24 22 ni wayan wiwin asthiningsih / history of low birth weight and exclusive breastfeeding on the incidence of acute respiratory infection in children under five years in contrast to the results of research conducted by other research with a p-value of lbw = 0.093, there is no relationship between lbw and the incidence of ari. this is because the toddler's immune system to infection is more influenced by current weight or nutritional status, not birth weight. in addition, if it is supported by the provision of complete immunization, especially measles immunization, the child is not susceptible to infectious diseases (ari). the same study was also conducted other research which said there was no relationship between lbw and ari in children aged 6-23 months.14 this can happen because ari is not only influenced by lbw, but several other risk factors outside the research variables can cause ari. in addition, children who have a history of lbw births are caused by not getting the nutrients needed during pregnancy; if supported by good nutritional status and exclusive breastfeeding, the child is not susceptible to ari disease. according to other research, babies born with a birth weight less than 2500 grams or lbw are more susceptible to ari or other respiratory tract diseases because babies born with lbw have a low body defense system, so pathogenic microorganisms will more easily enter and infect children under five years, including the ari.15 lbw is also closely related to the nutritional status of the mother during pregnancy; the nutritional status of pregnant women can affect the growth and development of the fetus so that the baby is born with a weight of <2500 grams.10 the results of this study also showed that as many as 18 (28.1%) respondents under five received exclusive breastfeeding and 5 (7.8%) respondents under five did not receive exclusive breastfeeding which had ari, while as many as 18 (28.1%) respondents under five were breastfed. exclusive breastfeeding and 23 (35.9%) respondents under five did not receive exclusive breastfeeding and did not experience ari at the loa bakung health center samarinda. this is in line with research, which shows a relationship between exclusive breastfeeding and the incidence of ari in infants. research 16 shows that the analysis of the relationship between exclusive breastfeeding and history of ari was obtained by 14 respondents (14.7%).1 in comparison, those who were given exclusive breastfeeding but not ari were 81 respondents (85.3%). there was a significant relationship between exclusive breastfeeding and a history of ari, p<0.05. children under five years who are not exclusively breastfed are more susceptible to ari because breast milk contains immunoglobulin a (ig. a) and immunoglobulin m (ig. m) ingredients. ig. a is an antibody that functions to agglomerate and destroys germs. at the same time, ig.m prevents the proliferation of viruses and neutralizes toxins and micro-organisms so that children under five years who are not exclusively breastfed will develop ari. if left untreated, ari will cause more pain and will cause death.1 according to a study conducted, children under five years with the incidence of ari tend not to get exclusive breastfeeding, which is 90.9%.17 exclusive breastfeeding is the best food with complete content for babies. exclusively breastfed babies will be more healthy and less sick compared to infants who are not exclusively breastfed.8 another study was also conducted on 18, which showed that out of 96 respondents, 66 respondents (68.8%) did not give exclusive breastfeeding, while 30 respondents (31.3%) did. the low rate of exclusive breastfeeding can be influenced by several factors, including the lack of mothers' knowledge about the importance of breastfeeding, working mothers, husband and family support, and the socioculture that develops in the community. research conducted other research shows that the incidence of ari varies widely between groups, and the incidence of ari is much higher in the group that is not south east asia nursing research, vol 4 no 4, dec 2022/ page 18-24 23 ni wayan wiwin asthiningsih / history of low birth weight and exclusive breastfeeding on the incidence of acute respiratory infection in children under five years exclusively breastfed compared to those who are exclusively breastfed. the relative risk of increasing ari in infants who are not exclusively breastfed is 2.46.19 according to other research an increase in the practice of breastfeeding programs is very much needed by focusing on exclusive breastfeeding and handling ari diseases because of the large impact on the health of children under five years.20 breast milk has elements that meet the baby's nutritional needs over about six months unless the mother is severely malnourished and the composition of breast milk changes with the baby's needs. antibodies and macrophage cells in breast milk and colostrum protect against certain types of infection. therefore, infants who receive exclusive breastfeeding are rarely affected by respiratory diseases, infectious diseases, and diarrhea. the same study was also conducted other research with the value = 0.007, which means a relationship exists between exclusive breastfeeding and the incidence of ari in children aged 12-24 months.21 calculation of odds ratio (or) means that children who do not get exclusive breastfeeding 4 times risk of experiencing ari incidence compared to children who are exclusively breastfed. similar results were obtained in study 22, which showed a significant relationship between exclusive breastfeeding and the incidence of ari (p=0.044, cc=0.276). this is also in line with research 23, which shows a difference in the incidence of ari in children under five years who are exclusively breastfed and nonexclusive with a p-value of 0.003, which means that the first hypothesis (h1) is accepted if p < 0.05. the results of this study are under the theory that states that ari is caused by several factors, one of which is exclusive breastfeeding, which shows that the incidence of ari is lower in exclusively breastfed children. this is because breast milk, apart from being a source of nutrition, can protect babies through the various components of the immune substances it contains. various scientific studies have been carried out by experts on the composition of breast milk and its effect on infant health.14 based on research conducted 1, there are several reasons why mothers do not give exclusive breastfeeding to their babies, among others, consider that breast milk is not sufficient, respondents work outside the home, think formula milk is better and more practical than breast milk, cannot express breast milk. some mothers still follow the old belief by directly giving food other than breast milk at 0-6 months. conclusion ari is one of the health problems that children under five years often experience. children under five years with a history of low birth weight and who did not receive exclusive breastfeeding at the age of 0-6 months are at risk of developing aris compared to children born with normal weight and receiving exclusive breastfeeding. to support the success of the ari prevention program, mothers must be diligent in routine pregnancy check-ups during the prenatal period to prevent the occurrence of lbw and be taught proper breastfeeding techniques to avoid early infant feeding so that they can be optimal in exclusive breastfeeding. acknowledgment the author would like to thank all mothers and children under five years who are willing to be respondents and participate in this study. the authors also thank the loa bakung public health center samarinda for helping the research process so that the activities run smoothly and according to the planned time. conflicts of interest the author does not have a conflict of interest that could bias the results in the research that has been done. south east asia nursing research, vol 4 no 4, dec 2022/ page 18-24 24 ni wayan wiwin asthiningsih / history of low birth weight and exclusive breastfeeding on the incidence of acute respiratory infection in children under five years references 1. jalil r, yasnani, sety lom. faktor-faktor yang berhubungan dengan kejadian ispa pada balita di wilayah kerja puskesmas kabangka kabupaten muna tahun 2018. jurnal penelitian kebidanan. 2018;3(4):1–8. 2. rahadjoe nn, supriyatno b, setyanto db. buku ajar respirologi anak. edisi 1 ce. jakarta: idai; 2015. 658 p. 3. kemenkes ri. profil kesehatan indonesia tahun 2018. science as culture. 2019. 4. tim riskesdas 2018. laporan provinsi kalimantan timur 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ners. 2018;13(2):213–8. patient safety at rsgmp unimus based on sistem nasional akreditasi rumah sakit (snars) 1.1 komisi akreditasi rumah sakit corresponding author: amalia nurhidayah amalianurhidayah77@gmail.com south east asia nursing research, vol 4 no 2, june 2022 issn:2685-032x doi: https://doi.org/10.26714/seanr.4.2.2022.62-69 original research patient safety at rsgmp unimus based on sistem nasional akreditasi rumah sakit (snars) 1.1 komisi akreditasi rumah sakit amalia nurhidayah1, edi sumarwanto1, dwi windu kinanti arti1 1 faculty of dentistry, universitas muhammadiyah semarang, indonesia article info abstract article history: submitted: may 6th 2022 accepted: june 21st 2022 published: june 30th 2022 keywords: patient safety; accreditation; hospital hospitals have an obligation to fulfil the patient’s right to obtain their safety and security while being treated in a hospital as a health service institution for the public. patient safety for the patient is a system that makes patient’s treatment safer, including risk assessment, identification and management of patient risk, analysis and reporting of incidents, competency to learn from follow-up incidents and implementation of solutions to minimize the risk and prevent injuries that caused by errors due a treatment. patient safety must be considered especially during the period of education, therefore rsgmp unimus as a learning institution for health service organizers must be considered in this regard. the objective of this study is to measure the readiness of patient safety policies at the dental and oral hospital, muhammadiyah university, semarang. this type of research is descriptive and quantitative by using a cross-sectional research design with the focus group discussion technique. based on the sistem nasional akreditasi rumah sakit 1.1 questionnaire by the komisi akreditasi rumah sakit (kars), rsgmp unimus get a fairly good score and partially completed accreditation requirements for aspects of the assessment of patient safety goals (skp) and integration of health education and hospital services (ipkp). achievement of patient safety goals and integration of health education and hospital services at rsgmp unimus based on the standard nasional akreditasi rumah sakit (snars) 1.1 which was carried out with the elemental assessment of the patient safety goals and integration of health education and hospital services standard are partially completed from the snars 1.1 assessment with a score of 74.2% and 63.2% which indicates that rsgmp unimus can make improvements to pass. introduction the health of the indonesian people has been determined in the constitution relating to human rights. article 28h states that if every individual has the right to obtain mental and physical well-being, to have a living environment and to have a healthy and good place to live, he has the right to receive health services. to meet these public health standards, hospitals have a very important role in establishing this right.1 one way to improve hospital services is to carry out accreditation which is used to meet the expectations and expectations of the community about hospital services. https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.4.2.2022.62-69&domain=pdf&date_stamp=2022-06-30 south east asia nursing research, vol 4 no 2, june 2022/ page 62-69 63 amalia nurhidayah / patient safety at rsgmp unimus based on sistem nasional akreditasi rumah sakit (snars) 1.1 komisi akreditasi rumah sakit accreditation is carried out by the hospital accreditation commission which is a high quality accreditation body at the national and international levels.2 the unimus educational oral and dental hospital is a learning location for prospective health workers in the field of dentistry. patient safety must be of utmost concern, reviewing the potential for treatment errors in each patient. so that's where patient safety must be considered, especially during the education period. this allows prospective health workers to become accustomed to reducing unwanted events in the future.3 problems regarding patient safety raises a lack of support from health workers. research in 2020 on patient safety at rsgmp unimus said that more than 90% of unimus dental profession students prioritize patient safety which means supporting the existence of patient safety goals at rsgmp unimus.4 based on this explanation, the authors want to assess how patient safety at rsgmp unimus is based on the national hospital accreditation system (snars) 1.1 hospital accreditation commission (kars). the purpose of this study was to measure the readiness of patient safety at the unimus teaching oral and dental hospital.5,6 method the type of study used in this study was descriptive with a qualitative approach and used a cross-sectional design with the help of focus group discussions based on national accreditation standards (snars) 1.1 compiled by the hospital accreditation commission (kars). the independent variable of this study is the patient safety program. this research was conducted for 4 days at the muhammadiyah university education dental and oral hospital in semarang on jalan kedung mundu raya number 22, sendangmulyo village, tembalang district, semarang city. central java province 50272. research subject table 1 assessment subjects results overview of unimus rsgmp universitas muhammadiyah semarang has various faculties, one of which is the faculty of dentistry which has been established since the issuance of an education administration license by the directorate general of higher education (dirjen dikti) ministry of national education number 129/e/o/2013 dated 18-04-2013, the study program unimus dentistry education is officially established. the teaching hospital which has a land area of 4200 m2 is located at jalan kedungmundu raya no. 22 semarang. to facilitate continuity in education, rsgmp unimus was built as a teaching hospital which functions as a place for integrated education, research and services in the field of dentistry.7 rsgmp unimus consists of 4 floors and has more than 50 dental units and 7 polyclinics for the care of general patients and koas. rsgm unimus has 7 specialist dentists and more than 10 general dentists. the advantage of the service to be provided is islamic dentistry services for the general public and children with special needs. rsgmp unimus has several facilities and services such as emergency installation, inpatient installation, outpatient installation, radiology installation, central surgery installation and pharmacy.8 no research subject 1 hospital director 2 k3 committee chair 3 chairman of the ppi committe 4 medical committe 5 heads of ipkp 6 dentist profession student representatives class of 2018-2020 south east asia nursing research, vol 4 no 2, june 2022/ page 62-69 64 amalia nurhidayah / patient safety at rsgmp unimus based on sistem nasional akreditasi rumah sakit (snars) 1.1 komisi akreditasi rumah sakit univariate analysis the analysis in this study uses univariate research to describe a phenomenon that will be examined regarding patient safety goals and the integration of health education in hospital services at rsgmp unimus. data processing and data analysis are processed based on frequency distribution and presented in tabular form.9,10 table 2 ipkp assessment results elements of assessment of health education integration in hospital services ipkp 1 regulations regarding the approval of owners and managers in making cooperation agreements for the implementation of clinical education in hospitals 50% ipkp 2 clinical education held in hospitals is managed by functional organizations that have management accountability, coordination, and clear procedures 50% ipkp 3 the number of clinical education participants admitted to hospitals is adjusted to the number of staff providing clinical education, variations in the number of patients, technology, and hospital facilities 50% ipkp 4 clinical staff have competence as clinical educators and are authorized by educational institutions and hospitals. 87,5% ipkp 5 the hospital ensures that the implementation of education that is carried out for every type and level of clinical staff education in the hospital is safe for patients and students. 37,5% ipkp 6 implementation of clinical education in hospitals that must comply with hospital regulations and the services provided are in an effort to maintain or improve patient quality and safety. 100% tabel 3. skp assessment results elements of patient safety goal assessment skp 1 hospitals establish regulations to ensure the accuracy of patient identification 80% skp 2.1 hospitals establish regulations for the process of reporting critical diagnostic results 75% skp 2.2 the hospital establishes and implements a hand-over communication process 50% skp 3 hospitals establish regulations to carry out processes to improve the safety of drugs that need to be watched out for 100% skp 3.1 rs establishes regulations to carry out the process of managing the use of concentrated electrolytes and electrolytes with certain concentrates 75% skp 4 the hospital establishes regulations to carry out the process of ensuring right-site, right-procedure and rightpatient undergoing procedures 66,7% skp 4.1 the hospital carries out safe surgical procedures with the who "surgical safety checklist". 50% skp 5 hospitals establish regulations to use and implement "evidencebased hand hygiene guidelines" to reduce the risk of infection 91,7% skp 6 hospitals set regulations to carry out processes to reduce the risk of patient falls. 62,5% achievement of target patient safety gets 74.2% and integration of health education in hospital services gets 63.2%.11 respondent data results focus group discussion results (skp & ipkp) the form of data collection in the focus group discussion was carried out by interviewing several respondents. interviews were conducted with key informants, namely the deputy director of rsgmp, the medical committee and the ipkp section and skp field representatives. respondent representatives from the teaching dental and oral hospital (rsgmp) south east asia nursing research, vol 4 no 2, june 2022/ page 62-69 65 amalia nurhidayah / patient safety at rsgmp unimus based on sistem nasional akreditasi rumah sakit (snars) 1.1 komisi akreditasi rumah sakit stated that they already had and were running the ipkp and skp programs which had been carried out by all staff and students to the leaders at the unimus rsgmp. however, it is still carried out in general under the supervision of the ministry of education and the k3 team. the leadership at rsgmp unimus has made regulations in the form of sops related to how policies apply, especially in the ipkp and skp fields. everything that is written and contained in these regulations is useful for improving the performance and safety of young dentists and patients themselves in the unimus rsgmp service. the education sector at rsgmp unimus stated that the ipkp was under the auspices of the education sector but had not been fully accepted, but the program had been implemented and was running in accordance with the applicable ipkp standards. rsgmp unimus has carried out several procedures related to the integration of health education. rsgmp unimus in collaboration with fkg unimus regulates regulations regarding doctors having to have spk and rkk first before becoming dpjp/dpkp working at rsgmp unimus. even in the acceptance of all students the number has been adjusted by cooperation between related institutions in order to improve services for patient safety.12 increased understanding is needed for this program, according to the deputy director of rsgmp unimus, this has been carried out routinely. both for internal and external coverage of the rsgmp itself. increased understanding can be carried out routinely or incidentally, for example training for patient safety to handling patients in the pandemic era. this is of great concern to improve the quality of security and comfort of existing services, as well as to add insight to staff and students at rsgmp unimus. the osh field at rsgmp unimus stated that there was an increase in patient safety and quality assurance of service by implementing patient safety goals. this is indeed still being done in general, but still based on the principles of patient safety which is a priority. everything has been stated in regulations related to patient safety that have been designed by the k3 team itself. clinical risks are all issues that can have an impact on the achievement of patient care. this program is very helpful in the course of service at rsgmp unimus itself. this also affects performance in the formation of regulations for programs available at rsgmp unimus. ipkp and skp at rsgmp unimus are very concerned about improving the quality of rsgmp unimus itself.4,8,13 discussion research on the implementation of the patient safety target program and the integration of health education at rsgmp unimus was carried out using the interview method to fill in the assessment elements by snars 1.1. respondents from this study were representatives of hospital leadership, the education team/committee and the k3 team/committee at the dental and oral hospital of the muhammadiyah university of semarang. interviews were conducted with 4 respondents namely drg. retno kusniati, m.kes as deputy director of rsgmp unimus, drg. arimbi m.hkes as the medical committee, drg. etny dyah harniati, mdsc as the head of the education sector and mrs. juni from the k3 sector representative. most of the respondents are hospital surveyors who really understand the fields related to accreditation. in the interviews that have been carried out, rsgmp unimus does not yet have a department that is specifically in charge of this field and all are still working closely with related intuitions. for example, the ipkp field is still responsible for the education sector and the skp team is carried out by the k3 field in general. however, this does not affect the performance and quality of the two fields.14 the results of the research conducted showed that there were 6 elements of patient safety target (skp) assessment of south east asia nursing research, vol 4 no 2, june 2022/ page 62-69 66 amalia nurhidayah / patient safety at rsgmp unimus based on sistem nasional akreditasi rumah sakit (snars) 1.1 komisi akreditasi rumah sakit 33 points and ipkp 6 elements of assessment of 19 points. this research was conducted to find out about the readiness of the patient safety target program at rsgmp unimus based on the national hospital accreditation standard 1.1 hospital accreditation commission. this is used to prepare and support accreditation at unimus oral and dental hospital. based on the results of the research conducted, the skp and ipkp at rsgmp unimus are quite good, but gradual improvements still need to be made. patient safety goals are a system that makes patient care safer, including risk assessment, patient risk identification and management, incident reporting and analysis, the ability to learn from incidents and their follow-up, and implementation of solutions to minimize risks and prevent injuries caused by mistakes resulting from carrying out an action or not taking the appropriate action. this is why good patient safety will affect optimal service and quality in the safety of care and patient care. especially in the community itself, quality and safe services will greatly meet expectations. as for health workers, especially young dentists, this will be an activity that meets the standard values for health services.15 overall research results, patient safety goals as meeting the standards set by the hospital accreditation commission with a minimum rating of 50%, this states that some of the patient safety goals at rsgmp unimus have been partially fulfilled with a score of 2079%. the results of the assessment of the assessment elements that have been carried out, the patient safety goals at rsgmp unimus have been partially fulfilled, skp 1 regarding patient identification with an assessment of 80%, skp 2.1 regarding the process of reporting critical values received an assessment of 75%, skp 2.2 regarding handovers of 50%, skp 3.1 with an assessment of 75%, skp 4 regarding regulation of patient handling with a value of 66.7%, skp 4.1 concerning actions according to the surgical safety checklist with an assessment of 50%, skp 5 regarding hand hygiene 91.7% and skp 6 regarding the risk of falling with rating 62.5%. in point skp 3, they got perfect points, namely 100%, but respondents stated that they would continue to improve the quality of patient safety goals in this case to maintain patient service comfort.11,15,16 the lowest score in skp 2.2 and skp 4.1 standards, skp 2.2 discusses the hand-over process that is not perfect, there are still many things that have not been implemented due to the absence of specific records for this matter. the handover form was not specially formed, everything was still included in the medical record and the consent form was from the start the standard for reporting from dgm to dpjp. this does not have a significant effect because for every patient service with dgm it is always supervised by the relevant dpjp, so that in treatment especially in integrity clinics if an unwanted event occurs, the dpjp immediately acts without filling out the approval form again. skp 4.1 regarding safe surgical procedures cannot be carried out perfectly because rsgmp unimus does not carry out several general surgical processes. likewise in skp 6 which is related to the risk of falling, the ohs stated that they had created regulations regarding the risk of falling, but at the rsgmp unimus which was still focused on treating outpatients this had not been implemented properly.17,18 skp 3.1 relating to the pharmaceutical field which states regarding the handling of concentrate electrolytes, this is due to the unavailability of special rooms and data for storing concentrated electrolytes. but there are already regulations that become a reference in storage. in addition, there is skp 1 which has a value of 80% which relates to correct patient identification. regulations on this matter have been considered with the existence of an sop which requires patient identification prior to carrying out the procedure, but this is not perfect because the rsgmp unimus only handles outpatient south east asia nursing research, vol 4 no 2, june 2022/ page 62-69 67 amalia nurhidayah / patient safety at rsgmp unimus based on sistem nasional akreditasi rumah sakit (snars) 1.1 komisi akreditasi rumah sakit patients specifically for dental and oral care so that there are several services or actions that have not been aligned, for example in the scope of taking specimens and procedures other than dental and oral care to coma management.11,19 the overall assessment of the integration of health education in hospital services (ipkp) at rsgmp unimus based on the collaboration between rsgmp unimus and fkg unimus. in this assessment, it states that there is a value of 37.5% in the ipkp 5 assessment regarding guaranteeing the safety of students at every level of education and ipkp 3 concerning alignment between students, staff and facilities with a value of 50%, then a value of 50% in ipkp 1 concerning collaboration agreement for clinical education providers and hospitals and ipkp 2 concerning functional organizations that manage clinical education, a score of 87.5% in ipkp 4 regarding standard competence regulations for clinical educators and a score of 100% in ipkp 6 concerning clinical education which must always be based on quality improvement and patient safety.16,20 several things cannot be assessed and cannot be assessed because rsgmp unimus itself is a special hospital that handles dental and oral services. this is very influential on the results of the assessment in accordance with the standard assessment elements. the hospital accreditation commission states that the overall points that must be met to pass are more than 80%, 60-80% points are stated to have to be repaired and if the score is below 60% it is declared not passing.21 patient safety goals at rsgmp unimus received a total score of 74.2% and integration of health education and hospital services scored 63.2% which indicates that rsgmp unimus must be more in implementing improvements for this field. the commitment of the leaders at rsgmp unimus to skp is still deep standard setting process by establishing a dedicated team for the skp itself. the department at rsgmp unimus is still in the process of being developed, especially for clinical indicators and managerial indicators. there are still many things that need to be improved in this process. cooperation between leaders and coordination between staff and monitoring is needed to improve the quality of services, especially in the field of patient safety. the national hospital accreditation standard 1.1 is very helpful in encouraging more changes, especially in the field of discipline in services at the rsgmp unimus. the leadership of rsgmp unimus also hopes for criticism and suggestions from the community to improve the management of services at the hospital. this can also be one of the motivations to improve the quality of human resources, especially dgm, because this has a very broad impact on good dental and oral services for the community. it should be remembered that the goal of patient safety is an indicator of the success of the quality of hospital services.15,22–24 conclusion patient safety goals at rsgmp unimus based on national hospital accreditation standards (snars) 1.1 which were carried out with element assessment have been partially fulfilled from the snars 1.1 assessment with a score of 74.2% which indicates that skp at rsgmp unimus can make more improvements to pass. integration of health education and hospital services at rsgmp unimus based on national hospital accreditation standards (snars) 1.1 which has been carried out has been partially fulfilled from the snars 1.1 assessment with a score of 63.2% which indicates that ipkp at rsgmp unimus must make more improvements to pass. there are several assessments on those that cannot be assessed (tdd) and cannot yet be assessed (bdd), for example in the field of specialist general patient care apart from south east asia nursing research, vol 4 no 2, june 2022/ page 62-69 68 amalia nurhidayah / patient safety at rsgmp unimus based on sistem nasional akreditasi rumah sakit (snars) 1.1 komisi akreditasi rumah sakit dental and oral care and also specialist and sub-specialist medical education. implementation of skp and ipkp is not perfect, still in the stage of forming a team/committee. the form of organization that is expected to manage this matter must be in accordance with statutory regulations management's commitment to skp is still in the stage of improving the quality of human resources and managerial improvement. all regulations related to skp and ipkp have been formed in regulations in the form of sops to carry out or become a benchmark for services at rsgmp unimus. acknowledgment the author would like to thank faculty of dentistry universitas muhammadiyah semarang which has supported this research. refereces 1. kementrian kesehatan ri. uu no. 44 tahun 2009 tentang rs. undang-undang republik indonesia. 2009;1:41. 2. haryoso aa, ayuningtyas d. strategi peningkatan mutu dan keselamatan pasien di rumah sakit umum daerah kepulauan seribu tahun 2019 – 2023. jurnal administrasi rumah sakit indonesia. 2019;5:115–27. 3. ardinansyah a, nurniza n. persepsi mahasiswa dan dosen terhadap pembelajaran keselamatan pasien pada tahap klinik program pendidikan kedokteran gigi universitas yarsi. majalah kesehatan pharmamedika. 2019;11:16–24. 4. kinanti dw, kusniati r. gambaran manajemen keselamatan pasien di rsgm unimus berdasarkan agency for health research and quality care (ahrq). jurnal manajemen dan administrasi rumah sakit indonesia (marsi). 2020;4:166–77. 5. mandawati m, fu’adi mj, jaelan j. impact of hospital acreditation: qualitative study to nurses in rsud krt setjonegoro of wonosobo. nurscope : jurnal penelitian dan pemikiran ilmiah keperawatan. 2018;4:23. 6. menteri kesehatan. peraturan menteri kesehatan republik indonesia nomor 47 tahun 2018. bitkom research. 2018;63:1–3. 7. keputusan menteri kesehatan republik indonesia. keputusan menteri kesehatan republik indonesia nomor 1204/menkes/sk/x/2004, tentang persyaratan kesehatan lingkungan rumah sakit. vol. 2004, cwl publishing enterprises, inc., madison. 2004. p. 352. 8. hidajati i. kajian yuridis pengawasan mutu rumah sakit khusus gigi dan mulut pendidikan melalui akreditasi rumah sakit. perspektif hukum. 2014;14:94–109. 9. the joint commission international. npsg 2022 presentation final. the joint comission i. 2022; 10. sutoto. national standard of hospital accreditation. standar akreditasi rumah sakit. 2018;421. 11. yunita, yusuf s, hengky hk. prevention and controlling of health-care associated infections (hais) in caretakers of inpatients in rumah sakit umum ‘aisyiyah st. khadijah kabupaten pinrang. jurnal ilmiah manusia dan kesehatan. 2022;5:521–8. 12. kusbaryanto. peningkatan mutu rumah sakit dengan akreditasi. mutiara medika. 2010;10:86–80. 13. arti dwk. analisis lokasi rumah sakit gigi dan mulut universitas muhammadiyah semarang di wilayah kedungmundu terhadap perspektif pelanggan. magna medica: berkala ilmiah kedokteran dan kesehatan. 2018;1:58. 14. kemenkes ri. klasifikasi rumah sakit. 2010;116. 15. ningsih ns, endang marlina. pengetahuan penerapan keselamatan pasien (patient safety) pada petugas kesehatan. jurnal kesehatan. 2020;9:59–71. 16. permenkes nomor 11 tahun 2017 tentang keselamatan pasien. peraturan menteri kesehatan republik indonesia nomor 11 tahun 2017 tentang keselamatan pasien. progress in physical geography. 2017;14:450. 17. depkes. pedoman manajerial pencegahan dan pengendalian infeksi di rumah sakit dan fasilitas pelayanan kesehatan lainnya. vol. 53, journal of chemical information and modeling. 2013. 1689–1699 p. 18. mokodompit mohfm, wowor vns, mintjelungan cn. pencegahan dan pengendalian infeksi silang pada tindakan ekstraksi gigi di poliklinik gigi rumah sakit pancaran kasih manado. jurnal e-biomedik. 2019;7. 19. kesehatan m. peraturan menteri kesehatan republik indonesia nomor 012 tahun 2012. 2012;3:1–47. 20. cahyono a. hubungan karakteristik dan tingkat pengetahuan perawat terhadap pengelolaan keselamatan pasien di rumah sakit. jurnal ilmiah widya. 2015;3:97–102. south east asia nursing research, vol 4 no 2, june 2022/ page 62-69 69 amalia nurhidayah / patient safety at rsgmp unimus based on sistem nasional akreditasi rumah sakit (snars) 1.1 komisi akreditasi rumah sakit 21. [kars] kars. standar nasional akreditasi rumah sakit edisi 1.1. komisi akreditasi rumah sakit. 2020;1–2023. 22. kesehatan m. peraturan menteri kesehatan republik indonesia nomor 27 tahun 2017. 2017;1–14. 23. kesehatan m. peraturan menteri kesehatan republik indonesia nomor 1173/menkes/per/x/2004 tentang rumah sakit gigi dan mulut. international journal of tropical insect science. 2004;8:104–10. 24. kesehatan k, indonesia r. kementerian kesehatan republik indonesia tahun 2011. 2011; the relation between knowledge and experience of facing flood toward the anxiety level of head families in the flood-prone areas corresponding author: dwi rahmah fitriani drf397@umkt.ac.id south east asia nursing research, vol 1 no 3, december 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.3.2019.120-127 original research the relation between knowledge and experience of facing flood toward the anxiety level of head families in the flood-prone areas dwi rahmah fitriani1, milkhatun1, mukhripah damaiyanti1, siti khoiroh muflihatin1, alfi ari fakhrur rizal1, ni wayan wiwin1 1 universitas muhammadiyah kalimantan timur, indonesia article info abstract article history: accepted december 28th, 2019 keywords: anxiety; awareness; head of family; flood families who reside in the surrounding flood-prone areas require flood preparedness to undertake preparedness so that family members do not create new problems such as anxiety. this study aims to determine the relationship of knowledge with experience in dealing with the level of anxiety of household head anxiety. this research is a cross-sectional descriptive correlation study and the sample used in this study is 225 households. the results of the study using the anova test showed that the knowledge and experience of dealing with floods were related to the anxiety of household heads in disaster-prone areas (p = 0.001; α = 0.05). multivariate of results were found that the most related factor was an experience. this study recommends that the family knowledge needs to be increased through simulation training to deal with floods by involving the regional management agency, the local government and the public health center introduction flood disasters can cause adverse effects in various areas of community life that can be in the form of material losses or moral losses. this often causes the rise of mental conditions because of the loss of property and families due to the disaster.1 the flood that occurred in 2014 was the biggest flood in the asian region with the widest area coverage including 52 events throughout various asian countries that led to the death of as many as 3559 people. the event should be taken seriously so that it requires special attention in the form of anticipatory efforts or activities so it will not cause bad impacts on people's lives in the future. shown that three respondents residing along the riverbank experienced anxiety and fear of the possibility of having a greater flood. they also feared if the dike cannot contain the water, it somehow threatened them, because if the dike falls their houses will be perished.2 this shows that people who live around disaster-prone areas can experience anxiety. anxiety is a condition that involves a person's physical, self-perception and relationship with others. it is also one of the reactions that can strengthen individuals to https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.3.2019.120-127&domain=pdf&date_stamp=2019-12-30 south east asia nursing research, vol 1 no 3, december 2019/ page 120-127 121 dwi rahmah fitriani / the relation between knowledge and experience of facing flood toward the anxiety level of head families in the flood-prone areas react upon an action or step when facing threats.3 when people in flood-prone areas feel threatened, the efforts should be made to reduce these impacts through preparedness activities. preparedness is an activity that carried out strategically in an effort to anticipate disasters through effective planning and through active steps from the community and all elements in the government and is a priority disaster phase in disaster management. preparedness that needs to be done before a disaster comes is based on factors including prior experience, knowledge, emergency planning and resource mobilization.4 so that the husband as ahead of the family can make preparedness as the person responsible for providing protection and a sense of security to his family. the results of a preliminary study found that the disaster-resilient village that formed by the government in lempake samarinda city was expected to be able to assist the community in dealing with floods by trying to make the necessary preparedness in dealing with floods. however, the factors that underlie the preparedness itself were experience, knowledge, resource mobilization, emergency planning and anxiety felt by household heads who live in disasterprone areas, were not clearly illustrated. therefore, researchers are interested in finding out more about the picture of preparedness factors that were owned by the head of the family and their relation to the level of anxiety in dealing with flooding. methods the design used in this study was descriptive correlational. the number of samples in this study was 225 people obtained through total sampling. data retrieval using a questionnaire, where respondents are given an explanation first about the research conducted, then given the time and freedom to make decisions about their involvement in research. data collection questionnaire for variables used the community disaster preparedness index for knowledge and experience factors consisting based on the 23 question items given. as for anxiety variables, the hamilton anxiety rating scale instrument consists of 14 statement items. researchers used the ethical principles of research that include self-determination, confidentiality, and privacy, justice, benefit, and nonmaleficence. researchers provided information/explanations of the research first, then provide freedom to prospective respondents to the decision of their involvement in research activities. researchers also maintained the confidentiality of respondents in all aspects of the identity and content of the questionnaire. this study upheld the principle of justice, all respondents were treated equally. in addition, this research also prioritized the goodness and interests of respondents. in the next step, the data were processed using univariate, bivariate and multivariate. the univariate analysis looks at the characteristics, knowledge, and experience as well as the anxiety of household heads. the bivariate analysis looks at the relationship between knowledge and experience in dealing with floods with the anxiety of family heads. researchers used the anova statistical test to determine the relationship between knowledge and experience with family head anxiety. further analysis by multivariate used a multiple logistic regression test to see which factors are most associated with household head anxiety. results the results showed that the average head of the household was 41.32 years old with an age range of 26-68 years. the sex of the head of the family was dominated by men as much as 91.1%. the education of the head of the family was mostly 40.8% high school. south east asia nursing research, vol 1 no 3, december 2019/ page 120-127 122 dwi rahmah fitriani / the relation between knowledge and experience of facing flood toward the anxiety level of head families in the flood-prone areas and the occupation of the largest head of the family was private / civil servants as much as 42.2%. while the average household head income was below <rp.2,256,000, of which was 53.8%. table 1 shows that the average for knowledge of the preparedness of household heads is 8.28 with a standard deviation of 2.39 and it is believed that 95% of the household's preparedness knowledge in dealing with floods ranges from 7.96 to 8.59. the average factor of family head preparedness experience was 6.98 with a standard deviation of 2.01 and it was believed that 95% of family head preparedness experience is in the range of 6.71-7.24. regarding anxiety level shown that the majority of family heads experienced mild anxiety which is 47.6% and the least number of family heads had moderate anxiety which was 23.1%. the results of the bivariate analysis in table 1 show that there was a relationship between knowledge and experience in dealing with floods with the level of anxiety of household heads in flood-prone areas (p=0,001; α = 0,005). and with the post hoc test showed a significant difference which was knowledge and experience in dealing with disasters with mild anxiety, moderate and severe head of household. table 1. distribution of preparedness factors and anxiety level of family head (n=225) indicators anxiety level low n=107 moderate n= 52 severe n=66 knowledge mean 8,28 sd 2,39 95% ci 7,96 – 8,59 experience 6,98 2,01 6,71 – 7,24 the results of multivariate modeling of the relationship of knowledge and experiences in dealing with flooding were related to the level of anxiety of household heads with age, gender, education, employment and income as a confounding variable. the results of the final modeling analysis of table 2 show that there was a relationship with the knowledge and experience of dealing with floods with the level of anxiety of household heads. experience is the most dominant factor due to the level of anxiety of family heads. table 2. head of family analysis of knowledge relations and experience with anxiety (n=225) indicators anxiety n mean p knowledge low 107 9.80 0.000 mild 52 8.07 high 66 5.96 experience low 107 7.61 0.000 mild 52 8.23 high 66 4.96 anova one way test. post hoc temhane analysis: mild vs. moderate p <0.05; mild vs severe p <0.05; moderate vs weight p <0.05. table 3 also shows that the most related to the level of anxiety of household heads are experienced in dealing with flood disasters, where the or obtained from the experience variable is 5.1 which means that the family head who has preparedness experience has a 5.1 chance of not having anxiety. the findings in this study are a model of the formation of a disaster prepared village in an effort in the pre-incident phase which includes mitigation or prevention and preparedness to avoid potential disasters such as community and population preparedness in disaster or emergency situations and preparedness when an area is at risk and has the potential to be at risk disaster emergency situation. the experience of communities who have been given training on earthquakes, floods and landslides in turkey to see disaster preparedness and management.5 a year later an evaluation was carried out on 400 people who had attended training one year before and 400 people who had not attended the training. the results show that there is a demographic social relationship, preparedness experience with cognitive, behavioral and psychological. the results of the regression analysis also showed that participants who had attended the training south east asia nursing research, vol 1 no 3, december 2019/ page 120-127 123 dwi rahmah fitriani / the relation between knowledge and experience of facing flood toward the anxiety level of head families in the flood-prone areas had the ability and showed preparedness behavior. before a disaster occurs, efforts need to be made in the form of plans that are made together actively when facing a disaster, monitoring disaster risk events and making warnings that require attention from the community itself and the local government. these efforts can be increased by having experience in managing disaster preparedness in flood-prone areas. this is in line with research the other research on perceptions and preparedness in bangladesh showing 75% of respondents who have had experience of earthquakes and tsunamis, have carried out activities to reduce the risk of natural disasters coming back.6 with the experience of disaster preparedness management in disasterprone areas that have been carried out before, it will have an impact on reducing the symptoms or problems that cause anxiety. this is also supported by another research found that using a qualitative study of respondents in japan who have an interest in disaster preparedness and have self-help groups to be able to manage anxiety when they are dealing with disasters.7 there are three themes associated with perceived anxiety, which are storing needed items, staying in a safe place and friends who can be invited to share to avoid anxiety. this shows the need for the closest support groups that the local community has to exchange ideas, information, and experiences in preparing so that local residents can jointly prepare properly when their regions face flooding by forming discussion groups. table 3. head of family final modeling results of preparedness factors for anxiety rates indicators b p or ci 95% knowledge -7,689 0,003 0,000 0,000-0,070 experience 8,415 0,000 5,125 3,968-5,130 constant 19,048 discussion the results of this study found that the average head of family experienced mild anxiety was 47.6%. anxiety occurs when individuals have difficulty facing problems, situations and life goals as a result of the stress of life faced, where the anxiety is influenced by predisposing and precipitation factors. predisposing factors are factors that can affect a person experiencing stress which includes biological, psychological and socio-cultural. and precipitation factors that can challenge, threaten or prosecute individuals who need additional energy and can result in tension and stressor, which includes experiencing or witnessing trauma, threats to physical integrity and threats to the self system6. this is in line with research conducted on families who were in the pre-disaster storm, showing that stressors experienced are significantly related to anxiety symptoms, as well as the sources that cause damage and trauma are significantly related to anxiety symptoms7. experience in dealing with disasters can provide capabilities that have been done before so as to help prevent physical and psychological impacts of individuals when in a potentially flooded area such as symptoms of anxiety that can be felt and can evacuate quickly and act accordingly when the warning is given so that the impact occurring due to a disaster can be avoided. the results of other research found that experience has seven different influences on the preparedness process, namely: encouraging thinking and speaking; increase awareness and knowledge; helping individuals understand the consequences of a disaster; develop trust; develop preparedness; affect emotions and feelings, and encourage community interaction on disaster issues.8 changes in preparedness behavior will have a positive impact, so there is a need for mutual coordination and communication between groups in the community so that south east asia nursing research, vol 1 no 3, december 2019/ page 120-127 124 dwi rahmah fitriani / the relation between knowledge and experience of facing flood toward the anxiety level of head families in the flood-prone areas recommendations and first handling can be done immediately during an emergency which can reduce the level of anxiety. to predict preparedness, behavioral models usually use variables at the level of individual analysis, such as risk perception and assessment of the effectiveness of possible actions (response-efficacy). the other research on 629 dutch citizens in the hague in an area below sea level shows that the influence has a direct and indirect effect on the level of preparedness. where more and more people participate in their communities the more they are prepared and the better use of social networks in facilitating citizens' preparedness for danger.9 anxiety can have an impact on life and make individuals feel uncomfortable, but with anxiety can help give warnings to individuals about the coming danger so it is expected to help improve the ability of individuals to carry out activities to fight danger and threats.10 most of the family heads in lempake village are facing flooding mostly experienced mild anxiety. according to the researchers' opinion, this could happen because the lempake kelurahan area is an area designated as a disaster-resilient region and already has disaster volunteers so that the possibility of local residents already have the preparation and capability in flood preparedness. anxiety can have an impact on life and make individuals feel uncomfortable, but the anxiety can help give warnings to individuals about the coming danger so it is expected to help improve the ability of individuals to carry out activities to fight danger and threats.11 this thing is in line with the research of showing three respondents whose homes are along the river banks, feel anxiety and fear of greater flooding and fear that if the embankment cannot hold water, their residence will sink down.2 this is also supported by research showing the results that 23% of respondents experience psychosocial stress when they are in a region prone to storms.12 relation of knowledge with the level of anxiety of the head of family. in this study, knowledge about flood preparedness was related to the level of anxiety of household heads in disasterprone areas (p = 0.001; α = 0.05). further analysis showed that there were significant differences in knowledge with a mild, moderate and severe head of household anxiety. this is in line with research conducted showing that education is associated with increasing disaster preparedness capability and also showing that disaster-related training is very effective given to individuals with higher education.13 this is also in line with research using multi-regression analysis that the factors that most contribute to disaster preparedness are prior knowledge and experience of disasters.14 and research conducted which shows that the clarity of information received by disaster victims is very helpful in overcoming anxiety disorders and other physical complaints due to stressors experienced. according to differences in knowledge between individuals can also be influenced by several external factors, namely environmental and socio-cultural and internal factors namely education, work, and age, where knowledge can be obtained through education or information obtained. information is needed by individuals in threatening situations in order to be able to solve problems faced by both personal problems or family problems that can have a direct impact on daily life. information provided and in accordance with the conditions and situations can suppress the emergence of new stressors because relevant information will have a positive impact on individuals. the results also showed that 23% of respondents answered no to the questions about temporary shelters that were known before the disaster. this shows that there is still a lack of information about where to evacuate if there’s a flood coming. south east asia nursing research, vol 1 no 3, december 2019/ page 120-127 125 dwi rahmah fitriani / the relation between knowledge and experience of facing flood toward the anxiety level of head families in the flood-prone areas the results showed that 63% of family heads had sufficient knowledge in dealing with floods, this was due to the lack of information about preparedness given directly to the community. research conducted on people's perceptions about floods and preparedness in japan, shown that some respondents who do not have enough knowledge about disaster preparedness have high concerns about the dangers posed by disasters that could arise suddenly and do not understand the preparations and efforts made in dealing with floods.15 this explained that when people did not have enough knowledge, then the individual can not make readiness in dealing with disasters and can cause anxiety. this is supported by research stated in his research in the philippines that respondents' knowledge must be prepared before a disaster event to increase knowledge and ability to deal with disasters through training and seminars.16 relation of preparedness experiences with the level of anxiety of the head of family. relationship of preparedness experiences with levels of head of household anxiety in this study experience in dealing with floods was related to the level of head of household anxiety in disaster-prone areas (p = 0.001; α = 0.05). further analysis showed that there were significant differences in experience factors with a mild, moderate and severe head of household anxiety. previous experience in dealing with floods made individuals able to respond to readiness when needed so that they can avoid the feeling of stress and anxiety when the area has the potential to experience disaster again. the experience of the head of the family in preparing preparedness was in the moderate category (69.8%), where there were 22% of respondents who did not prepare according to the management training that had been followed, because when faced with flooding previously only made preparations in accordance with the emergency at the time. previous experience can increase preparedness in facing disasters and provide information on disasters indirectly to individuals about the impact of disasters so that they can do better activities in carrying out disaster preparedness.16,17 in line with research conducted on floods and preparedness shows that the experience of having been prepared before had a high relationship with community preparedness in dealing with flooding. the previous experience can provide capabilities that have been done previously so as to help prevent physical and psychological impacts of an individual when in a potentially flooded area such as anxiety symptoms that can be felt and can evacuate quickly and act accordingly when the warning is given so that the impact occurs due to disaster can be avoided. research conducted explained that the factor reported contributing to anxiety in daily life was a history of previous stress and natural disaster events of 22.8% which was a source of stress in life.18 previous experience could increase preparedness in the face of natural disasters that can provide more information to individuals to do things that are likely to have an impact on preparedness to be better.19 there were several studies that indicate that previous experience provides a positive relationship to preparedness that can be influenced by the effectiveness of the preparedness and frequency of experience in dealing with disasters.20 there are still family heads who experience severe anxiety because they are currently in a potentially catastrophic region, namely the condition of the house is located close to the source of the flood and during this research, there is often rain with high enough rainfall so that the head of the family experiences anxiety when a sudden flood occurs especially at night. based on this, it is expected that the head of the family has good experience in preparedness by having an independent group to exchange south east asia nursing research, vol 1 no 3, december 2019/ page 120-127 126 dwi rahmah fitriani / the relation between knowledge and experience of facing flood toward the anxiety level of head families in the flood-prone areas experiences so that each head of the family can have different preparedness experiences. this is in accordance with explaining the previous experience in pre-disaster preparedness is related to the preparedness and stress behavior of respondents and respondents who have made preparedness in the face of a disaster can make individuals not easily experience anxiety which can have a detrimental impact. conclusion this research found that most of the anxiety possessed by the head of the family was low anxiety, but there were still those who experienced moderate and severe anxiety. the results showed that knowledge and experience in dealing with flooding were related to the level of anxiety of household heads. further analysis found that there was a significant difference between knowledge and experience in dealing with floods with a mild, moderate and severe head of household anxiety in flood-prone areas. with experience in dealing with flooding was the most related factor to the level of anxiety of household heads in floodprone areas. acknowledgments thank you to all of the respondents and those who have helped this research and support from the ministry of technology and education research and rector of the university of muhammadiyah kalimantan timur. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. nurjannah, sugiharto r, kuswara d, bp s, adikoesoemo. no title manajemen 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to environmental hazards. soc sci q. 2003. doi:10.1111/1540-6237.8402002 18. clapp jd, olsen sa, danoff-burg s, et al. factors contributing to anxious driving behavior: the role of stress history and accident severity. j anxiety disord. 2011. doi:10.1016/j.janxdis.2011.01.008 19. karanci an, aksit b, dirik g. impact of a community disaster awareness training program in turkey: does it influence hazardrelated cognitions and preparedness behaviors. soc behav pers. 2005. doi:10.2224/sbp.2005.33.3.243 20. jóhannesdóttir g, gísladóttir g. people living under threat of volcanic hazard in southern iceland: vulnerability and risk perception. nat hazards earth syst sci. 2010. doi:10.5194/nhess-10-407-2010 symptom and disability one year after traumatic brain injury corresponding author: nury sukraeny nury_sukreny@yahoo.com south east asia nursing research, vol 1 no 1, june 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.1.2019.43-51 original article symptom and disability one year after traumatic brain injury nury sukraeny1 1 university of muhamadiyah semarang article info abstract article history: accepted may 7th, 2019 key words: symptom; disability; tbi tbi is a leading cause of death and disability worldwide. the effects of tbi can significantly disrupt the lives of those who are injured and survive. tbi can affect patients in the physical, cognitive, behavioral and emotional domains which appear from the acute phase and can remain long-term. this cross sectional survey aimed to examine the disability after tbi by the components of icf and also to describe the symptom present in one year after tbi. tbi patients were recruited from the medical record data of patients admitted to the neurosurgery unit who at least 12 month after discharge from hospital and able to be followed up. the drs was used for measured disability. total 56 tbi patients were recruited in this study, 58.9% of the subjects were classified as mild tbi, while 37.5% and 3.6% of them were classified as moderate and severe tbi respectively. more than half of subjects (62.5%) reported of current symptoms with headache as a most common reported. based on drs was found that 83.9% of the subjects have no disability, whereas 3.6% had a mild disability, 5.45 had a partial disability, and 7.2% had a moderate disability. the results demonstrated that a tbi survivors face substantial disability and symptom 1 year after injury. to optimise health and well-being outcomes, clinicians need to identified the needs of patients with less severe tbi and treated during the post-acute period. introduction tbi is a leading cause of death and disability worldwide. the majority of tbi cases are due to road traffic injuries, which account for nearly 60% of all cases of tbi1 the increase in road traffic injuries is also projected to become the third leading cause of global disease and the second leading cause of disease for lowand middle-income countries by 2020. the burden of tbi is manifested in all regions of the world, and is especially prominent in low-and middle-income countries.1 in indonesia, based on the indonesia health profile by the ministry of health republic of indonesia, tbi is currently included in the top ten diseases in hospitalized patients. the number of tbi patients in 2010 was 25,281.2 the effects of tbi can significantly disrupt the lives of those who are injured and survive. tbi can affect patients in the physical, cognitive, behavioral and https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.1.2019.43-51&domain=pdf&date_stamp=2019-06-23 south east asia nursing research, vol 1 no 1, june 2019/ page 43-51 44 nury sukraeny / symptom and disability one year after traumatic brain injury emotional domains which appear from the acute phase and can remain long-term.3–6 the who developed the international classification of functioning, disability, and health (icf) framework for describing health and health-related states. the icf development went through multiple revisions, including the original international classification of impairments, disabilities, and handicaps (icidh) and the intermediate working draft, international classification of functioning and disability (icidh-2) before reaching its current form.7 in the icf, “disability” was replaced with the simpler and more general term “activity”. handicap has been replaced with “participation restriction”. handicap and participation are different words for similar constructs, the latter designed to have a more positive slant.8 in the icf framework, a person’s functioning is conceived as a dynamic interaction between health condition (disease, disorder, injuries, and trauma) and contextual factor using bio-psycho-social approach. the icf consists of two parts including (1) functioning and disability and (2) contextual factor. functioning and disability has two components; (1) body structure and (2) activity and participation. it can be used to indicate problems with a three components outcome; (1) impairment, (2) activity limitation, and (3) participation restriction. the purpose of this study was to examine the disability after tbi by the components of icf and also describe the symptom present in one year after tbi. methods patients fulfilling the following criteria were enrolled in this study: (1) diagnosed with mild to severe tbi, but oriented with respect to time, place and person at the time approached, (2) age 18-65 years, (3) at least 12 month after discharge from hospital and able to be followed up, (4) have no spinal cord injury, history or current psychiatric disease, terminal illness, or comorbidity such as mi, copd, and gout. subjects were recruited from the medical record data of patients admitted to the neurosurgery unit at kariadi hospital. total of 56 subjects were used in this study. disability was measured by disability rating scale (drs).9 it consists of 8 items with a 29-point measure. the drs was designed to measure changes in recovery levels of adults with tbi, where the total scores are meant to reflect the level of disability. the various items of drs address all three who categories: impairment, activity limitation, and participation restriction. the first three items of the drs (“eye opening”, “communication ability”, and “motor response”) are a slight modification of the gcs and reflect impairment ratings. cognitive ability for “feeding”, “toileting”, and “grooming” reflect the level of activity limitation. the “level of functioning” and “employability” reflects participation restriction.10 a score of zero meant the person had no disabling impairments detected by the scale, while the maximum score of 29 indicated vegetative death.11 total scores have been used to describe different clinical levels of disability as follows: none (0), mild (1), partial (2-3), moderate (4-6), moderately severe (7-11), severe (12-16), extremely severe (17-21), vegetative state (22-24), and extreme vegetative state (25-29) (bellon et al.). the inter-rater reliability of in-person assessments with the drs has been established (r = .97-.98) and the test-retest reliability of the drs has also been established (spearmen ρ = .95).11 demographic and health status data were collected and reviewed from each patient’s medical record. this included age, gender, religion, marital status, educational level, occupation, average income, family status, time after injury, access to rehabilitation, and current symptom. in addition, the gcs was assessed on admission for classifying south east asia nursing research, vol 1 no 1, june 2019/ page 43-51 45 nury sukraeny / symptom and disability one year after traumatic brain injury the severity of tbi using the criteria (1) mild tbi with gcs 13-15, (2) moderate tbi with gcs 9-12, and severe tbi with gcs <8. results the characteristics of 56 subjects are shown in table 1.the mean age of subjects was 33.84 (sd 12.56) years old with range from 18-59 years old. the majority of subjects were male (75%) with an average time after injury of 19.24 (sd 2.98) months, range from 13-24 months. about half (60.7%) of subjects was married and 17.9% had educational levels lower than junior high school. although more than half of the subjects worked as labors (73.2% before injury and 64.3% after injury), the number of jobless was increasing after injury from 5.4% to 10.8%. majority of the subjects were moslem who most (93%) of them living with the family with the number of family range from 0 to 9. majority of the subjects diagnosed with tbi were caused by traffic accident. based on gcs, it was found that 58.9% of the subjects were classified as mild tbi, while 37.5% and 3.6% of them were classified as moderate and severe tbi respectively. table 1 characteristic of subjects (n=53) variables f % mean (sd) age (year) (minimum-maximum=18-59) 33.84 (12.57) gender male 42 75 female 14 25 religion muslim 56 100 marital status single 20 35.7 married 34 60.7 widow/widower 2 3.6 level of education no schooling 1 1.8 elementary school 9 16.1 junior high school 12 21.4 senior high school 28 50 diploma 3 5.4 bachelor 3 5.4 occupation before injury student 9 16.1 government employee 3 5.4 labors 41 73.1 no occupation 3 5.4 occupation after injury student 8 14.2 government employee 3 5.4 labors 39 69.6 no occupation 6 10.8 time after injury (months) (minimum-maximum= 13-24) 19.27 (2.98) south east asia nursing research, vol 1 no 1, june 2019/ page 43-51 46 nury sukraeny / symptom and disability one year after traumatic brain injury variables f % mean (sd) living together with family yes 52 92.9 no 4 7.2 number of families living together (minimum-maximum=0-8 persons) 3.7 (1.7) access to rehabilitation no 47 83.9 yes 9 16.1 use complementary therapy no 48 85.7 yes 8 14.3 gcs on admission 12.83 (2.21) mild tbi (13-15) 33 58.9 moderate tbi (9-12) 21 37.5 severe tbi (< or equal to 8) 2 3.6 cause of injury motorcycle accident 38 67.9 traffic accident 14 25 falling 3 5.4 violence 1 1.8 table 2 the number and percentage of symptom of the subjects) variables f % current symptom present no 21 37.5 yes 35 62.5 headache* 30 53.5 memory problem* 6 10.7 fatique* 3 5.3 emotional problem* 2 3.5 vision problem* 1 1.8 cognitive problem* 1 1.8 pain* 1 1.8 stiff face* 1 1.8 nose problem* 1 1.8 *= each patient can have more than one symptom the number and percentage of symptom of the subjects are shown in table 2. more than half of subjects (62.5%) reported of current symptoms as follows: headache (53.5%), problems with memory (10.7%), fatigue (5.3%), emotional problem (3.5%), visual problems (1.8%), cognitive problem (1.8%) , pain (1.8%), stiff face (1.8%), and nose problem (1.8%). table 3 the number and percentage of drs of the subjects categorized by level of disability level of disability f % none (0) 47 83.9 mild (1) 2 3.6 partial (2-3) 3 5.4 moderate (4-6) 4 7.2 the disability of the subjects based on drs was found that 83.9% of the subjects have no disability, whereas 3.6% had a mild disability, 5.45 had a partial disability, and 7.2% had a moderate disability (table 3). south east asia nursing research, vol 1 no 1, june 2019/ page 43-51 47 nury sukraeny / symptom and disability one year after traumatic brain injury discussion the majority of the tbi subjects in this study were male, which was similar to previous studies.12–18 the who report (2004) on road traffic injury prevention reported that males account for 73% of deaths and 70% of all disability-adjusted life years (dalys) lost because of road traffic injuries. according to the cause of tbi, it was found that the majority of the subjects diagnosed with tbi sustained their injuries in road traffic accidents. this result was consistent with the second global status report on road safety by the who (2012) in that 90% of road traffic injuries occur in lowand middle-income countries, such as indonesia. similarly, it was also reported that in lowand middle-income countries, motorcycle riders account for a large portions of road traffic injuries. most of the subjects in this study were young adults (m = 33.84, sd = 12.5) with the median age of 32 years old. this finding was consistent with a previous study which reported that young adults accounted for the majority of tbi subjects.19,20 moreover, a report on the incidence of tbi showed that there was bimodal age distribution in adult populations.21,22 the first peak occurs in young adults with motor vehicle crashes being the major cause of tbi. the second peak occurs within the elderly population with falls being the predominant cause of tbi.21,22 regarding the employment status of tbi patients, it was found that the number of unemployed subjects increased from 5.4% before injury to 10.8% after injury. this finding may reflect that some tbi patients could not return to normal life after their injury. the tbi results in physical and functioning limitations which need longterm care. as reported in previous studies, more than a half of tbi patients had changed their vocational status after they encountered problems with employment.23 consistent with those results, role limitations at work and school was confronted by tbi patients.20 more than a half of the subjects in this study reported having current symptoms such as headaches, memory problems, fatigue, the vision problems, emotional problem, cognitive problem, pain, stiff face, and nose problem. some of patient reported having more than one symptom. this finding was consistent with previous studies which reported the physical impact of tbi on patients.3,5 after three months, approximately half of the mild tbi subjects reported at least one persistent symptom, and the persistence of symptoms continued at one year after injury even though they received early active rehabilitation.5 among those symptoms reported in this study, headaches were the most common among the tbi subjects, which was consistent with a previous study.24 in this study only a lesser amount required access to rehabilitation. it was noted that only a small number of subjects joined a rehabilitation program in this study (n=9). this reflects the situation of indonesia, where access to rehabilitation units is limited. it is estimated that although over 80% of the world’s people with disabilities live in low and middle income countries only 2% have access to rehabilitation services.11 the tbi person who is admitted in a post acute rehabilitation program may have a better outcome. the outcome of tbi persons admitted to a post rehabilitation program at early admission (less than 1 year post injury) versus late admission.25 it was found that all groups showed improvements between admission and discharge on measures of overall disability, independence, home competency, and productivity, and these gains were maintained at follow-up. in addition, the greatest gains were obtained in persons entering a post rehabilitation program within 6 months post injury.25 post acute neuropsychological rehabilitation can have long-term beneficial effects.26 the south east asia nursing research, vol 1 no 1, june 2019/ page 43-51 48 nury sukraeny / symptom and disability one year after traumatic brain injury rehabilitation group showed significantly lower levels of brain injury symptoms and higher levels of competency. they also rated internal locus of control and general self-efficacy as significantly higher, anxiety and depression levels significantly lower, and qol significantly higher in the rehabilitation group.26 moreover, a systematic review of the effectiveness of multidisciplinary rehabilitation following acquired brain injury in adults of working age showed strong evidence that more intensive programs were associated with more rapid functional gains.27 the impact of multifaceted rehabilitation services on functional outcomes after tbi for individuals with significant physical and cognitive difficulties, as well as those with added behavioral complications. the result showed that the rehabilitation treatment model achieved significant functional gains for neuropsychologically-impaired adults with and without associated behavioral and substance problems.28 moreover, in indonesia, besides modern medicine, there are traditional treatments that have been lasted a long time and are entered in the community. tbi patients after discharge from hospital are less likely to follow up in a hospital. more commonly they prefer traditional treatments such as herbs or massages or visiting spiritual healer. even though in the community, tbi patients can access services from community health center. however, community health center only provide primary care for simple disease or symptom. caring for tbi patients after the acute phase, like other disabled groups, is mostly done at home with family. because traditional medicine has become part of indonesian culture and is also more available, it is more likely to be used for curing patients. as reported in who-south east asia regional (chaudhury & rafei, 2001), traditional medicine and traditional practitioners in indonesia, who have developed in line with community needs, are to provide the alternative health services. these practitioners are very popular and familiar in the community, because they are easily accessible and valuable, and have been proved empirically safe.29 those symptom and disability which persist 1 year after injury would be affecting the quality of life (qol) of patients with tbi. it is evidence that a lesser degree of disability was related to higher qol.30 cognitive dysfunction, the activity of daily living (adl) dysfunction, and gos at the time of hospital discharge for tbi patients related significantly to qol.31 congruent with previous studies, patients with lower functional independence have significantly more decreased rates of life satisfaction than patients with greater functional independence.32 conclusion tbi survivors after 1 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indonesian tuberculosis patients corresponding author: lilis lismayanti lilis.lismayanti@umtas.ac.id south east asia nursing research, vol 4 no 4, dec 2022 issn:2685-032x doi: https://doi.org/10.26714/seanr.4.4.2022.25-32 original research effectiveness of application of daily medicine boxes to compliance with antituberculosis drug consumption in indonesian tuberculosis patients miftahul falah1, lilis lismayanti1, nina pamela sari2, asep setiawan1, nia restiana1, usman sasyari1, hani handayani2, rosy rosnawanty2, neni nuraeni2, indra gunawan3, kiki meilani2, tukimin bin sansuwito1, faridah mohd said1, asita elengoe4, munirah munirah1 1 faculty of nursing, lincoln university college, malaysia 2 faculty of health sciences, universitas muhammadiyah tasikmalaya, indonesia 3 faculty of nursing, national taipei university of nursing and health sciences, taiwan 4 faculty of applied science, lincoln university college, malaysia article info abstract article history: submitted: oct 23th 2022 accepted: nov 30th 2022 published: dec 15th 2022 keywords: tb; adherence; daily medicine box tuberculosis (tb) is one of the infectious diseases and is a major cause of poor health, thus becoming one of the leading causes of death in the world. in 2021 the world health organization (who) said that, 9.9 million people experienced tb disease worldwide. it is also estimated that every year there are 13,110 cases of people who die from tb disease. the number of tb cases in indonesia is estimated at 845,000 cases in 2020 with 393,323 tb cases notified. according to data from the tasikmalaya city health office in 2020, there were 1.045 cases of tb sufferers in tasikmalaya city. tb disease can be cured by taking treatment for 6 months. adherence to treatment is one way to prevent failure in tb treatment. the daily medicine box is one solution to improve patient compliance with anti-tb treatment. this study aims to determine the effectiveness of daily medication use on adherence to anti-tb medication in tb patients at the tamansari public health center, tasikmalaya city. this study uses a quantitative approach with the research method of pre-experimental design, one group with pre-test & post-test. the sample was 16 respondents in this study, wilcoxon signed rank test used in this research. results: the results showed that the pretest-posttest had an effect of the daily medicine box on adherence to taking anti-tb drugs in tb patients with p-value 0.000 <0.05. therefore, it can be concluded that there is a significant difference between before and after being given treatment. this study recommended that tb patients apply the daily medicine box as a tool to improve adherence to taking drugs so as to reduce failure in tb treatment. introduction tuberculosis (tb) is one of the most common infectious diseases and the leading cause of poor health and the highest cause of death in the world. in 2020 it is estimated that 9.9 million (8.9-10.9 million) people experience tuberculosis in the world, of which 5.5 million are affected by tb including men, 3.3 million women and 1.1 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.4.4.2022.25-32&domain=pdf&date_stamp=2022-12-15 south east asia nursing research, vol 4 no 4, dec 2022/ page 25-32 26 lilis lismayanti / effectiveness of application of daily medicine boxes to compliance with anti-tuberculosis drug consumption in indonesian tuberculosis patients million children. a person who has hiv disease accounts for 8% of the total people affected by tb. the 8 countries with the highest cases are: india, china, indonesia, the philippines, pakistan, nigeria, bangladesh and south africa. approximately 1.5 million people died of tb in 2020, including 214,000 people with hiv cases. globally, the tb incidence rate fell by 11% between 2015 and 2020 (from 142 to 127 new cases per 100,000 population) including a 1.9% decrease compared to 2019.1 the number of tb cases in indonesia is estimated at 845,000 cases in 2020 with 393,323 confirmed tb cases, the prevalence rate of tb cases is 7,921 confirmed rr/mdr tb cases, 4,590 rr/mdr tb enrolled cases, 33,366 cases of tb in children, then for tb cases with hiv as many as 8,003 cases, while for deaths due to tb as many as 13,110 cases, there are about 83% successful in treatment.2 according to basic health research data, the number of tb sufferers in west java province is (0.63%), west java is the third largest in indonesia after papua and banten. the results of the data obtained for the number of tb patients were 62,218 cases. the data identified that tb cases in west java were still quite high.3 data from the health service of tasikmalaya city in 2020, there were 1,141 tb patients in tasikmalaya city, all tb cases were registered and treated in tasikmalaya city as many as 1,045 patients, and were declared cured as many as 77.00%. the total number of complete patient treatment is 385 people. tb is a disease caused by amycobacterium tuberculosis, which is a type of aerobic bacteria that lives in the lungs, or in other body organs that have high oxygen pressure and are in the same temperature as themselves.4,5 tb can be transmitted through the air such as droplets from coughs, sneezes, or sputum that is transmitted from patients to healthy people. droplets containing tb bacilli can remain in the air for about two hours, depending on the quality of the airways and the light in the room.6–8 there are many factors that can influence the occurrence of tb disease, including the following factors, including individual factors, bacterial factors, and environmental factors. individual factors are various things that can affect the patient's immune system, such as hiv/aids, nutritional deficiencies, diabetes mellitus (dm), and also the use of immunosuppressants. for this bacillus factor, the concentration of old germs meets new germs. as for environmental factors such as air ducts, the density of the occupants of the house, to the lighting in the room. as for nutritional status, it is one of the important factors in the occurrence of an infection such as tb, where the nutritional status of a person who is lacking can make it easier for someone to be infected with tb bacteria.9 there are several efforts and prevention of risk factors for tb disease, namely by doing several ways such as cultivating good and correct cough ethics, cultivating clean and healthy living habits, being able to maintain and improve the quality of housing and the environment in accordance with healthy home standards, increase body immunity, apply prevention and control. tb infection in health service facilities, as well as outside health service facilities, as well as treatment for tb co-morbidities.3 to treat tb disease, several countries have strategies for tb control which are also often referred to as the directly observed treatment short (dots) strategy. this expansion strategy can be carried out with the principle of quality dots services by implementing the five components of the dots strategy, namely by means of: political commitment, microscopic examination, providing anti-tb drugs, availability of quality recording and reporting.3 patients who behave disobediently in taking medicine will hinder the success of therapy and even lead to failure of the therapy they get. south east asia nursing research, vol 4 no 4, dec 2022/ page 25-32 27 lilis lismayanti / effectiveness of application of daily medicine boxes to compliance with anti-tuberculosis drug consumption in indonesian tuberculosis patients in improving the patient's behavior to comply with taking oat, several strategies can be used, one of which is by providing assistive devices such as daily medication boxes. the medicine box given to the patient contains several medications and can be closed with a border and a label showing the day and time of the week. a tb patient only needs to carry a box of medicine every day, but the medicines can be stored for 7 days. in addition, the daily medicine box also helps remind patients to take their medicine on.10,11 a previous study conducted on the effectiveness of daily administration of medication for hypertension in patients with hypertension and found the following results: 16 respondents (80.0%) became compliant, and 4 respondents (20.0%) did not comply after being given a medication box. statistical test results p-value = 0.000, it can be concluded that there is an effect of giving daily medicine boxes on adherence to taking hypertension medicine in hypertensive patients.10 the research regarding the effectiveness of giving posters and medicine boxes to improve drug adherence in patients with diabetes mellitus obtained the following results "the majority of respondents had a low level of drug adherence as many as 29 respondents (88%), after the wilcoxon test, p = 0.000 < = 0.05. it was concluded that there was an effect of poster media and drug installation boxes in increasing medication adherence for diabetes mellitus patients”.12 judging from previous research and also preliminary studies that have been carried out regarding the administration of medicine boxes in patients with hypertension and diabetes mellitus patients, the results are effective, while for tb disease, research has not been carried out. therefore, this study was conducted to find out whether there is an effect of the application of the daily medicine box on the adherence of tb patients to taking anti-tb drugs, if the patient is given a tool in the form of a daily medicine box. method the type of research used is quantitative with a pre-experimental design type of research. the approach in this research uses the one group pretest posttest design. the place where this research was conducted is at the tamansari health center and conducted in june 2022. the population in this study were tb patients seeking treatment at the tamansari health center. the sample in this study used nonprobability sampling with a total sampling of 16 populations in total. the instrument in this study used the indonesian version of the morisky medication adherence scale-8 (mmsa-8) questionnaire which had been validated. the mmsa-8 questionnaire was created in early 1986 by donald e. morsky of the university of california and is a questionnaire to measure patient medication adherence. this mmas-8 instrument has been developed in several languages, such as french, thai, malaysian and korean versions, and indonesian versions which have been tested for validity and reliability. to measure patient compliance in taking anti-tb drug in asia, the mmsa-8 questionnaire is the most frequently used method in assessing adherence to tuberculosis patients and the reseacher has got permission to use this questionnaire. mmas-8 is a questionnaire with 8 questions related to medication adherence. for questions 1-7 if the patient answers "yes" will be given a score 0 but if the patient answers "no" then he is given a score 1, for question no 5 if he answers "yes" he is given a score 1. as for the 8th question using a 5point likert scale (0-1), then the results are added with a score 1-7 questions. the 5point likert scale consists of 5 respondents' answers, where if the respondent answers never then a score 1 is given, once is given a value of 0.75, those who answer sometimes are given a score 0.50, the answer is usually south east asia nursing research, vol 4 no 4, dec 2022/ page 25-32 28 lilis lismayanti / effectiveness of application of daily medicine boxes to compliance with anti-tuberculosis drug consumption in indonesian tuberculosis patients given a score 0.25 and for those who answer is usually given a score 0.25. answer is always given a score 0 the number of values with a level of compliance, namely high compliance has a score 8, moderate compliance has a score 6-<8, and low compliance has a score 0-<6 (amalia, 2020). the researcher asked for approval from tb patients at the tamansari public health center to volunteer to be respondents in this study, then an informed consent carried out and provide an explanation of the process, as well as the objectives of the study. the data analysis method in this study used univariate and bivariate analysis with the statistical test used, namely the wilcoxon signed rank test. results level of compliance before and after being given a daily medicine box.n table 1 frequency distribution of adherence levels before and after being given a daily medicine box indicators f % before high compliance 0 0 medium compliance 11 68,8 low compliance 5 31,3 after high compliance 14 87,5 medium compliance 2 12,5 low compliance 0 0 based on table 1, the results of the frequency distribution test of the level of adherence to medication were obtained, namely for respondents in the moderate compliance category, 11 people with a percentage of 68.8%. and for respondents with low compliance category as many as 5 people with a percentage of 31.3%. based on table 1, the results of the frequency distribution test of the level of adherence to medication are obtained, namely for respondents in the high compliance category, 14 people with a percentage of p87.5%. and for respondents with moderate compliance category there are 2 people with a percentage of p12.5%. the analysis of respondents based on the level of compliance before and after being given a daily medicine box is as follows: table 2 analysis of respondents based on the level of compliance before and after being given a daily medicine box characteristic mean p pre-test 2,31 (±0.479) 0,0001* post-test 1,13 (±0.342) * wilcoxon based on table 2, the results of the descriptive statistical test data score scores for adherence to taking medication before being given a daily medicine box, a mean 2.31, median 2.00, standard deviation 0.479, minimum value 2 and maximum value 3. statistical test data scores for adherence to taking medication after being given a daily medicine box, a mean of 1.13, a median of 1.00, a standard deviation of 0.342, a minimum value 1 and a maximum value 2. based on table 2 it can be seen that the value of sig. on the data before (pre-test) of p0.029 <0.05 and the value of sig. the data after (post-test) of p0.000 <0.05 so it can be concluded that the two data are not normally distributed. the mean value of the patient's level of compliance in taking oat before the intervention is 2.31 with a standard deviation of 0.479. while the mean after the intervention is 1.13 with a standard deviation of 0.342. based on table 6 above, it is explained that in the data from the wilcoxon signed ranks test there is a change in the p value before and after the intervention is given. positive ranks with an n = 16 means that the entire sample experienced an increase in the score from pretest to posttest. the mean pranksp or the average increase is 8.50 and the sum of ranksp or the number of positive rankings is 136.00 and the ties value is 0 meaning that there is no similarity in the values between the pretest and posttest. south east asia nursing research, vol 4 no 4, dec 2022/ page 25-32 29 lilis lismayanti / effectiveness of application of daily medicine boxes to compliance with anti-tuberculosis drug consumption in indonesian tuberculosis patients based on table 2, it is known that the value of asymp. sig (2-tailed) is p0.000 <0.05. therefore, it can be concluded that ha is accepted, ho is rejected, which means that there is a significant difference in the results of filling out the questionnaire before (pretest) and after (post-test). discussion the results of this study showed that most of the respondents before being given a daily medicine box were in the moderate category. and after being given a daily medicine box for 21 days, most of them were in the high compliance category. in line with the study of papeo et al., (2021) showed the level of adherence based on the mmas-8 questionnaire filled out by 75 patients, with 69% of tb patients having high adherence, 15% indicating moderate adherence and 16% indicating adherence. low adherence to the use of anti-tb drug. the researchers found that, of the six characteristic factors investigated (age, gender, occupation, income, education, and duration of treatment), the factors that had a significant impact on anti-tb drug adherence were gender (p=0.01) and occupation (p=0.03). the study program taken and having heard of tb disease is a factor related to tb knowledge.14 another study revealed that knowledge had a positive effect on medication adherence at the level of tofu with a p value 0.041. because knowledge is considered very important for the success of tb treatment because patients will get information about the mode of transmission, stages of treatment, treatment goals, side effects of drugs, and complications of the disease. the knowledge that a person has will affect how he should behave, plan and also in making decisions.15 compliance in treatment reflects the patient's behavior in obeying all advice and instructions given by medical personnel such as doctors, nurses and pharmacists regarding everything that must be done to achieve optimal treatment, one of which is adherence to taking anti-tb drug. this is a condition for achieving the success of the treatment carried out.12 the research results obtained from the wilcoxon signed rank test results in an asymp.sig (2-tailed) value 0.000 <0.05. so it can be concluded that there is a significant difference in the results of filling out the questionnaire between before and after being given a daily medication box, which means that there is an effect of the daily medication box on adherence to taking antitb drug. the results of this study were strengthened by research conducted by puspita et al., (2020) explaining that from the results of the study, 20 respondents (100.0%) did not comply with taking hypertension drugs. a total of 16 respondents (80.0%) after being given a daily medicine box became compliant and 4 respondents (20.0%) did not comply after being given a daily medicine box. the results of the statistical test with a value of p = 0.000, it can be concluded that there is an effect of giving daily medicine boxes on adherence to taking hypertension drugs in hypertensive patients. another study showed that the compliance rate of patients who used daily medicine boxes was 81% and those who used conventional pill bottles were 86%, but more patients were satisfied with daily medicine boxes, which was 61% compared to conventional pill bottles, which was 11% and thought that daily medicine boxes were more helpful in increasing adherence to taking medicines by as much as 50%. in using conventional pill bottles as much as 11%.12 one of the solutions to improve patient compliance in taking medication is by providing a tool in the form of a daily medicine box that can be stored in a place that is easily visible to the patient so as to make the patient remember to take the south east asia nursing research, vol 4 no 4, dec 2022/ page 25-32 30 lilis lismayanti / effectiveness of application of daily medicine boxes to compliance with anti-tuberculosis drug consumption in indonesian tuberculosis patients medicine more. by providing a tool in the form of a daily medicine box, it will help patients to be more obedient in taking drugs. this is in line with other research explaining that a tool has been created to overcome adherence to routine drug consumption, medicine boxes are considered to be able to help the elderly who have complaints of hypertension, diabetes, tuberculosis or diseases that require the consumption of drugs.10 every day for a long time. this is reinforced by the results of interviews that the researchers conducted with several respondents who had a high level of adherence after being given a daily box of drugs. respondents said that the daily medicine box given can reduce forgetfulness and that the daily medicine box is also easy to carry everywhere when the respondent travels. by providing a tool in the form of a daily medicine box, it will help patients remember so that they can improve adherence in taking anti-tb drug. in addition to medicine boxes, knowledge, family support, the role of health workers is proven to have a significant influence on medication adherence 16. research by 17 said that patients who received good family support could improve pulmonary tuberculosis treatment adherence so as to increase the success rate of pulmonary tuberculosis treatment. another study found that family values who always interacted directly with patients could act as a medication companion to fully support the treatment program that the patient is currently undergoing.18 families who understand emotional support will meet the patient's needs, so that there is potential for successful treatment and healing of tb clients. another study found that the support provided by caregivers can help empower tb patients during the treatment period by providing continuous encouragement and as a supervisor for taking medication. caregiver support is also an important factor in showing sympathy, helping patients to be more confident and willing to accept their situation. therefore, the patient's healing process will take place optimally,19 furthermore,20 argue that with complete information about pulmonary tb treatment, families can carry out the function of health services for pulmonary tb clients who are undergoing treatment. pulmonary tb clients need medical therapy and positive attention and feedback from the family.21 family support and motivation greatly affect the success of tb treatment. the family always reminds the patient to take my medicine regularly and generally take care of him. the need for support is given to patients when they comply with treatment and have confidence in their recovery.22 this study is in line with research conducted by hannan & hidayat, (2013) which states that a good family can lead in the success of treatment and have a high awareness of tb client care. the role of the environment and good health services are expected to be able to support the provision of information to patients related to information, disease science, and correct treatment which will be able to reduce the risk of the spread of pulmonary tb disease and the healing rate continues to grow. this fact shows that families who have good knowledge and understanding of the importance of their role and function in caring for pulmonary tb patients so that they can provide good support.24 furthermore, social support is also important for people with chronic diseases such as tuberculosis because social support can affect individual behavior, such as decreasing anxiety, helplessness, and hopelessness, which in turn can improve health status. increased health status means that it will improve the quality of life of patients. conclusion based on the results of the pretest-posttest, it can be concluded that there is a significant effect between before and after being given treatment from the daily medicine box on adherence to taking oat in tb patients at south east asia nursing research, vol 4 no 4, dec 2022/ page 25-32 31 lilis lismayanti / effectiveness of application of daily medicine boxes to compliance with anti-tuberculosis drug consumption in indonesian tuberculosis patients tamansari health center. therefire, the researchers hope that tb patients can apply this daily medicine box to increase adherence to taking drugs. acknowledgment the author would like to thank all respondents and participate in this study. conflicts of interest the author does not have a conflict of interest that could bias the results in the research that has been done. references 1. who. world health day 2021. geneva; 2021. 2. kemenkes ri. profil kesehatan indo-nesia. pusdatin.kemenkes.go.id. 2021. kementrian kesehatan republik indonesia. 3. kemenkes ri. tuberkulosis ( tb ). tuberkulosis. 2018;1(april):2018. 4. cdc. trends in tuberculosis — united states. usa; 2011. 5. selasa pius; israfil. ; teli margaretha. selfmanagement for patients in the treatment program of pulmonary tuberculosis in kupang city, east nusa tenggara province indonesia. european journal of molecular & clinical medicine. 2020;7(10):2882–9. 6. lestari muslimah dd. physical environmental factors and its association with the existence of mycobacterium tuberculosis: a study in the working region of perak timur public health center. jurnal kesehatan lingkungan. 2019;11(1):26. 7. kemenkes ri. pedoman nasional pengendalian tuberkulosis-keputusan menteri kesehatan republik indonesia nomor 364. kementerian kesehatan republik indonesia. 2011;(pengendalian tuberkulosis):110. 8. chen x, du l, wu r, xu j, ji h, zhang y, et al. the effects of family, society and national policy support on treatment adherence among newly diagnosed tuberculosis patients: a crosssectional study. bmc infect dis. 2020;20(1):1– 11. 9. marlinae et al. desain kemandirian pola perilaku kepatuhan minum obat pada penderita tb anak berbasis android. 1st ed. theana s, lutfiani a, marisa, editors. yogyakarta: cv mine; 2019. 1–99 p. 10. puspita rr, pratiwi rd, , fenita purnama sari indah de, sandria tambunan vay. pemberian kotak obat harian terhadap kepatuhan mengkonsumsi obat hipertensi pada pasien hipertensi. edu dharma journal. 2020;4(1):31–5. 11. pradipta is, houtsma d, van boven jfm, alffenaar jwc, hak e. interventions to improve medication adherence in tuberculosis patients: a systematic review of randomized controlled studies. npj prim care respir med. 2020;30(1). 12. sentana ad, pratama k. efektivitas poster dan kotak obat dalam meningkatkan kepatuhan minum obat pasien diabetes melitus. bima nursing journal. 2021;2(2):104. 13. papeo drp, immaculata m, rukmawati i. hubungan antara kepatuhan minum obat (mmas-8) dan kualitas hidup (whoqolbref) penderita tuberkulosis di puskesmas di kota bandung. indonesian journal of pharmaceutical education. 2021;1(2):86–97. 14. falah m, tai cy, lu yy, liu cy, lismayanti l. tuberculosis knowledge among university students in indonesia. south east asia nursing research. 2019;1(2):95. 15. mientarini ei, sudarmanto y, hasan m. hubungan pengetahuan dan sikap terhadap kepatuhan minum obat pasien tuberkulosis paru fase lanjutan di kecamatan umbulsari jember. ikesma. 2018;14(1):11. 16. nopiayanti g, falah m, lismayanti l. faktorfaktor yang berhubungan dengan tingkat kepatuhan minum obat pada penderita tb di kota tasikmalaya. healthcare nursing journal. 2022;4(1):243–7. 17. suarnianti, selan ch, sumi ss. evaluasi peer group support dan family support terhadap kepatuhan pengobatan pada pasien tuberkulosis paru: literature review. 2021;11(1):51–8. 18. reza tf, nalugwa t, nantale m, adams k, fielding k, nakaweesa a, et al. design and execution of a public randomization ceremony to enhance stakeholder engagement within a cluster randomized trial to improve tuberculosis diagnosis in uganda. contemp clin trials commun. 2021;22:100707. 19. irnawati mn, t siagian ie, ottay ri. pengaruh dukungan keluarga terhadap kepatuhan minum obat pada penderita tuberkulosis di puskesmas motoboi kecil kota kotamobagu. jurnal kedokteran komunitas dan tropik. 2016;4(2):59–64. 20. hayati d, musa e. hubungan kinerja pengawas menelan obat dengan kesembuhan tuberkulosis di upt puskesmas arcamanik south east asia nursing research, vol 4 no 4, dec 2022/ page 25-32 32 lilis lismayanti / effectiveness of application of daily medicine boxes to compliance with anti-tuberculosis drug consumption in indonesian tuberculosis patients kota bandung. jurnal keperawatan. 2016;4(1):10–8. 21. sukumani jt, lebese rt, khoza lb, risenga pr. experiences of family members caring for tuberculosis patients at home at vhembe district of the limpopo province. curationis. 2012;35(1):54. 22. kartikasari d, rejeki s, wuryanto e. hubungan peran keluarga sebagai pengawas minum obat (pmo) dengan kepatuhan minum obat pada penderita tuberkulosis paru di puskesmas kedungwuni ii kabupaten pekalongan. jurnal ilmu keperawatan. 2012;5(1):71–9. 23. hannan m, hidayat s. peran keluarga dalam perawatan penderita tuberkulosis paru di kecamatan gapura kabupaten sumenep. jurnal kesehatan “wiraraja medika.” 2013;17– 0. 24. nastiti ad, kurniawan c. hubungan dukungan keluarga dengan kepatuhan kontrol pasien tb paru stikes dian husada corresponding author : ayudewi.akper@unej.ac.id di wilayah puskesmas kedundung kecamatan magersari kota mojokerto pendahuluan tb paru atau tuberkulosis adalah penyakit m. 2020;15(1):78–89. murottal and clasical music therapy reducing pra cardiac chateterization anxiety corresponding author: yunie armiyati yunie@unimus.ac.id south east asia nursing research, vol 1 no 2, september 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.2.2019.52-60 original research murottal and clasical music therapy reducing pra cardiac chateterization anxiety sapta darmadi1, yunie armiyati2 1 dr. kariadi general hospital semarang 2 university of muhamadiyah semarang article info abstract article history: accepted september 30th, 2019 key words: classical music; murottal therapy; anxiety; cardiac catheterization the high incidence of patients with coronary heart disease is directly proportional to the increase in cardiac catheterization. many patients who experience anxiety pre heart catheterization will need nursing action. relaxation with classical music therapy and or murottal therapy can reduce patient anxiety. the aim of this study was to determine the effectiveness of murottal therapy and classical music therapy to reduce the anxiety of patients pre heart catheterization in the elang installation of dr. kariadi hospital semarang. the study was a quasi experiment study with two group pre and post test design. the research sample consisted of 16 patients in the classical music therapy group and 16 in the murottal therapy group. the results of the study showed that there were differences in the effectiveness of murottal therapy and classical music therapy to decrease the anxiety of patients pre heart catheterization in the elang installation of dr. kariadi hospital semarang (p-value 0.028). murottal therapy is more effective in reducing anxiety. music therapy and murottal therapy given with a duration of 30 minutes creates a calm and comfortable atmosphere so that the body becomes more relaxed, blood circulation more smoothly, blood pressure and other vital signs will decrease and can reduce anxiety in patients pre cardiac catheterization. murottal therapy is more effective in reducing anxiety. it is hoped that the results of this study will become the basis of hospital agencies in developing standard operating procedure (spo) management of anxiety in the provision of nursing care to patients cardiac pre-catheterization. introduction the world health organization (who) reports that an estimated 17.9 million people died from cardiovascular diseases (cvds) in 2016, representing 31% of all global deaths. of these deaths, 85% are due to heart attack and stroke.1 indonesia has a tendency to increase the incidence of cardiovascular disease. the national prevalence for heart disease in 2018 is 1,5% based on diagnosis by health professionals and symptoms.2 cardiovascular disease is a public health problem in developed and developing countries, this disease is divided into 3 groups, namely heart function disorders, heart structure disorders, infections and non-inflammation, and disorders of the https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.2.2019.52-60&domain=pdf&date_stamp=2019-09-30 south east asia nursing research, vol 1 no 2, september 2019/ page 52-60 53 yunie armiyati / murottal and clasical music therapy reducing pra cardiac chateterization anxiety vascular system.3 based on the proportion of urban mortality in the 45-54 years age group, ischemic heart disease ranks third (8.7%) as the cause of death, first place is stroke (15.9%) and second place is diabetes mellitus (14.7%). the prevalence of coronary heart disease based on diagnosed doctor interviews in indonesia increases with age by 0.5%, and based on diagnosed doctors or symptoms by 1.5%.2 according to the survey sample regristration system (srs) at 2014 in indonesia, it showed that coronary heart disease (chd) was the highest cause of death in all ages after stroke by 12.9%.4 various methods are used to recognize the diagnosis of coronary heart disease, ranging from non-invasive techniques such as electrocardiography (ecg) to invasive examinations such as coronary angiography (cardiac catheterization). catheterization (derived from the word cardiac catheterization, or heart catheterization and abbreviated as catheterization) is the act of inserting a small tube (catheter) into the arteries and / or veins and tracing them to the heart, other blood vessels and / or other organs to which they are directed xray assistance.5 cardiac catheterization has therapeutic and diagnostic support functions but also has risks in the form of arrhythmias, emboli, nerve changes, vasovagal changes and other additional disorders that are ischemic, allergic and vascular complications. a total of 2631 patients undergoing cardiac catheterization at rsup dr. kariadi semarang, among them 1,920 (73%) had coronary intervention (cardiac catheterization by stenting). numerous studies shown that the action of cardiac catheterization can cause anxiety in patients, efforts to reduce anxiety can be given with nonpharmacological therapy. cardiac catheterization is an invasive procedure that for some people will have a psychological impact on the patient. patients who will undergo invasive cardiac catheterization procedures will experience feelings of anxiety and stress. the magnitude of the impact caused by anxiety will affect the activity of the central nervous system to activate the hypothalamus pituitary adrenal axis and the sympathetic nervous system which is characterized by an increase in pulse frequency and blood pressure. this is very dangerous because the high heart rate and blood pressure will aggravate the cardiovascular system and increase oxygen demand and heart work.6 patient's anxiety needs to get special attention in nursing because every nursing action must quickly make effective coping of the patient in order to reduce perceived stress so that physiological and emotional balance is achieved.7 preliminary study data at dr. kariadi hospital semarang in august 2018 showed that most patients who will undergo cardiac catheterization experience anxiety. it is not uncommon to delay catheterization because the patient's anxiety affects hemodynamics. survey of 10 patients who will undergo cardiac catheterization found that 100% of patients expressed anxiety, 50% experienced moderate anxiety, 10% experienced severe anxiety and 40 people experienced mild anxiety. the results of interviews with the person in charge of the cardiac catheterization room, nurses and doctors in the cardiac catheterization room of dr. kariadi hospital found that most of the patient's response when he entered the heart catheterization room, facial expressions looked scared, confused, some even had a sudden increase in blood pressure and increased heart rate. nurses must implement appropriate interventions to deal with patient anxiety. various non-pharmacological measures of independent management based on nursing intervention classification (nic) can be done to overcome patient anxiety including relaxation therapy, guided imagination, increased safety, music therapy, counseling and meditation facilitation.8 south east asia nursing research, vol 1 no 2, september 2019/ page 52-60 54 yunie armiyati / murottal and clasical music therapy reducing pra cardiac chateterization anxiety listening to music has a moderate effect on anxiety in people with coranary heart desease (chd). studies that used music interventions in people with myocardial infarction found more consistent anxiety‐ reducing effects of music.9 music stimulation increases endorphine release and this decreases the need for drugs. the release of endorphins also provides a distraction from pain and can reduce anxiety.10 religious therapy with murottal al qur'an verses can also speed healing. study in s to determine the effect of murrotal audio therapy of qur'an surah arrahman to the level of anxiety in presurgery senile cataract patients showed there was the influence of anxiety differences of respondents before and after given audio therapy qur'an surah arrahman.11 research has shown the effect of murottal (al-qur'an) therapy on reducing anxiety levels of patients who will undergo laparatomy surgery.12 the use of murotal music therapy and classical music both can significantly reduce the anxiety of patients with various cases of the disease, including in patients who will undergo surgery. it is necessary to examine which interventions are better and more effective in reducing the anxiety of patients undergoing cardiac catheterization. researchers interested in examining the effectiveness of murottal therapy and classical music therapy on reducing anxiety of patients pre cardiac catheterization at the elang installation of dr. kariadi general hospital semarang. methods the research method used was quasy experimental (quasy experiment) with the research design is two group pre and post test design. the target population in this study were all patients who will undergo cardiac catheterization at the elang installation of dr. kariadi general hospital semarang with the sampling technique in this study using purposive random sampling. the research sample calculated using the federer formula obtained a sample of 16 people as a group who were given classical music therapy and 16 people as a group who were given murottal therapy selected according to the inclusion criteria, namely patients treated in the eagle room of rsup dr. kariadi semarang, the first iscemic heart disease (ihd) patient who will undergo a cardiac catheterization program, more than 30 years old and cooperative, muslim, patients with mild to severe anxiety, male sex, minimum education at primary school. the study was conducted in february may 2019 in the elang installation of dr. kariadi general hospital semarang by paying attention to research ethics including the principle of benefits, the principle of respecting human rights (respect human dignity) and the principle of justice (right to justice). an ethical clearancec letter issued by the medical research ethics commission diponegoro university. data collection instruments in this study were carried out using an anxiety measurement tool which in its use of the interview method. anxiety level measurement tool is the numeric rating scale (nrs) for anxiety. anxiety score is assessed based on the range of intensity of anxiety felt by the client with a zero score category said there is no anxiety, a value of 10-30 mild anxiety, a value of 40-60 moderate anxiety, a value of 70-90 severe anxiety, and a value of 100 panic. the instrument of classical was performed using a mozart clarinet concerto in a major k 622 adagio classical music by using smart phone. murottal therapy surah ar-rahman sung by muzammil hasballah with a medium timbre, 44 hz pitch, regular harmony and consitent, rhythm andate lilting, volume 60 decibels, medium intensity amplitude with a time duration of 30 minutes. the intervention was carried out by giving classical music and murottal surah ar rahman to each group, listening by lying down for 30 minutes using headphones. anxiety scale is measured south east asia nursing research, vol 1 no 2, september 2019/ page 52-60 55 yunie armiyati / murottal and clasical music therapy reducing pra cardiac chateterization anxiety before and after the intervention in each group. data were analyzed by univariate and bivariate tests. analysis of differences in anxiety levels in patients pre cardiac catheterization before and after given murottal therapy and classical music therapy using the wilcoxon test. analysis of the differences in murottal therapy and classical music therapy on the reduction in anxiety of patients pre cardiac catheterization at the elang installation of dr. kariadi semarang hospital uses the mann-whitney test. results the results showed the average age of respondents in group i (classical music therapy) is 44.25 years and the oldest age is 56 years. group ii (murottal therapy) obtained an average age of respondents was 45.38 years and the oldest age was 56 years. the results showed that patients who will undergo cardiac catheterization more in the respondents with undergraduate education by 62.5% in group i and 43.8% in group ii. occupational respondents the majority work as private employees as many as 6 people (37.5%) group i (classical music therapy) and 5 people (31.2%) in group ii (murottal therapy). length of stay was 1 day for 8 people (50%) in group i and 9 people (56.2%) in group ii. table 1 distribusi responden berdasarkan pekerjaan, pendidikan dan lama hari rawat characteristik group i (clasical music therapy) group ii (murottal therapy) f % f % job not working private employees laborers entrepreneur civil servants 2 2 6 4 2 12,5 12,5 37,5 25,0 12,5 2 1 5 5 3 12,5 6,2 31,2 31,2 18,8 education junior high school senior high school college 1 10 5 6,2 62,5 31,2 2 7 7 12,5 43,8 43,8 length of stay 1day 2 days 3 days 8 5 3 50,0 31,2 18,8 9 5 2 56,2 31,2 12,5 total 16 100 16 100 the results showed that before being given classical music therapy the majority of respondents experienced moderate anxiety, namely as many as 10 people (62.5%). after being given classical music therapy there was a decrease in the level of anxiety in respondents, the majority (56.2%) experienced mild anxiety. table 2 anxiety level before and after being given classical music therapy (n = 16) anxiety level group i (classical music therapy) before classical music therapy after classical music therapy f % f % mild anxiety medium anxiety severe anxiety 4 10 2 25,0 62,5 12,5 9 7 0 56,2 43,8 0,0 total 16 100 16 100 the anxiety level of respondents after being given murottal therapy decreased with an average decrease in anxiety level score 20.62 compared to before being given murottal therapy and the majority after south east asia nursing research, vol 1 no 2, september 2019/ page 52-60 56 yunie armiyati / murottal and clasical music therapy reducing pra cardiac chateterization anxiety being given murottal therapy experienced mild anxiety by 13 people (81.2%) compared to before being given music therapy, the majority (75.0%) experienced moderate anxiety. table 3 anxiety level before and after being given murottal therapy (n = 16) anxiety level group ii (murottal therapy) before murottal therapy after murottal therapy f % f % mild anxiety medium anxiety severe anxiety 2 12 2 12,5 75,0 12,5 13 3 0 81,2 18,8 0,0 total 16 100 16 100 the results of statistical analysis with wilcoxon test showed that in group i (classical music therapy) decreased anxiety levels of 12 people (75.0%) and increased and remained as many as 2 people each (12.5%). group ii (murottal therapy) showed that as many as 15 people (93.75%) had decreased anxiety levels and only 1 person (6.25%) with a fixed anxiety level. table 4 differences in anxiety levels before and after being given classical music therapy and murottal therapy (n1 = n2 =16) variabel respons f mean rank p value anxiety level before and after classical music therapy increase decrease not change 12 2 2 anxiety level before and after murottal therapy increase decrease not change 15 0 1 8 0,001* wilcoxon test* the results showed that the average decrease in anxiety levels in group ii (murottal therapy) was higher at 19.97 compared to group i (classical music therapy) by 13.03. research shows that there is a difference between murottal therapy and classical music therapy to decrease patient anxiety before cardiac catheterization at elang instalation of dr. kariadi hospital semarang. table 5 differences in the effectiveness of murottal therapy and classical music therapy against decreased patient anxiety before cardiac catheterization (n1 = n2 =16) decrease of anxiety level mean rank pvalue group i (clasical music therapy) 13,03 0,028 group ii (murottal therapy) 19,97 discussion the results of this study indicate that the average patient who will undergo cardiac catheterization is an adult age. cardiac catheterization patients tend to increase in adulthood. this is due to lack of awareness of running healthy habits. coronary heart disease arises due to abnormal accumulation of lipids or levels of fat and fibrous tissue in the walls of blood vessels that result in changes in the structure and function of the arteries caused by ateroslerosis. atherosclerosis causes inadequate blood supply to the heart and heart muscle cells to lack blood components. this causes ischemia in the heart muscles so that the patient will experience chest pain and in more severe ischemic conditions can be accompanied by damage to heart cells that are.3 the patient's age also influences the type of relaxation therapy that will be given. adult patients tend to prefer relaxation therapy that is selfapproach to god, so that the provision of nursing interventions that are in accordance with the patient's age criteria will help in the success of the patient's health and care program. the results showed that patients who will undergo cardiac catheterization more in the respondents with undergraduate education by 62.5% in group i and 43.8% in group ii. one of the trigger factors that can cause south east asia nursing research, vol 1 no 2, september 2019/ page 52-60 57 yunie armiyati / murottal and clasical music therapy reducing pra cardiac chateterization anxiety anxiety is education status. the higher a person's education, the level of anxiety tends to decrease compared with people who have a low level of education. low educational levels were significantly associated with both anxiety and depression.13 the level of anxiety is closely related to the level of education, where someone will be able to find information or receive information well. a high level of education will quickly understand the conditions and circumstances that will cause increased anxiety in the person. the work of respondents in this study found that the majority worked as private employees as many as 6 people (37.5%) group i (classical music therapy) and 5 people (31.2%) in group ii (murottal therapy). work is one of the reasons for patients experiencing anxiety when a heart catheterization will be performed. this is due to the patient's concern for the safety of the soul and the patient's ability to perform work after the action. patients who have jobs that require physical exertion will experience a decrease in the ability for patients to do so so that they appear worried about the threat of continuing their work and have an effect on the socioeconomy of the family.14 the results of this study showed that the majority of days of treatment were 1 day as many as 8 people (50%) in the classical music group and 9 people (56.2%) in the murottal therapy group. length of stay related to the patient's experience of the heart catheterization to be performed. previous experience of surgery and information obtained by the patient on the first day through the explanation of informed consent will affect the knowledge of the patient about the procedure for cardiac catheterization to be performed so that it will reduce anxiety and anxiety in patients.7 after being given classical music therapy there was a decrease in the level of anxiety in respondents where the majority experienced mild anxiety by 9 people (56.2%) with the lowest value of 20 and the highest of 50, and an average level of anxiety of 34.38. the results of research on the level of anxiety experienced by patients before undergoing cardiac catheterization increased with the approaching time of action, moreover cardiac catheterization has been known to have various kinds of possible complications during the process of action. psychological preparation is needed by patients who will undergo cardiac catheterization. the results of this study are in line with the results of several existing studies. other research in patients with preoperative laparotomy shows that before being given murottal (al-qur'an) therapy, moderate anxiety was 56.2% and severe anxiety was 43.8%. after being given murottal (alqur'an) therapy, most (65, 6%) experienced mild anxiety.12 the systematic review indicates that music listening may have a beneficial effect on preoperative anxiety. these findings are consistent with the findings of three other cochrane systematic reviews on the use of music interventions for anxiety reduction in medical patients.9 anxiety is an obscure and pervasive concern, which is related to feelings of uncertainty and helplessness. this anxiety does not have a specific object, which is experienced subjectively and communicated interpersonal.15 one of independent nursing intervention to overcome anxiety is to provide classical music therapy and murottal therapy. classical music and murottal therapy provides a relaxing and calming effect so that it can reduce anxiety in patients. the sound of clasiccal music and the qur’an creates a group of frequencies that reach the ear and then moves to the brain cells and influences them through the electromagnetic fields this frequency is produced in these cells. the cells will respond to these fields and modify their vibrations. this change in vibration can make the brain relax and calm. south east asia nursing research, vol 1 no 2, september 2019/ page 52-60 58 yunie armiyati / murottal and clasical music therapy reducing pra cardiac chateterization anxiety the results showed a decrease in anxiety levels after given murottal therapy. murrotal auditory stimulation has a relaxing effect increase the formation of endorphins in the control system descent and make relaxation.16 listening to the verses of the qur'an has a calming effect and makes the patient closer to his creator. based on this, the patient can surrender and surrender all the conditions set by god for the heart catheterization that will be undertaken by the patient, so that the patient can become more relaxed and reduce anxiety on the patient. al-qur'an reading murottal has a constant rhythm, regular and no sudden changes. murottal al-qur'an's tempo and low notes have a relaxing effect and can reduce stress and anxiety.17 murottal therapy will increase one's awareness of god, whether that person knows the meaning of the qur'an or not. this awareness will lead to totality surrender to allah, in this state the brain in alpha waves in the form of brain waves creates optimal brain energy so that it can relieve stress and reduce anxietyn.18 the results of this study indicate a p-value of 0.007 in group i and 0.001 in group ii < (0.05), it can be concluded that there is a significant difference between anxiety levels in patients pre-cardiac catheterization before and after classical music therapy and murottal therapy at rsup dr. kariadi semarang. classical music therapy and murottal therapy are both sounds that can provide a therapeutic effect by providing relaxation to the patient so as to reduce the anxiety experienced by patients pre cardiac catheterization. music therapy and murottal therapy given with a duration of 30 minutes creates a calm and comfortable atmosphere so that the body becomes more relaxed, blood circulation more smoothly, blood pressure and other vital signs will decrease and can reduce anxiety in patients pre cardiac catheterization. however, interventions with classical music therapy still found patients with increased anxiety levels after being given classical music therapy. this is because the music therapy given is less favored by the patient, so the patient's concentration cannot focus on the music given and still imagine the heart catheterization action to be performed. murottal therapy in this study can reduce the level of anxiety of patients pre cardiac catheterization. this is because essentially murottal al-qur'an therapy with regular rhythm and correct reading is also a music. the qur'an is able to bring calm and minimize anxiety. murottal therapy works on the brain, wherewhen driven by external stimulation (therapy al-quran) then the brain produces chemicals that are called neuropeptide.17 these molecules transport their existing receptors in the body so the body gives bait behind a sense of comfort.the administration of murottal alqur'an therapy has been proven to be effective in increasing β-endorphine levels in patients who are sung with slow, gentle, full-of-depth tempers that can cause a relaxation response. auditory (sound) therapy can reduce stress hormones, activate natural endorphins, increase feelings of relaxation, and divert attention from fear, anxiety and tension, improve the body's chemical system so that it lowers blood pressure and slows down breathing, heart rate, pulse, and brain wave activit.10 murottal therapy can reduce anxiety scores by 42.8% while classical music therapy can reduce anxiety scores in preterm cardiac catheterization patients by 23.6%. this study showed 93.75% of respondents experienced a decrease in anxiety scale and only 1 respondent (6.25%) did not experience a change in anxiety scale. the decrease in anxiety occurs because the murottal therapy given is more understandable by the respondent. murottal therapy in the form of chanting alqur'an verses of the ar-rahman letter can be felt soothing to the heart, calming and getting closer to god so that patients are more relaxed and reduce the level of anxiety pre cardiac catheterization. south east asia nursing research, vol 1 no 2, september 2019/ page 52-60 59 yunie armiyati / murottal and clasical music therapy reducing pra cardiac chateterization anxiety the qur'an has a great influence on a person's psyche. listening to the qur'an will give you the effect of peace in the body because of the elements of meditation, autosuggestion and relaxation. this sense of calm will then provide a positive emotional response that is very influential in bringing about positive perception.18 researchers used ar-rahman's letter because of the surah contains a great wisdom for humanity in general and for muslims in particular. this is related to the degree of thankfulness in the broadest sense of the meaning of the disobedience of the giver (allah almighty). surah arrahman is preceded by a statement about the nature of allah, the beneficent god. his generosity is the source of all the gifts given to all mankind. research showed using murottal therapy is more effective in reducing anxiety levels in patients pre cardiac catheterization compared to classical music therapy. this is possible because murottal therapy has an indispensable aspect in overcoming anxiety, namely its ability to form new coping to overcome anxiety before undergoing cardiac catheterization. other studies also support the findings of this study. research in postoperative patients shows that murottal therapy has been shown to be more effective in reducing anxiety compared to other music therapies urottal therapy has been proven to be more effective in reducing anxiety compared to other music therapies murottal therapy has an indispensable aspect inovercoming anxiety, murottal has the ability to form a new coping to overcome anxiety. murottal therapy has two important points, has a beautiful rhythm and also can psychologically motivate and provide encouragement in facing the problems being faced.10 whereas in music therapy, it only has one point, which has a beautiful tone. murottal also increases calm because there is a spiritual closeness to god. we recommend that nurses can apply the provision of murottal qur'an and classical music therapy to overcome the anxiety of patients who will undergo cardiac catheterization surgery. to reduce the anxiety of muslim patients, nurses can apply murottal al qur'an. conclusion murottal therapy and classical music in reducing anxiety in patients pre cardiac catheterization. nurses can apply classical music therapy and murotal therapy to reduce the anxiety of patients who will undergo cardiac catheterization. acknowledgements we wish to express our appreciation to all patients who participated in this study and to the dr. kariadi general hospital semarang for valuable assistance during data collection. conflicts of interest neither of the authors have any conflicts of interests that would bias the findings presented here. references 1. who. cardiovascular diseases (cvds)2013 [cited 2019 22 september]. available from: https://www.who.int/news-room/factsheets/detail/cardiovascular-diseases-(cvds). 2. balitbangkes. hasil utama riskesdas 2018 jakarta: kemenkes; 2018 [cited 2019 07 november ]. available from: http://www.depkes.go.id/resources/downloa d/info-terkini/hasil-riskesdas-2018.pdf. 3. smeltzer sc, bare bg, hinkle jl, cheever kh. brunner & suddarth's textbook of medicalsurgical nursing. 13th ed: lippincott williams & wilkins; 2013. 4. kemenkes. penyakit jantung penyebab kematian tertinggi, kemenkes ingatkan cerdik2017 20 september 2019 [cited 2017 29 july]. available from: http://www.depkes.go.id/article/view/17073 100005/penyakit-jantung-penyebabkematian-tertinggi-kemenkes-ingatkan-cerdik.html. https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds http://www.depkes.go.id/resources/download/info-terkini/hasil-riskesdas-2018.pdf http://www.depkes.go.id/resources/download/info-terkini/hasil-riskesdas-2018.pdf http://www.depkes.go.id/article/view/17073100005/penyakit-jantung-penyebab-kematian-tertinggi-kemenkes-ingatkan-cerdik-.html http://www.depkes.go.id/article/view/17073100005/penyakit-jantung-penyebab-kematian-tertinggi-kemenkes-ingatkan-cerdik-.html http://www.depkes.go.id/article/view/17073100005/penyakit-jantung-penyebab-kematian-tertinggi-kemenkes-ingatkan-cerdik-.html http://www.depkes.go.id/article/view/17073100005/penyakit-jantung-penyebab-kematian-tertinggi-kemenkes-ingatkan-cerdik-.html south east asia nursing research, vol 1 no 2, september 2019/ page 52-60 60 yunie armiyati / murottal and clasical music therapy reducing pra cardiac chateterization anxiety 5. pdski. pedoman laboratorium kateterisasi jantung dan pembuluh darah. jakarta: pdski; 2018. 6. darliana d. perawatan pasien yang menjalani prosedur kateterisasi jantung. idea nursing journal. 2012;3(3). 7. potter pa, perry ag, stockert pa, hall am. fundamental of nursing. 9 ed. pensylvania: elsevier; 2017. 8. butcher hk, bulechek gm, dochterman jmmc, wagner c. nursing interventions classification (nic) e-book: elsevier health sciences; 2018. available from: https://books.google.co.id/books?id=l4lidwa aqbaj. 9. bradt j, dileo c, potvin n. music for stress and anxiety reduction in coronary heart disease patients. cochrane database of systematic reviews. 2013(12). 10. faradisi f, aktifah n. pengaruh pemberian terapi murottal terhadap penurunan kecemasan post operasi. profesi (profesional islam): media publikasi penelitian. 2018;15(2):6. 11. syafei a, suryadi y. pengaruh pemberian terapi audio murottal qur’an surat ar-rahman terhadap tingkat kecemasan pada pasien preoperasi katarak senilis. jurnal kesehatan. 2018;9(1):126-30. 12. faridah vn. terapi murottal (al-qur’an) mampu menurunkan tingkat kecemasan pada pasien pre operasi laparatomi. jurnal keperawatan. 2016;6(1). 13. bjelland i, krokstad s, mykletun a, dahl aa, tell gs, tambs k. does a higher educational level protect against anxiety and depression? the hunt study. social science & medicine. 2008;66(6):1334-45. 14. hawari d. manajemen stress, cemas dan depresi. jakarta: fakultas kedokteran universitas indonesia; 2014. 15. stuart gw. principle and practice of pscychiatric nursing. 10 ed. st louis: elsevier; 2013. 16. armiyati y, editor pengaruh perangsangan auditori murrotal (ayat-ayat suci al-qur’an) terhadap nyeri pada pasien yang terpasang ventilator mekanik di ruang icu rumah sakit islam sultan agung semarang. konferensi nasional ppni jawa tengah; 2017. semarang. 17. widyarti. pengaruh bacaan al-qur’an terhadap intensitas kecemasan pasien sindroma koroner akut di rs hasan sadikin bandung: padjajaran university; 2011. 18. rahayu da, hidayati tn, imam ta. the effect of murottal therapy in decreasing depression of patients undergoing hemodialysis. media keperawatan indonesia. 2018;1(2):6-. https://books.google.co.id/books?id=l4lidwaaqbaj https://books.google.co.id/books?id=l4lidwaaqbaj increased the adolescent self-identity using the peplau-erickson-stuart model corresponding author: eni hidayati enihidayati@unimus.ac.id south east asia nursing research, vol 1 no 3, december 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.3.2019.128-136 case report increased the adolescent self-identity using the peplau-erickson-stuart model eni hidayati1, novy helena catharina. daulima2, ice yulia wardani2 1 university of muhammadiyah semarang, indonesia 2 university of indonesia, indonesia article info abstract article history: accepted december 28th, 2019 keywords: adolescent; therapeutic group therapy; family psychoeducation without proper stimulation, self-identity formation in adolescents may lead to inferiority, and further to the mental health problem. it is important to give positive stimulation for adolescents and psychoeducation for the family properly and effectively to improve adolescence identity development. as we know, adolescence is a period of age which is considered to be problematic and crucial for them to set their remarkable foundation regarding the interaction with the surrounding people and environment. this research was aimed to find out the result of therapeutic group therapy for adolescent and family psychoeducation toward the improvement of adolescence development. a case report was used as the method of the research, in which 5 clients were given health education care according to the problem faced by the family during the adolescence development stimulation. the special therapy given was the adolescence therapeutic group therapy and family psychoeducation. the result of therapeutic group therapy is the ability to improve family and adolescence self-identity development within the 10 aspects of adolescence stage; biological, psychosexual, cognitive, language, moral, spiritual, emotional, psychosocial, talent, and creativity. the result of the research was expected to be an input for the department of health, especially for the administrator of the community health program in dealing with adolescence mental problems. the research is also expected to be the evidence-based practice in the community of mental health nursing. introduction mental health is welfare represented by happiness, balance, satisfaction, selfachievement, and optimism. mental health can also be described as having a positive attitude, improvement, development, selfactualization, unity, freedom, and also own the convenient perception between reality and the ability to adapt to the surrounding environment.1 mental health is also a condition where an individual realizes his or her ability, able to control stress, and productively works and gives a contribution to society. therefore, it can be concluded that mental health is referred to welfare where an individual realizes his or her ability, able to relieve stress, has the suitable perception between reality and the ability for the adaptation with the surrounding environment, owns selfactualization, and able to productively https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.3.2019.128-136&domain=pdf&date_stamp=2019-12-30 south east asia nursing research, vol 1 no 3, december 2019/ page 128-136 129 eni hidayati / increased the adolescent self-identity using the peplau-erickson-stuart model works and gives a contribution to the society.2 improvement and development simultaneously happen in our life. the development is accomplished according to the pattern of each development stage which is also the result of the previous development stage and the requirement for the next stage. adolescence is a crucial stage in which adolescent starts to form selfidentity, independence, and eager to be involved in a mission.3 some factors affect adolescence mental health is biological, psychological, and sociocultural factors. besides, health, environment, and individual attitude are also the supporting factors which influence adolescence mental health development. the environment means family, school, and peer group for the adolescence. in this case, the government has been facilitated by adolescence development by providing non-formal health care. it is done by giving optimum guidance to adolescents' intellectual development and stimulating adolescents' creative thinking and problem-solving ability. the nursing care is given to the self-identity formation, either the professional or specialist nurse was given using peplau's interpersonal model. it is possible since the self-identity formation in adolescents may be reoccurred as they did not feel comfortable during the nursing caregiving process. according to peplau (1991), a nurse should have the value, uniqueness, art, and nursing science-based interpersonal relationship in delivering the health practice. those aspects help nurses to build a therapeutic relationship with the adolescent. peplau (1991)stated that the therapeutic relationship will achieve the goals when the nurse accomplished 4 stages of the relationship, which are orientation, identification, exploitation, and resolution.3 the therapy given by a nurse for the family is family therapy, group therapy, psychoeducation therapy, supportive therapy, self-assistance therapy, and therapeutic group therapy.4 on the other hand, the most suitable therapy for the adolescence development stage is group therapy and environmental therapy. one of the therapy techniques used to optimize adolescence development is therapeutic group therapy (tgt). it is a group therapy that enables the members to share their experiences, to help each other, and to find problem solving and anticipation, by giving an effective way to control stress.5 tgt is aimed to defend the homeostasis on either the possible spontaneous changes or continuous event. tgt helps the member to prevent health problems, training and developing group member potency, and also improve member’s self-quality in order to be able in solving any problems of life.6 this therapy is given to all the age levels based on its development stage. it can also be done in a group and individually by stimulating development and improvement. one of the research about adolescence selfidentity was showed about the identity achievement status, as the subject taken was the college students who are in the last stage of adolescence age.7 on the other hand, other research showed that therapeutic group therapy significantly improved the family's cognitive and psychometric ability in stimulating children's development.8 it improved the cognitive and psychometric ability at 45.5% from the initial 38.5%. the other study stated that self-improvement and selfidentity are significantly improved after therapeutic group therapy.9 on the other hand, the other group which was not given the same treatment could not show any significant improvement. adolescence is a crucial stage for problems and to form a solid basis for the internal competence which enables an individual to adapt and interact with the surrounding environment.6 the nursing care for the adolescents in this study used peplau interpersonal relationship approach and the development south east asia nursing research, vol 1 no 3, december 2019/ page 128-136 130 eni hidayati / increased the adolescent self-identity using the peplau-erickson-stuart model theory from erickson. the theory stated that a therapeutic relationship as the interpersonal process which involved nurse and client communicative interaction in order to identify and solve the client’s problem. during the therapeutic relationship, it is suggested that the nurse employs his or her self as the instrument to defend and build the relationship with the client. this way, it is expected for the client to be able to deliver all of his or her feelings and the nurse can further draw the solution in the following nursing care. in applying the interpersonal relationship to the client, the nurse as an outsider carried the orientation and identification stage during the adolescence analysis. after the analysis, the nurse carried the exploitation stage, which was the nursing care practice. after that, the resolution stage was applied using the interpersonal relationship theory of peplau during the evaluation of the nursing care applied. methods the nursing care applied was using the case report model. it was a detail report about signs, symptoms, diagnosis, treatment, and also the follow up on a client. it is usually applied for an unusual or new event either on a group or individual client. the case report in this study reported the case on the client from rw 04 mulyaharja with the adolescence self-identity therapy by the specialist nurse as explained in table 1. the intervention plot was in accordance with the interpersonal theory of peplau and the theory of erickson started from the analysis, nursing diagnosis, nursing care practice and nursing care practice result, client's support system, and also the difference after the application of the intervention. the data gained was primary data from scanning format and evaluation instrument (prepost) on the adolescent self-identity diagnosis. there were 5 healthy adolescents taken as clients. all of the clients were finished with specialist nursing care practice, therapeutic group therapy, and family psychoeducation. results from table 1, we can see that in the physical and psychosocial aspect, the average improvement was mainly on the weight gain aspect from 60% to 100%, with the overall average 80% to 100%. besides, for the cognitive and linguistic aspect, the highest improvement was on able to suspect with the improvement from 60% to 100%, with the overall improvement of 84.61% to 98.46%. for the moral and spiritual aspect, we can see the understanding of the ethical value, religious and social value of 80% to 100% with the overall value was from 85.71% to 100%. from the emotional and psychosocial aspect, we can see the improvement in able to not forcing the parents to follow their demand from 60% to 100%, with the average value of 83.33% to 96.66%. from talent and creativity, the significant improvement was on the ability in delivering questions and opinions from 60% to 100%, with the overall value of 65.71% to 94.28%. it can be concluded that the biggest deviation was on the emotional and psychosocial aspects with 14.29%. first, the clients were given specialist nursing practice which was consisted of 5 sessions. the first session, identify the personal problem faced by the caregiver or the parents with the adolescent in the family. in the second session, the method of stimulating adolescence improvement was explained. after that, stress management was carried in the third session. burden's management was carried on the fourth session, and the use of the supportive family system in the fifth session. from table 2, we are able to see the characteristic, predisposition factor, and the precipitation factor of the five clients. client ms. s owned the ability of female, 14 years old, second grade of junior high school, parents are labors whose income below the provincial minimum wage, having 5 siblings. ms. s is healthy, without any serious disease history, normal eating pattern, the weight gain in accordance to south east asia nursing research, vol 1 no 3, december 2019/ page 128-136 131 eni hidayati / increased the adolescent self-identity using the peplau-erickson-stuart model the development, client is able to deliver her opinion, able to critically speak about problem, able to differentiate which is good and bad, loves to try new thing, has many friends, able to adapt in the new environment, extrovert, cheerful, involve in some social activities. the following (table 3) is the explanation about the ability of adolescence self-identity formation from the development task before and after the intervention of therapeutic group therapy and family psychoeducation. table 3 explained about adolescence selfidentity ability involved: able to objectively assess himself/herself at 80% which represents 100% improvement. the achievement in the self-identity formation stage depends on the problem-solving process in the previous stage. if an adolescent failed in the previous development task, the result may influence the following stage. the next, about the ability to figure in the future, was improved from 60% to 100%. the ability to make a decision was improved from 60% to 100%. the love of the individual self-was improved from 40% to 100%. the ability to interact with others was improved from 80% to 100%. the responsibility was improved from 60% to 80%. adolescents started to represent their independence by 100%. and they were able to solve the problem with assistance was improved from 80% to 100%. table 1 tgt effectiveness toward self-identity achievement on adolescent in rw 4 mulyaharja district no adolescence change pre post number of clients % number of clients % 1 physical & psychosexual aspect a. the appearance of puberty signs b. weight gain c. height improvement d. interest to sex opposite e. improved sexual fantasy and imagination f. improved self-interest 4 3 4 4 4 5 80 60 80 80 80 100 5 5 5 5 5 5 100 100 100 100 100 100 average 4 80 5 100 2 the cognitive and linguistic aspect a. able to think about the causative effect b. able to suspect c. able to decide d. able to gather idea, thinking, and concept e. able to analyze f. the change in people perception g. able to understand others h. able to think systematically i. able to think logically j. able to think idealistically k. able to solve the problem l. improved linguistic ability m. mastering special linguistic term (slang language) 3 4 4 4 4 5 4 5 4 5 4 4 5 60 80 80 80 80 100 80 100 80 100 80 80 100 5 5 5 5 4 5 5 5 5 5 5 5 5 100 100 100 100 80 100 100 100 100 100 100 100 100 average 4.23 84.61 4.92 98.46 3 moral & spiritual aspect a. understand the ethical value, religious and social norms. b. care on others’ need c. have a good manner toward parents and teachers d. good to friends e. start to obey the rule in society f. diligently do the religious practice g. enjoining good and forbidding wrong 4 4 5 4 5 4 4 80 80 100 80 100 80 80 5 5 5 5 5 5 5 100 100 100 100 100 100 100 average 4.28 85.71 5 100 south east asia nursing research, vol 1 no 3, december 2019/ page 128-136 132 eni hidayati / increased the adolescent self-identity using the peplau-erickson-stuart model no adolescence change pre post number of clients % number of clients % 4 emotional & psychosocial aspect a. able to not forcing the parents to follow their demand b. able to control themselves c. emotionally stable d. able to adapt to the environment e. give concern to other f. get achievement 3 5 4 4 4 5 60 100 80 80 80 100 5 5 5 5 4 5 100 100 100 100 80 100 average 4.16 83.33 4.83 96.66 5 talent & creativity aspect a. own the improving special talent b. follow extra activities c. critical d. curious e. able to deliver opinion and question f. interested in the new experience g. interested in challenging 3 3 3 4 3 4 3 60 60 60 80 60 80 60 5 5 4 5 4 5 5 100 100 80 100 80 100 100 average 3.28 65.71 4.71 94.28 table 2. case description client’s initial case description ms.s female, 14 years old, second grade of junior high school, parents are labors whose income below the provincial minimum wage, having 5 siblings. ms. s is healthy, without any serious disease history, normal eating pattern, the weight gain in accordance to the development, client is able to deliver her opinion, able to critically speak about problem, able to differentiate which is good and bad, loves to try new thing, has many friends, able to adapt in the new environment, extrovert, cheerful, involve in some social activities. ms. n female, 17 years old, first grade of vocational high school, parents are entrepreneurs whose income above the provincial minimum wage, has 1 sibling. ms. n is healthy, without any serious disease history, normal eating pattern, the weight gain in accordance to the development, client is able to deliver her opinion, able to critically speak about problem, able to differentiate which is good and bad, loves to try new thing, has many friends, diligently does the prayers, active in school organization activities, able to adapt in the new environment, extrovert, cheerful, involve in some social activities. the client has had a conflict with the peer around her school and house environment. ms. y female, 18 years old, the third grade of vocational high school, parents are whose income below the provincial minimum wage, having 3 siblings. ms. y is healthy, without any serious disease history, normal eating pattern, the weight gain in accordance to the development, client is able to deliver her opinion, able to critically speak about problem, able to differentiate which is good and bad, loves to try new thing, has many friends, diligently does the prayers, active in school organization activities, able to adapt in the new environment, extrovert, cheerful, involve in some social activities. there is a history of chronic disease in the client's family. the aunt and father of ms. y suffered from hypertension. ms. y had been hospitalized when she was 10 (varicella) and 15 (fever, throat problem). the client has an irregular eating pattern with coffee consumption habits since she was 13, at least 1 glass per day. mr. s male, 14 years old, second grade of junior high school, the parent is a driver whose income below the provincial minimum wage, has 2 siblings. the client has gastritis history and had been hospitalized a year ago, smoking since he was 13, have had alcohol when he was 12. the client also had a conflict with the peer from school and the house environment. the client rarely does the prayer and never joins the social activities. there is a history of chronic disease in the client's family. the grandfather and mother of the client suffered from hypertension. mr. p male, 15 years old, the third grade of junior high school, his father was a police officer, but then dropped out from the office because of scamming scandal, the father is now jobless with the income below the provincial minimum wage, has 3 siblings. the client has an irregular eating pattern with coffee consumption habits since he was 13, at least 1 glass per day. there is a history of chronic disease in the client's family. the mother of the client suffered from hypertension. the client is an introvert, silent, and rarely joins the social activities. south east asia nursing research, vol 1 no 3, december 2019/ page 128-136 133 eni hidayati / increased the adolescent self-identity using the peplau-erickson-stuart model table 3 ability in self-identity formation pre and post specialist therapy for clients in rw 4 mulyaharja district self-identity count % able to objectively assess himself/herself pre 4 80 post 5 100 delta 20 able to figure the future pre 3 60 post 5 100 delta 40 able to make decision pre 3 60 post 5 100 delta 40 love himself/herself pre 3 60 post 5 100 delta 40 able to interact with others pre 4 80 post 5 100 delta 20 responsible pre 3 60 post 4 80 delta 20 independent pre 5 100 post 5 100 delta 0 able to solve a problem with the assistance pre 4 80 post 4 100 delta 20 discussion the case and care management by specialist nurse delivered the therapeutic group therapy and family psychoeducation for 5 adolescence clients who were in the selfidentity formation stage. from the result, it could be seen that all of the aspects of adolescence development were improved. the family was able to take care and facilitate clients, while the clients are able to use the supporting source from the inside and outside the family to deal with health problems. after therapeutic group therapy, the biological development of clients was improved. on the other hand, from the literature review, there was no study explained the influence of the therapy toward biological development. according to other studies that the optimum stimulus such as maintaining body health, a healthy lifestyle, maintain cleanliness, regular exercise, immediate treatment for illness, and a healthy diet was able to affect the physical and biological development. there was a significant improvement in adolescence psychosexual development after the therapy. in terms of distortion, an adolescent may interact with homosexual activity. the orientation may also be affected by the appearance and gender identity formation.10 based on the other case study on gay adolescents, it was stated that gay adolescents were trapped in gender identity confusion.11 in this case, group therapy was able to strengthen and improve adolescents’ self-identity. besides, group therapy also enables adolescents to give positive feedback to others, giving chance to build self-identity and learn from normal people. gender identity is able to influence sexual orientation. as mentioned by freud, the normal characteristic of a genital psychosexual stage was within the adolescence stage (12-18 years old). it can be seen from the sexual attraction, south east asia nursing research, vol 1 no 3, december 2019/ page 128-136 134 eni hidayati / increased the adolescent self-identity using the peplau-erickson-stuart model improved sexual fantasy, and the improved interest in their own appearance according to their gender1 the result of the study concluded that psychosexual development was improved in line with the biological development in a form of hormonal change and physical change, especially in the reproductive organs. this way, the therapy needs at least 6 sessions to accomplished. the ability in cognitive development was not significantly improved before and after the tgt. according to piaget, the adolescence period is the period where the thinking pattern of an individual changes from the concrete to formal operational. the formal operational thinking involves the ability to think abstractly, think hypothetically, able to use future perspective, able to figure out the possibilities and consequences from things happened, and the development of the ability in making the decision. able to relate an idea, thinking or concept, analyze and solve the problem, start to think ideally, logically, and systematically to solve the problem.9 the cognitive development was not improved as to achieve cognitive development require more abstract thinking training. during the cognitive stimulation session, the researcher only applied two sessions of therapy which involved the explanation about cognitive ability should be accomplished by adolescents and also the game to stimulate thinking ability, asking ability, and problemsolving ability. and then, during the linguistic development stage, there was a significant improvement after the therapeutic group therapy intervention. referred to the result of other research was expected that the entire individual has learned about all the linguistic and performance skill to well understand and produce certain language when they enter the adolescence period.12 the linguistic development was supported by the operational formal cognitive ability. cognitive development definitely improves linguistic ability. the correlation between development and self-identity was that selfidentity came from self-assessment and observation. the combination of the developments from all of the aspects of the development formed the characteristic of an individual that differentiates one to another. an adolescent who has accomplished the formal operational development is able to think logically, make the hypothesis, imagine his or her future identity, and able to solve the problem.13 the problem in linguistic development may involve the difficulty in delivering the opinion, the unsystematic sentence, and the inability to understand some words in their own language. it is possible as linguistic ability requires the intensive and comprehensive process, despite the fact that adolescents commonly have been trained to speak, delivered the opinion, and asked the question. the ability to moral development was improved after the application of therapeutic group therapy. the result of the research was not in line with other studies which concluded that the therapeutic group was able to help the member in changing maladaptive attitudes. ethical value and system was the main instrument to control the impulse during the self-identity formation. during the therapy, the therapist should actively apply positive moral values such as respecting the other group members, presenting a well-mannered attitude, obeying the rule, and applying discipline value. after the therapeutic group therapy, spiritual development was also improved. the adolescents tended to be more interested in religious value, try to apply the value, and stay away from the religious forbid. there was no study examining the influence of group therapy on spiritual development. the moral development can be improved by respecting the noble value, differentiate between good and bad, right and wrong, and also possess a good attitude. after the therapeutic group therapy, the emotional development of the adolescents was improved. it meant that group therapy south east asia nursing research, vol 1 no 3, december 2019/ page 128-136 135 eni hidayati / increased the adolescent self-identity using the peplau-erickson-stuart model significantly influenced emotional development such as improving adaptive skills, giving more concern to others, able to control demand and anger. the emotional development would also form an individual character in reacting to a problem. psychological problems, dynamic psychological state, the complexity of ego defense, and adolescent's character are able to influence self-identity formation.14 according to other research that group therapy enables adolescents to express emotion and behavioral problems, give feedback on the annoying behavior of others, learn how to tolerate, and give chance to practice new behavior.15 in group therapy, adolescents are able to learn how to care and love each other, and how to restrain temperament. the group therapy was given to adolescents for two weeks to show a significant result to restrain anger in adolescents. there was also an improvement in the psychosocial development of adolescents. the result of this nursing care was in line with the conclusion of other research which stated that group therapy builds a healthy relationship, especially with the opposite sex.16 it will further stimulate future realization, create balance in the family, build openness, productivity, love, and able to avoid conflict, confrontation, and also temperamental behavior in the family. the group intervention was proven to be effective for adolescents since adolescents are easier to accept the peer's opinion more than the adult's opinion. it is the opinion which usually emphasizes on the importance of relationship, the importance of group's norms for the socialization, the cooperation between group members, and the group which is able to listen very well. there was an improvement in talent and creativity development after therapeutic group therapy. according to other research that talent can be trained to be a special skill in a certain area. in order to dose, training, knowledge, experience, and motivation are needed.17 during the sixth session of the therapy, the researcher has given the talent stimulation by giving the knowledge about the importance of talent and also giving the chance to show some talents such as singing, poetry, storytelling, including how to give the reward for the performance. the only problem was not all of the clients agreed to perform in front of others. some of them also have the talent of which impossible to be demonstrated in that session, such as swimming, playing football, and playing badminton. conclusion most of the clients for the therapeutic group therapy were from early and mid-stage of adolescence, mostly females, mostly the first children in the family with two or three siblings. all of the adolescents in the group went through positive improvement and skill. the ability of family for the selfidentity formation was also improved. all of the mothers had been used the available health care. the therapeutic group therapy was applied within the 10 aspects of adolescence stages (biological, psychosexual, cognitive, language, moral, spiritual, emotional, psychosocial, talent, and creativity). the interpersonal model by peplau, erickson, and stuart were suitable for the adolescents. it was possible since the stages of the interpersonal relationship involved orientation, identification, exploitation, and resolution stages were applicable for the adolescence and enable the students to easily apply the nursing care. acknowledgments thank you to all of the informan and those who have helped this case study. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. south east asia nursing research, vol 1 no 3, december 2019/ page 128-136 136 eni hidayati / increased the adolescent self-identity using the peplau-erickson-stuart model references 1. stuart, g.w&laria m. principles and practiv of psychiatric nursing. in: 8th ed. st louis: mosby; 2009. 2. who. mental health atlas 2014. 3. potter pag. fundamental of nursing. vol volume 1. edisi 7. jakarta: salemba medika; 2009. 4. alligood mr. nursing theory and their work (8thed). in: elsevier. philadelphia: elsevier; 2017. 5. varcarolis & halter. foundation of psychiatric mental health nursing a clinical approach 6th ed. in: elsevier. canada: elsevier; 2010. 6. keliat, akemat., daulima, n. h. c., & nurhaeni h. keperawatan kesehatan jiwa komunitas: cmhn basic course. in: jakarta: egc; 2011. 7. jannah. pengaruh terapi geeneralis latihan keterampilan sosial terhadap pencapaian identitas diri remaja panti asuhan di kabupaten banyumas. unpubl thesis. 2012. 8. trihadi. dkk. pengruh terapi kelompok terapeutik terhadap kemampuan keluarga dalam memberikan stimulasi perkmbangan kanak-kanak dikelurahan bubulak kota bogor. unpubl thesis. 2009. 9. bahari. pengaruh terapi kelompok terapeutik terhadap perkembangan identitas diri remaja di kota malang. in: jakarta: nursing department of univeristy of indonesia.; 2010. 10. kumrun, a. & thompson r. ego identity status and self-monitoring behavior in adolescents. adolesc res. 2003:1-16. 11. ali,m&ansori m. psikologi remaja perkembangan peserta didik. in: 6th ed. jakarta: pt bumi aksara; 2010. 12. hasanah. pengaruh terapi kelompok terapeutik remaja dan psikoedukasi keluarga terhadap perkembangan identitas diri remaja. keperawatan. 2017;9 no 1:13-23. 13. grnholm, e. et al. group cognitive-behavioral social skills training for older outpatients with chonic schizophrenia. j cogn psychoter n int q. 2006;18(3):265-279. 14. lench h. anger manageement: diagnostic difference and treatment implication. j soc clin psychol. 2014;23(4):512-531. 15. puspitasari, d. l., mubin, m. f. &targunawan. gambaran psikologis: konsep diri pada anak remaja di wilayah banjir rob. jurnali lmu keperawatan dan kebidanan. 2014. 16. maryatun. pengaruh terapi kelompok terapeutik terhadap perkembangan di panti sosial marsudi putra dharma pala ideralaya. keperawatan sriwij. 2014;1(1). 17. purwadi. hubungan gaya pengasuhan orang tua denagan eksplorasi dan komitmen remaja dalam domain pekerjaan. 2004. intermittent exercise triggers synthesis of cyp19 aromatase as a key enzym for estrogen formation in sprague dawley rat bone innovarectomy corresponding author: sri widodo sriwidodo@unimus.ac.id south east asia nursing research, vol 1 no 2, september 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.2.2019.67-75 original research intermittent exercise triggers synthesis of cyp19 aromatase as a key enzym for estrogen formation in sprague dawley rat bone innovarectomy sri widodo1, sri kadarsih soedjono2, denny agustiningsih2 1 university of muhamadiyah semarang 2 gadjah mada university, yogyakarta article info abstract article history: accepted september 30th, 2019 key words: intermittent exercise; cyp19 aromatase; estrogen; ovarectomy menopause is a permanent cessation of menstrual cycle due to reduced secretion of the hormone estrogen which can result in osteoporosis. osteoporosis is characterized by the process of bone resorption faster than the process of bone formation, resulting in a decrease in bone mineral density and bone microarchitecture damage resulting in bones becoming brittle and easily fracturing. physical exercise is a holistic intervention to prevent osteoporosis due to menopause. this study is a pure experimental study using a post-test only control group design research design. the subjects of the study were the 12-week-old sprague dawley rat. the number of groups is 5 with the number of rats per 6 animals. there was a significant difference between the ovarectomy group of rats and the ovarectomy group of mice and were given intermittent exercise treatment of cyp19 aromatase expression. discussion: muscle contractions that occur due to intermittent exercise treatment can produce large amounts of il-6 and il-6 mrna which can stimulate estrogen production. local estrogen production can reduce bone resorption and increase bone formation and bone density intermittent exercise can trigger the process of the synthesis of the cyp19 aromatase enzyme in ovarectomy rat femur bones introduction menopause is defined as a state of permanent cessation of menstrual cycles due to reduced secretion of ovarian hormones that occur naturally or are caused by surgery, chemotherapy or radiation (nelson, 2005). women at menopause will experience symptoms of hot flushes or sensations of heat in the body radiating to the face, vaginal dryness, sleep disorders, cognitive changes, mood changes (alazzawi, 2009), and those associated with long-term health problems that may be affected by the disease coronary heart disease and osteoporosis (cutson and meuleman, 2000). osteoporosis is a progressive chronic disease characterized by a process of bone resorption faster than the process of bone formation, resulting in decreased bone mineral density and bone microarchitecture damage resulting in bones becoming brittle and easily fracturing (rizolli et al., 2008). the world health organization (who) https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.2.2019.67-75&domain=pdf&date_stamp=2019-09-30 south east asia nursing research, vol 1 no 2, september 2019/ page 67-75 68 sri widodo / intermittent exercise triggers synthesis of cyp19 aromatase as a key enzym for estrogen formation in sprague dawley rat bone innovarectomy defines osteoporosis as a disease characterized by reduced bone mass and bone tissue microarchitecture abnormalities due to increased bone fragility and the risk of bone fractures (conference report, 1991). osteoporosis or loss of bone mass in menopausal women and / or after ovarectomy is mainly due to estrogen deficiency (doren, 2002). hormone replacement therapy is believed to reduce menopausal symptoms and prevent osteoporosis, cardiovascular disease and alzheimer's type dementia at menopause (hanafiah, 1999). however, prolonged administration of hormone replacement therapy to women will increase the risk of developing breast cancer (ross, 1997), the risk of getting endometrial cancer (grady, et al. 1995) and the risk of ovarian cancer (rodriguez, et al. 2001). giving estrogen alone or a combination of estrogen and progestin increases the risk of stroke by 40%. progestin supplemented estrogen also increases the risk of coronary disease, pulmonary embolism and breast cancer (women’s health clinical research center, 2006). controversy and the many complications resulting from hormone replacement therapy at menopause have led to the development of a holistic and natural approach to managing menopause including regulating diet, physical exercise or sports, skills in regulating body and brain rhythms, supplementation and herbal (mckee and werber, 2005). research on the effect of exercise in overcoming menopausal symptoms has been carried out among them, stating that physical exercise or exercise is useful to prevent osteoporosis, obesity, depression and cardiovascular disease (slaven and lee, (1997). the effect of exercise on osteoporosis among others, stated that running sports during 9 weeks has an impact on increasing bone mineral content and bone mineral density of vertebrae and tibia in adult mice (yeh et al., 1993). isometric exercise performed by rotating movements without displacement or weight gain can have an impact on increasing bone formation with increased ability bone reconstructs or improves bone shape for bone strength requirements (yeh et al., 2001). running sports with a slope of 11% and a speed of 21 meters / minute performed as many as 40 sets of intervals 1 minute running and 1 minute rest for 4 weeks can prevent the process of bone loss in ovarectomy rats by suppressing the process of bone resorption (wong et al., 2006). running sports can prevent the total decrease in strength of the femur, tibia and humerus bones so that it is useful to eliminate the effects of ovarectomy on bone (peng et al. (2009). running sports contribute to the degree of protection against cartilage degeneration in mice after ovarectomy (chang et al., 2010). running sports with a slope of 11% and a speed of 20 meters / minute carried out as many as 40 sets of intervals 1 minute running and 1 minute rest for 4 weeks and administration of genistein can prevent the process of bone loss in ovarectomy rats (nakajima et al., 2001). regular exercise with moderate zone intensity can increase serum estrogen levels in postmenopausal women (agustingsih, 2006). the effect of exercise in overcoming the symptoms of menopause, probably due to the effect of exercise on estrogen and estrogen levels is most likely derived from extragonadal aromatization, this is given in women after menopause all estrogen and almost all androgens are made locally in the peripheral tissues of dhea (dehydroepiandrostenedion) (liben, 2006). research relating to the effect of exercise on the formation of extragonadal estrogens has also been carried out among them, stating that the expression of cyp19 aromatase in adipose tissue is higher due to regular exercise in ovarectomy rats (bebasari, 2010). cyp19 aromatase expression in the adrenal cortex is higher due to regular south east asia nursing research, vol 1 no 2, september 2019/ page 67-75 69 sri widodo / intermittent exercise triggers synthesis of cyp19 aromatase as a key enzym for estrogen formation in sprague dawley rat bone innovarectomy exercise for 8 weeks in ovarectomy mice (asnawati, 2010). exercise prevents the accumulation of fat in the liver and increases the expression of α (alpha) estrogen receptors in rats that are ovarectomized or not ovarectomized and whether or not estrogen therapy is given (hao et al., 2010). has not been studied about the effect of intermittent exercise on the expression of cyp19 aromatase in the femur bone. methods this research is a pure experimental study using a post-test only control group design research design. this study was conducted to determine the effect of intermittent exercise on the expression of cyp19 aromatase, in ovarectomy femur bones. the research variables included independent variables namely intermittent exercise which is a treatment of running sports with a slope of 11% and a speed of 21 meters / minute conducted 40 times intervals 1 minute running and 1 minute resting, a total time of 80 minutes per day as much as 5x in one week for 4 weeks. the dependent variable was the level of cyp19 aromatase expression which was the percentage of cells from the observation of 10 field views of fragments of femur bone tissue after immunohistochemical staining using cyp19 primery antibody kit using 400x magnification in brown. the subjects of this study were female sprague dawley rats aged 12 weeks or ± 3 months with a body weight of 140-186 grams. rat animals were obtained from the experimental animal maintenance unit (uphp) of the integrated research and testing laboratory (lppt) unit iv of the gadjah mada university (ugm) in yogyakarta. the number of groups was 5 with the number of rats in each group being 4 and added 2 for each so that each group became 6. the research materials used were catgut, cotton, xylazine and ketamine hcl sewing threads for rat anesthesia, 70% alcohol, povidone iodine, gloves, small pots as samples to be examined, saline, 1.5 ml microtube, microhematocrit tubes, buffers 10% formalin, 5% formic acid as a decalcification agent, calcium obtained by mixing and heating caco3 powder in cmc. standard rat feed in the form of ad ii pellets with water content of 12% crude protein 15%, crude fat 3-7%, crude fiber 6%, ash 7%, calcium 0.9-1.1%, phosphorus 0.6-0, 9%, antibiotics and coccidiostats. preparation ingredients are alcohol with various concentrations (30%, 40%, 50%, 60%, 70%, 80%, 90%, 96% and 100%) for dehydration and rehydration, xytol, phosphate buffer saline (pbs) , buffer citrate. immunohistochemical staining of rabbit serum, primary antioby, bioetynilated secondary antibodies, streptavidine peroxidase, diaminobenziydine (dab), hematoxylin mayer, mounting with e.z mount goat and canada balsam. the tools used in research; special treadmills for rats (gama-tread 2006), minor surgical instruments for ovarectomy (scapel, scissors, sewing thread, sewing needles, needle holders and tweezers), injection syringes, digital scales, mouse cages with rat eating and drinking equipment and digital cameras . histological preparations, slices of rat femur bone tissue, namely microtome, staining jar, microwave, poly-lysine coated slides microscope, coverslip, timer and ssa tool; homogenizer to destroy rat bone tissue. to observe preparations that have been colored using a light microscope and micrographic tools. results the results of this study relate to the parameters measured in this study, namely the expression of cyp19 aromatase using a sample of rat femur bone tissue. observation and evaluation of cyp19 aromatase expression was carried out on immunohistochemical preparations with cy19 aromatase antibodies that would south east asia nursing research, vol 1 no 2, september 2019/ page 67-75 70 sri widodo / intermittent exercise triggers synthesis of cyp19 aromatase as a key enzym for estrogen formation in sprague dawley rat bone innovarectomy show a cytoplasm of cells that were brown or positively painted (expressing cyp19 aromatase) and cell cytoplasm which did not express cyp19 aromatase in dark blue or purple. each preparation was observed and examined as many as 10 visual fields. the percentage of cyp19 aromatase expression can be done by counting the number of cells that express cyp19 aromatase and cells that do not express cyp19 aromatase in each slice. the percentage of cyp19 aromatase expression was done by counting the number of cells expressing cyp19 aromatase and those not expressing cyp19 aromatase in each field of view as the total number of cells. calculate the percentage of cyp19 aromatase expression by counting the number of cells expressing cyp19 aromatase multiplied by 100% divided by the total number of cells. an example of a description of cyp19 aromatase expression in a preparation is shown in figure 1. x figure 1 picture of cyp19 aromatase expression on ihc painting on observation of olympus light microscope at 400x magnification description: x. cells that express cyp19 aromatase the average description of cyp19 aromatase expression, osteoclast counts and calcium levels in ovarianectomized femur bones of 12 samples with observations of each sample of 10 visual fields grouped into five treatment groups, are shown in table 1. table 1 mean ± standard deviation of parameters for all treatment groups parameter mean ± standard deviation of all parameters in all treatment groups x1 x2 ekspresi cyp19 aromatase 0.15±0.36a 7.57±3.34ab information: a, b = the same letter in one line shows that there are significant differences between treatment groups x1 = ovarectomy group of rats x2 = group of rats that were ovarekotmi and treated with intermittent exercise the mean levels of cyp19 aromatase expression showed different values in the group of ovarectomy rats and the group of rats that were ovarectomized and treated with intermittent exercise. the ovarectomy group of rats obtained a mean cyp19 expression level of 0.15 standard deviations of 0.36. in the group of ovarectomized rats and treated with intermittent exercise, the mean cyp19 expression level was 7.57 with a standard deviation of 3.34. statistical analysis of the effects of intergroups on cyp19 aromatase expression was analyzed using the mannwhiteney test. mann-whiteney test results between the ovarectomy group of rats and the ovarectomy group of rats treated with intermittent exercise related to their effect on cyp19 aromatase expression obtained mean levels of 3.50 and mean levels of 9.50, with a p value of 0.003 (p ≤ 0.05). this shows a significant difference between the ovarectomy group of rats and the ovarectomy group of rats who were given intermittent exercise treatment related to their effect on the expression of cyp19 aromatase, which means that the intermittent exercise treatment in ovarectomy rats gave a significant increase in the level of cyp19 aromatase expression south east asia nursing research, vol 1 no 2, september 2019/ page 67-75 71 sri widodo / intermittent exercise triggers synthesis of cyp19 aromatase as a key enzym for estrogen formation in sprague dawley rat bone innovarectomy in ovarectomy femur bone with a difference in mean level of 6.00. discussion this research is a pure experimental study using a post-test only control group design research design. the study was conducted using 30 experimental female white mice (rattus norwegicus) sprague dawley strain aged 12 weeks (3 months). some of the reasons why using mice as experimental animals in this study are because they have the same analogy as humans, have conditions or information that can be transferred / transmitted, have genetic similarities that can be applied to all living things, have a common background behind knowledge related to biological processes, available and affordable in terms of cost or price, easy and able to adapt to research treatments and have ethical and social code implications (davidson et al., 1987). the existence of comfort and relevance or can be compared with conditions in humans (rodger et al., 1993). the advantages of using mice as experimental animals include cheap or inexpensive, easy to maintain and are commonly publicly used rats for research (o'brien et al., 1997). rats are used as experimental animals aged 12 weeks (3 months) with the consideration that mice reach the maturity of sexual organs at 2.5 months (jee & yao, 2001) or 3 months (kalu, 1991), so according to the research design that makes rats in menopausal conditions induced by ovarectomy surgery. this is because age is closely related to bone mass and bone strength in both humans and mice (martin, 2002). twelve rats were divided into two treatment groups, each group consisted of six samples which included the x1 treatment group namely the ovarectomized rat group and were given a standard feeddrink which was at the same time a negative control group from the x2 treatment group namely the ovarectomy rat group, fed with standard drinks and treated with intermittent exercise. the reason for ovarectomy is because the ovarectomy mouse model is well known to be used in postmenopausal osteoporosis research. after ovarectomy the process of bone resorption exceeds the process of bone formation resulting in loss of bone mass (wronski et al. 1989). ovarectomy was agreed to have the same effect of histological changes on rat bone and human bone so that this could provide benefits related to information about bone mass loss in menopausal humans (kalu, 1991). ovarectomy is a method used to produce menopausal conditions artificially (wronski & yen, 1992). ovarectomy is a potential factor that can induce the process of bone matrix deminaralization in mice (cesnjaj et al. 1991). the ability of bones to repair damage due to ovarectomy in mice is the same as the ability of bones in humans (abee et al. 1993). osteoporosis is a chronic progressive disease characterized by bone resorption process faster than bone formation process, resulting in decreased bone mineral density and bone microarchitecture damage resulting in bones becoming brittle and easily fracturing (rizolli, et al., 2008). osteoporosis or loss of bone mass in menopausal women and / or after ovarectomy is mainly due to estrogen deficiency (doren, 2002). the research sample used is femur bone tissue, this is based on consideration that the strength of mechanical stress in the femur bone in the neck is a very sensitive indicator of bone loss due to ovarectomy, orchidectomy and immobilization (peng et al., 1994). it also relates to osteoporosis predilection areas that often occur in the femur, vertebrae, pelvis and forearm bones (sherwood, 2001). the results of statistical analysis using the mann-whitney test obtained p value of 0.003 (p ≤ 0.05), which means that intermittent exercise treatment in ovarectomy rats had a significant effect on increasing the expression of cyp19 aromatase in the ovaryectomy of the rat south east asia nursing research, vol 1 no 2, september 2019/ page 67-75 72 sri widodo / intermittent exercise triggers synthesis of cyp19 aromatase as a key enzym for estrogen formation in sprague dawley rat bone innovarectomy bone. an increase in the expression of cyp19 aromatase in ovarectomy rat femur bone in this study, is in line with the concept that regular exercise with a moderate zone can increase serum estrogen levels in postmenopausal women (agustiningsih, 2006). regular exercise is likely to reduce the degree of perimenopausal estrogen deficiency, at least activating estrogen production which does not originate in the ovaries or extragonadal regions (asnar, 2005). more specifically in line with the concept that estrogen biosynthesis by extragonadal tissue; adipose, bone, mammary and brain tissue are highly dependent on the presence of circulating steroid c19 precursors (labrie et al. 1997). synthesis of the hormone estrogen can occur in osteoblasts or bones (bruch et al. 1992, bayard et al. 1995). estrogen biosynthesis by extragonadal tissue; adipose, bone, mammary and brain tissue are highly dependent on the presence of circulating steroid c19 precursors (labrie et al. 1997). cyp19 aromatase is a key enzyme in the process of estrogen synthesis in peripheral / extragonadal tissue, especially in bone tissue (watanabe, et al. 2004). this enzyme is expressed in response to catalyzing aromatization processes for transformation from c19 androgens to c18 estrogens such as estradiol to estron transformation (simpson et al. 1994; conley & hinshelwood, 2001; kamat et al. 2002; bulun et al. 2005). this cyp19 aromatase parameter is certainly appropriate as an indicator for assessing the effect of a combination of measured exercise exercise and calcium supplementation as an effort to prevent or manage osteoporosis during menopause and / or after ovarectomy which is mainly caused by estrogen deficiency (doren, 2002). the cyp19 aromatase enzyme is expressed as a response in catalyzing the aromatization process for the transformation from androgen or testosterone to estrogen and from androstenediol to estron (simpson et al. 1994;). figure 2 the role of aromatase in the biosynthesis of steroid hormones in the adrenal and gonad glands (payne and hales, 2004) the mechanism of the occurrence of cyp19 aromatase expression in ovarectomy rat femur bones due to intermittent exercise in this study is most likely because the muscle contractions that occur due to intermittent exercise treatment can produce large amounts of il-6 and il-6 mrna. muscle biopsy after exercise shows an increase in il-6, this indicates that muscle contraction is a stimulus for il-6 production by muscles (toft et al., 2002). interleukin-6 is thought to work like a hormone, carrying out metabolic control by increasing energy supply during exercise. with increased glucose uptake by muscles, hepatic glycogenolysis must be activated. the content of muscle glycogen affects the release of il-6 during exercise (steinacker, 2004)., states that the expression of aromatase in bone osteoblasts can be triggered by several cytokines including il6 (pedersen, 2004). increased aromatase activity in bone osteoblast cells triggers an increase in local estrogen production which can decrease bone resorption and increase bone formation and bone density will be maintained because of the role of estrogen produced by the activation of aromatase induced by il-6 (purohit et al., 1992) this is in accordance with the theory that cytokines, especially il-6 can increase aromatase expression (shozu & simpson, 1998). running sports with a slope of 11% and a speed of 21 meters / minute south east asia nursing research, vol 1 no 2, september 2019/ page 67-75 73 sri widodo / intermittent exercise triggers synthesis of cyp19 aromatase as a key enzym for estrogen formation in sprague dawley rat bone innovarectomy conducted as many as 40 sets of intervals 1 minute running and 1 minute rest for 4 weeks can prevent bone loss in ovarectomy rats by suppressing the process of bone resorption (wong et al., 2006). running sports with a slope of 11% and a speed of 20 meters / minute carried out as many as 40 sets of intervals 1 minute running and 1 minute rest for 4 weeks and administration of genistein can prevent the process of bone loss in ovarectomy rats (nakajima et al., 2001). conclusion the level of cyp19 aromatase expression of femur bone tissue in rats that are ovarectomized and given intermittent exercise treatment is higher than the level of cyp19 aromatase expression in rats that are only ovarectomized. intermittent exercise can trigger the process of the synthesis of the cyp19 aromatase enzyme as a key enzyme for the formation of the hormone estrogen in the ovaryectomy of the femur bone. acknowledgements we wish to express our appreciation to all all those who have helped in this study. conflicts of interest neither of the authors have any conflicts of interests that would bias the findings presented here. references 1. abee t, chow jwm, lean jm, chambers tj. 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mass in young rats: an animal model of isometric exercise. j musculoskel neuron interact:1(3):235-240 http://www.nejm.og/ exploring the quality of life and the related factors among the elderly corresponding author: indra gunawan indrasarkid@yahoo.com south east asia nursing research, vol 2 no 1, march 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.1.2020.1-10 original research exploring the quality of life and the related factors among the elderly indra gunawan1, mei-hsiang lin2, hsiu-chin hsu3 1 universitas muhammadiyah tasikmalaya, indonesia 2 national taipei university of nursing and health sciences, taiwan 3 chang gung university of science and technology, taiwan article info abstract article history: accepted january 27th, 2020 keywords: elderly; depression; quality of life as the rapidly growing population of elderly people in the world that means they would be facing all challenges to their quality of life. as age increases, quality of life is often reported to decline. they are also at risk of mental illness, neurological disorder and more health problems affecting their quality of life. depression is a common mental disorder among the elderly. the objective of this study is to understand the relationship between depression and quality of life among the elderly in an indonesian nursing home. this research use the descriptive correlational and cross-sectional design was applied. there were 114 elderly recruited by convenient sampling. the results of this study showed the mean age of the elderly was 71.2 at the time of data collection ranging from 65 to 76 years old. the variables associated with quality of life were age, gender, education, marital status, ethnicity, chronic disease, and depression status. moreover, the study found that, as predictors, the variables that influenced the quality of life according to relevance were: age, depression status, and educational level. age and depression status is recognized as significant predictors of the quality of life among the elderly in an indonesian nursing home. the result of the study would serve as references to the future and related promotion for the same field of the study. introduction the elderly population in the world is increasing day by day. according to the united nations in 2017 the population of elderly people age 60 or more was 962 million; twice in 1980, when there were 382 million elderly people worldwide. moreover, by 2050, the number of elderly is expected to double, is projected to reach nearly 2.1 billion .1 indonesia is one of top five most populous countries in the world and it is elderly population is growing rapidly. based on the 2010 population census, the number of elderly in indonesia was 18.1 million people (7.6% of the total population). in 2014, that number had risen to 18,781milion people. the population is expected to rise exponentially, reaching 27.08 million in 2020, and 33.69 million in 2025 .2 in the future, a large number of elderly people in indonesia will have both positive and negative consequences. if the elderly are healthy, active and productive they can live independently and will have a positive https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.1.2020.1-10&domain=pdf&date_stamp=2020-03-31 south east asia nursing research, vol 2 no 1, march 2020/ page 1-10 2 indra gunawan / exploring the quality of life and the related factors among the elderly impact. on the other hand, large numbers of elderly people become a burden if they have health problems that result in increased health care costs and decreased family incomes. increased disability combined with, lack of social and environmental support is not a friendly situation for the elderly.2 elderly people often encounter several difficulties in old age. the elderly often face several vulnerabilities, both physical and social. these include suffering from chronic illness, loneliness and, in any case, lack of physical protection. because of their physical weakness or mental disability, they both experience decreasing levels of autonomy themselves and limit the autonomy of other family members. it is a serious problem because it can be led to decreased quality of life (qol) for the elderly. the world health organization (who) has defined qol as “an individual’s perception of life in the context of culture and value system in which he or she lives and with his or her goals, expectations, standards, and concerns”.3 who has recently warned its member states that as people around the world live longer, soaring levels of chronic diseases and reduced qol were poised to become a global public health challenge.4 as the rapidly growing population of elderly people in developed and developing country that means they would be facing all challenges to their quality of life. the challenge is to delay the incidence of disability and ensure qol will remain optimal among elderly people.5 but as age increases, quality of life is often reported to decline.6 for elderly people, good qol usually means good living conditions. they can live independently and have many friends. subjectively, they feel satisfied with their lives and experience a high level of happiness.7 although most elderly have good mental health, they are also at risk of mental illness, neurological disorder and more health problems than younger people.4 depression and dementia are the two most common mental disorders among the elderly; depression is a common affecting about7% of the world’s older population. depression is a common reaction to health problems, and in elderly people, depression was often an underdiagnosed problem. people can be depressed caused by trauma or illness; suffering from an earlier loss, or they may seek health care for somatic complaints that were bodily manifestations of depression.8 depression among the elderly has a high recurrence rate and is usually chronic.9 the prevalence of depression among the elderly in nursing home populations is very high. the prevalence rate of depression in nursing homes is three to four times higher than among elderly people living in the community.10 the institutionalized elderly commonly experience psychological distress. for instance, in taiwan, about 43% of elderly people living in nursing homes experience depressive symptoms, while in hongkong nursing homes, that number rises to about 65%.11 mazurek found that in three nursing homes in major cities in poland, that average score on the geriatric depression scale was 7.2±3.77, indicating moderate depression among resident based on the result of his survey of 300 resident .12 in indonesia, one study found that the percentage of elderly people who were depressed in a nursing home was higher than they living at home/ community. found 39% of elderly people were depressed living in the nursing home and 30% of elderly people were depressed living in the community/home.13 as the elderly population continues to grow, in china today’s elderly who are highly dependent on help are choosing to move to nurse homes, which is related to a decrease in the number of caregivers in the family.14 therefore, a limited study has been conducted to explore the relationship between depressions to the quality of life. for this reason, it is reasonable to ask: ‘what are the differences between the diverse health/sickness cultures?’, and ‘how does south east asia nursing research, vol 2 no 1, march 2020/ page 1-10 3 indra gunawan / exploring the quality of life and the related factors among the elderly influence the elderly quality of life?’ the objective of this study is to understand the relationship between depression and quality of life among elderly in indonesian nursing home. methods design this study adopted a descriptive correlational and cross-sectional design to collect data using a structured questionnaire with face-to-face interviews. participants a convenience sampling technique was used. a total of 114 subjects elderly who were recruited from five nursing homes in bandung city. the inclusion criteria were as follows: (1) participants must be fluent in indonesian (2) participants must be willing to participate in the study and sign an informed consent form (3) ages 60 years and above (4) living in a nursing home bandung. the exclusion criteria consisted of (1) elderly nursing home residents who are healthcare providers or practitioners (2) elderly who do not consent after getting information about this study (3) elderly with dementia. data collection the recruitment period was conducted from july 2018 to september 2018. after getting permission from the institutional review board (irb), the researcher made an appointment with each respondent who was agreed to participate in the research. the researcher has explained the research procedures, explain its purpose, and obtained written informed consent. after the participants pass through these stages, the researcher conducted face-to-face interviews using the questionnaires. analysis each participant was assigned a study id for data entry and then the data entered into ibm spss statistics 20.0 to calculate a total score for each of the questionnaires based on the participants’ responses. descriptive statistics, including frequencies and percentages, used to describe demographic variables such as gender, educational background, ethnicity, and marital status. sample t-test and one-way anova, pearson correlation coefficients and stepwise multiple regressions used for univariate analysis. ethical considerations the study protocol and consent form were approved by the institutional review board of the department of health and also the national committee of field development and research of bandung city (institutional review board approval: 16mmhis92e). results descriptive statistics of the study population, depression status, and quality of life ‘the mean age of the elderly was 71.2 (sd ± 2.88) at the time of data collection ranging from 65 to 76 years old. the majority of the respondents were female, with 75 (65.8%) females and 39 (34.2%) males. most of the participants (n = 103, 90.4%), were single including widower and only 11(9.6%) were married. regarding the educational background, the majority of respondents (n = 61, (53.5%), are the primary school. as many as 27 (23.7%) are a junior high school, a total of 11 (9.6%) elderly have the education until senior high school, and around 15 (13%) had not completed primary school. among several ethnicities, the sundanese elderly outnumbered the others. of the elderly in the study population, 61 (53.5%) were sundanese, 42 (36%) were javanese, south east asia nursing research, vol 2 no 1, march 2020/ page 1-10 4 indra gunawan / exploring the quality of life and the related factors among the elderly and 11 (9.6%) were bataknese. according to their chronic disease of the respondents, around 37 (32%) elderlies had others disease including complications disease, 21 (18.8%) elderlies with hypertension, 23 (20.2%) elderlies with diabetes mellitus, 15 (13.2) elderlies with stroke and around 18 (15.8%) elderlies had osteoarthritis (table 1). table 1 demographic characteristics of the respondents indicators n % mean ± sd age 71.2 ± 2.88 65-68 16 14 69-72 62 54.4 73-76 36 31.6 gender male 39 34.2 female 75 65.8 marital status married 11 9.6 single or widowed 103 90.4 educational background senior & junior high school 38 33.3 primary & no school 76 66.7 ethnicity bataknese 11 9.6 javanese 42 36.8 sundanese 61 53.5 chronic disease osteoarthritis 18 15.7 ht 21 18.8 dm 23 20 stroke 15 13 others 37 32.5 note, ht = hypertension; dm = diabetus mellitus; others = multiple chronic conditions. regarding depression status, the mean depression score among the elderly was 9.17 (sd ± 2.28). the majority of respondents (n = 61, 53.5%), had moderate depression. as many as 27 (23.7%) had mild depression, around 11 (9.6%) elderly had no depression and a total of 15 (13%) elderly had severe depression (table 2). meanwhile, regarding the quality of life status, the mean score was 73.46 (sd ± 13.29). most of the respondents (n = 80, 70.2%) had a moderate quality of life, 23 (20.0%) respondents had poor quality of life and 11 (9.6%) respondents had a high quality of life (table 2). table 2 the distribution of depression status indicators n % mean ± sd min max depression 9.17 ± 2.28 4 13 1. no depression 11 9.6 2. mild depression 27 23.7 3. moderate depression 61 53.5 4. severe depression 15 13.2 quality of life 73.46 ± 13.29 52 109 1. poor qol 23 20.2 2. moderate qol 80 70.2 3. high qol 11 9.6 the difference between demographic to quality of life the result showed that there was a significant difference between the quality of life (qol) and age variable with f = 118.01, p<.001 and post hoc showed a result that the age group of 65-68 years old had better qol than the age group of 69-72 years old or over. another variables also showed that there were a significant difference between qol with gender, marital status, and educational background among the elderly with t =3.24, p = 0.002 ; t = 16.72, p = <0.001 ; t = 10.63, p =<0.001 respectively. similarly, the statistical result showed that there was a significant difference between qol and ethnicity among the elderly, with f = 59.28, p<0.001and post hoc showed that bataknese had better qol than other ethnicities such as javanese and sundanese. finally, the result showed that there was a significant difference between qol and chronic disease among the elderly with f = 51.34, p <0.001, and post hoc test showed south east asia nursing research, vol 2 no 1, march 2020/ page 1-10 5 indra gunawan / exploring the quality of life and the related factors among the elderly that the elderly had osteoarthritis had better qol than ht, dm, stroke, and others (table 3). table 3 the significant difference between demographic variables to quality of life indicators n mean ± sd f/t p post hoc age 65-68 16 94.88 ± 10.52 118.01 <0.001 (1)> (2) 69-72 62 75.44 ± 4.18 73-76 36 60.56 ± 10.21 gender male 39 79.36 ± 15.30 3.24 0.002 female 75 70.40 ± 11.02 marital status married 11 101.18 ± 5.11 16.72 <0.001 single or widowed 103 70.50 ± 10.07 educational background senior & junior school 38 86.84 ± 9.64 10.63 <0.001 primary & no school 76 66.78 ± 9.17 ethnicity bataknese 11 94.55 ± 11.24 59.28 <0.001 (1) > (2) javanese 42 79.52 ± 7.93 sundanese 61 65.49 ± 9.83 chronic disease osteoarthritis 18 93.33 ± 10.85 51.34 <0.001 (1) > (2) ht 21 78.43 ± 4.16 dm 23 74.13 ± 3.74 stroke 15 71.27 ± 5.35 others 37 61.46 ± 10.35 note, ht = hypertension; dm = diabetus mellitus; others = multiple chronic conditions. the relationship between depression and quality of life this study used pearson correlation, to determine the relationships between depression status and quality of life among the elderly. the result found that depression status was negatively and significantly related to the quality of life (r =-0.859, p<0.001) among the elderly (table 4). table 4 the relationship between depression status and quality of life indicator depression status quality of life depression status 1 quality of life -0.859** 1 the factors predictor of the quality of life stepwise multiple regression was used to test the contributions of all independent variables for their influence on basic computer competence. three predictors variables, including age, depression status, and educational level accounted for 77% of the variance (table 5). south east asia nursing research, vol 2 no 1, march 2020/ page 1-10 6 indra gunawan / exploring the quality of life and the related factors among the elderly table 5 the predict factors of the elderly’s quality of life indicators unstandardized coefficients standardized coefficients β r2 adjusted r2 f p b s e age -0.488 0.054 -0.594 0.641 0.638 199.824 <0.0001 depression status -0.142 0.018 -0.601 0.730 0.725 36.461 <0.0001 educational level 0.363 0.083 0.320 0.770 0.764 19.243 <0.0001 discussion descriptive statistics of the study population, depression status, and quality of life the mean age of the residents was 71.2 years at the time of data collection. their ages ranged from 65 to 76 years. almost two-thirds of the respondents were female, with 65.8% (n=75) female and 34.2% (n=39) male. this age distribution is similar to that of the population as a whole. based on data issued by the indonesian government which shows that life expectancy in indonesia was approximately 67 years for men and 71 years old for women at the time of data collection. life expectancy is projected to increase by around 5% between 2020 and 2030. the great majority of nursing home residents, 90.4% (n=103), were single. the category “single” included widowers, divorced people, and those who never married. at 9.6% (n=11), less than onetenth of the nursing home residents were married. as regards education, just over half of the respondents had completed primary school (n=61, 53.5%), and 23.7% (n=27) had completed junior high school, with a total of 9.6% (n=11) completing senior high school, and around 13% (n=15) had not completed primary school. this population had a notably higher level of education compared to elderly sundanese as a whole; most older sundanese are illiterate or have only completed an elementary school education.15 just over half of the participants were of sundanese ethnicity (n=61, 53.5%); 36% (n=42) were javanese, and 9.6% (n=11) were bataknese. this reflects the fact that sundanese people are concentrated in the provinces of west java, bandung, jakarta, and the western part of central java.16 around 32% (n=37) of respondents had more than one chronic illness: 21 (18.8%) had hypertension, 23 (20.2%) had diabetes mellitus, 15 (13.2%) had had a stroke, and about 18 (15.8%) had osteoarthritis. as we get older, the risk of chronic disease and comorbidities increases and a person undergoes many changes, including physical, psychological, economic, social and spiritual changes. the age distribution of respondents indicated that most elderly respondents were of advanced age (age 75 or above). at that age, the elderly begin to experience health crises. in line with the research conducted by kartika in indonesia, this study found that the participants who experienced depression were in the highest in the age group, 60 to 74 years.17 this study found that most depressed residents had moderate depression (53.5%). similarly, a study conducted by mazurek in three nursing homes in major cities in poland found an average score on the geriatric depression scale was 7.2±3.77, indicating moderate depression, based on the results of a survey of 300 nursing home residents.12 among the elderly, depression is often an under-diagnosed problem. depression may be caused by trauma or illness and suffering from an earlier loss. it is common to seek south east asia nursing research, vol 2 no 1, march 2020/ page 1-10 7 indra gunawan / exploring the quality of life and the related factors among the elderly health care for somatic complaints that are bodily manifestations of depression. the difference between demographic to quality of life this study found a significant association between demographic factors, such as age, gender, marital status, educational background, ethnicity, and chronic disease, and quality of life. this study found that age was associated with quality of life among the elderly at five nursing homes in indonesia. the younger elderly group reported a higher quality of life than the older elderly group. these results are similar to findings from another study conducted by shah et al in gujarat, which likewise found that age was related to the quality of life among the elderly, with the older elderly having a lower quality of life than others age groups.18 a study conducted in nursing homes in brazil showed that qol levels peaked between age 60 and 69, but decreased in every decade of life thereafter so that more than half of people aged seventy-five years and over could be considered to have unsatisfactory qol. the results of this study revealed significant differences between genders in terms of quality of life among the elderly at nursing homes in indonesia. specifically, elderly males had a better quality of life than females. a study conducted by khaje et al in teheran similarly found significant differences between genders, with males having a higher quality of life than females. a survey conducted among 400 elderly people ages 60 years and over also revealed that males got higher scores than the females on quality of life in nursing homes in marivan city, iran. in this study, marital status was significantly associated with quality of life among the elderly in the nursing homes. the results showed that elderly people who were married had a greater quality of life than people who were single or divorced. an association between marital status and quality of life among the elderly has been proven in several studies. for example, the previously found study on elderly people in india found that currently, married people had a better quality of life than people who were divorced, widowed, or separated. another factor that is associated with quality of life among the elderly is educational background. the results of this study revealed that the elderly with a higher level of education reported better quality of life than the elderly with lower levels of education. this finding is similar to other studies. for example, bhatia et al did a study in the district of ludhiana in india. they found that qol has a significant correlation with an education background. specifically, older adults with a high school or higher education had significantly higher qol scores than elderly people who were illiterate .19, 20. similarly, quality of life has been reported to be lower among elderly people with less education in taiwan.21 the results of this study found a significant association between ethnicity and quality of life among the elderly. in this study, elderly bataknese had a higher quality of life than elderly javanese and sundanese. another study conducted by reeves et al also found a significant qol difference between ethnic groups in american nursing homes, finding that mexican americans had a lower quality of life than non-hispanics whites in nursing homes.22 the results of this study found a significant association between chronic disease and quality of life among the elderly in indonesian nursing homes. elderly with multiple chronic conditions had lower quality of life than those who had only one. a study conducted by canbaz in turkey which likewise found that elderly people with chronic illnesses scored lower on qol than the elderly without chronic disease across all four domains.23 similarly, a study south east asia nursing research, vol 2 no 1, march 2020/ page 1-10 8 indra gunawan / exploring the quality of life and the related factors among the elderly conducted by bouchet (2000) found that participants with a history of chronic disease scored higher on all items in each domain of the sf36 group questionnaire than those without a history of chronic disease. furthermore, a study by leach found that elderly people worried that their physical and mental state would cause emotional distress to others. the relationship between depression and quality of life the findings of this study revealed a negative correlation between depression levels among the elderly and their quality of life. results showed that the elderly with the highest level of depression had a lower quality of life, compared to the elderly with a lower level of depression who had a higher quality of life. this association is confirmed by several studies. for example, a study conducted by chan in china reported that the subjective quality of life is really low among chinese elderly age 65 years and over with depression, compared with nondepressed elderly. similarly, unalan et al. found that depression has a negative relationship to qol among elderly people, and quality of life is a protective factor against dying. depression is associated with difficulty adapting. as time goes by, some older persons may partly accept their loss of health and function; adjusting expectations is one way to bridge the gap between what is actual and what is possible.24 however, depressive disorder or severity of depressive symptoms in older people are associated with poor psychological resources and coping strategies.25 the factors predictor of the quality of life the first factor is age. in this study, revealed that the older elderly groups (75 years or over) more often complained about their life are very severe. living conditions, lack of activities due to physical weakness, illness, an uncomfortable environment and feeling insecure about their physical appearance were currently the trigger factors that increased the burden of life among the elderly. this finding was linearly by the result of the study conducted by rohmah and bariyah, that stated that the elderly people reported often experienced unsatisfied feeling the changes in physical, social, cognitive, and vulnerability .26. another factor that greatly influences the quality of life among the elderly in nursing homes in bandung, indonesia was depression. in this study it was revealed that the majority of the elderly in nursing homes in the city of bandung experienced moderate depression, this might be caused by a lack of activities carried out by the elderly while in institutions and supported by the absence of consultation or psychological examination services for those who are depressed. depression in the elderly has a serious negative impact on social and physical life where it causes a decrease in the quality of life and causes parents to dependency on others .27. lastly, the educational level was the major predictor that influenced the quality of life among the elderly in bandung nursing homes. this study found that the majority of the respondent had a low educational level and few of them had higher educational levels such as senior high school. this finding is in line with other studies conducted by maricha and wirasto in indonesia that have found that illiteracy among elderly people age 75 years or older is a problem among elderly living in nursing homes; it has been a concern for a long time in indonesia. conclusion the study has provided an insight into how the quality of life among the elderly in indonesian nursing homes. the mean score for quality of life scores among the elderly was 73.46 out of 120, at the time of data collection. this study included two hundred and fourteen, all elderly at the nursing homes in bandung city indonesia. the mean age of the elderly was 71.2 at the time of data collection ranging from 65 to 76 years south east asia nursing research, vol 2 no 1, march 2020/ page 1-10 9 indra gunawan / exploring the quality of life and the related factors among the elderly old. most of the respondents (65.8%) were female and included several ethnicities, such as sunda, batak, and jawa. there were more students of sunda ethnicity than any other group. these study findings showed that overall, that variable associated with quality of life were age, gender, educational background, marital status, ethnicity, chronic disease, and depression status. moreover, age, depression status, and educational level are all predictors of the quality of life elderly in indonesian nursing homes. acknowledgments i want to say thank you to all the family who has participated in success this research, especially to my mother, my father and my lovely wife. and also i want to say thank you to my best advisor for always supporting me and giving me good advice. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. de pauw m. global population aging from a human rights perspective: the need for a un convention on the rights of older persons. global europe–basel papers on europe in a global perspective. 2017(114). 2. indonesia kkr. pelayanan dan peningkatan kesehatan usia lanjut. jakarta: kementerian kesehatan republik indonesia. 2015. 3. whoqol w. whoqol-brief introduction, administration, scoring and generic version of the assessment. who december. 1996. 4. shah vr, christian ds, prajapati ac, patel mm, sonaliya k. quality of life among elderly population residing in urban field practice area of a tertiary care institute of ahmedabad city, gujarat. journal of family medicine and primary care. 2017;6(1):101. 5. mohapatra s, gambir i, singh i, mishra n. nutritional status in elderly people of varanasi district. indian j prev soc med. 2010;40(3):15256. 6. netuveli g, wiggins rd, hildon z, montgomery sm, blane d. quality of life at older ages: evidence from the english longitudinal study of aging (wave 1). journal of epidemiology and community health. 2006;60(4):357-63. 7. oguzturk o. differences in quality of life in rural and urban populations. 2008. 2008:5. 8. brunner ls. brunner & suddarth's textbook of medical-surgical nursing: lippincott williams & wilkins; 2010. 9. ismail z, fischer c, mccall wv. what characterizes late-life depression? psychiatr clin north am. 2013;36(4):483-96. 10. sun y, zhang d, yang y, wu m, xie h, zhang j, et al. social support moderates the effects of selfesteem and depression on quality of life among chinese rural elderly in nursing homes. archives of psychiatric nursing. 2017;31(2):197-204. 11. tsai yf, chung jw, wong tk, huang cm. comparison of the prevalence and risk factors for depressive symptoms among elderly nursing home residents in taiwan and hong kong. int j geriatr psychiatry. 2005;20(4):31521. 12. mazurek j, szcześniak d, talarska d, wieczorowska-tobis k, kropińska s, kachaniuk h, et al. needs assessment of elderly people living in polish nursing homes. geriatric mental health care. 2015;2(3-4):9-15. 13. wulandari afs, rahayu ra. kejadian dan tingkat depresi pada lanjut usia: studi perbandingan di panti wreda dan komunitas: faculty of medicine; 2011. 14. gu d, dupre me, liu g. characteristics of the institutionalized and community-residing oldest-old in china. social science & medicine. 2007;64(4):871-83. 15. sunaryo mk, wijayanti hr, kp s, kep m, kom s, kuhu mm, et al. asuhan keperawatan gerontik: penerbit andi; 2016. 16. kurniasih n, komariah n, rodiah s. designing sundanese cultural literacy programs based on national curriculum of 2013 for students of elementary schools in cileunyi sub-district, bandung regency, indonesia. ina-rxiv november. 2017;13. 17. kartika s. gambaran tingkat depresi pada lanjut usia (lansia) di panti sosial tresna wredha budi mulia 01 dan 03 jakarta timur. jakarta; 2012. 18. arslantaş d, metintaş s, ünsal a, kalyoncu c. eskişehir mahmudiye ilçesi yaşlılarında yaşam kalitesi. osmangazi tıp dergisi. 2006;28(2):819. 19. chen h-m, chen c-m. factors associated with quality of life among older adults with chronic disease in taiwan. international journal of gerontology. 2017;11(1):12-5. 20. bhatia s, swami h, thakur j, bhatia v. a study of health problems and loneliness among the elderly in chandigarh. indian journal of community medicine. 2007;32(4):255. south east asia nursing research, vol 2 no 1, march 2020/ page 1-10 10 indra gunawan / exploring the quality of life and the related factors among the elderly 21. lai k-l, tzeng r-j, wang b-l, lee h-s, amidon rl, kao s. health-related quality of life and health utility for the institutional elderly in taiwan. quality of life research. 2005;14(4):1169-80. 22. reeves sl, brown dl, baek j, wing jj, morgenstern lb, lisabeth ld. ethnic differences in poststroke quality of life in the brain attack surveillance in corpus christi (basic) project. stroke. 2015;46(10):2896901. 23. canbaz s, sünter at, dabak s, pekşen y. the prevalence of chronic diseases and quality of life in elderly people in samsun. turkish journal of medical sciences. 2003;33(5):335-40. 24. mcdowell i. measuring health: a guide to rating scales and questionnaires: oxford university press, usa; 2006. 25. sivertsen h, bjørkløf gh, engedal k, selbæk g, helvik a-s. depression and quality of life in older persons: a review. dementia and geriatric cognitive disorders. 2015;40(5-6):311-39. 26. rohmah ain, bariyah k. kualitas hidup lanjut usia. jurnal keperawatan. 2015;3(2). 27. mangoenprasodjo as. mengisi hari tua dengan bahagia: pradipta publishing; 2005. factors related work load stress among migrant semi-skilled workers in messaieed qatar corresponding author: zaenal mutaqin zaenal_mutaqin77@yahoo.com south east asia nursing research, vol 1 no 1, june 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.1.2019.27-36 original article factors related work load stress among migrant semi-skilled workers in messaieed qatar zaenal mutaqin1 1 messaieed medical center qatar petroleum article info abstract article history: accepted may 7th, 2019 key words: stress; stressors; migrant semi-skilled workers stress is a condition arising from the gap between the demands generated by the transaction between individual and environment with resources of the biological, psychological, or social system. this study aims to determine factors that led to the stress of indonesian semi-skill migrant workers in messaieed qatar. method using descriptive analytical study with crosssectional design. the study sample was 70 respondents of semi skill indonesia migrant workers in messaieed qatar. the results showed a relationship between physical condition with the level of stress (p value=0.000 with r=0.407), the better of physical condition the milder levels of stress. there is a relationship between psychological burden with the level of stress (p value=0.01 with r=0.305), the lighter of psychological burden the milder level of stress. there is no relationship between extreme weather with the level of stress (p value=0.252 with r=0.139). there is a relationship between workload with the level of stress (p value=0.001 with r=0.379), the lighter workload the milder level of stress. there was a relationship between neighborhood conditions with stress level (p value=0.000 with r=0.541), the better condition of the neighborhood the milder level of stress. recommendations of this study are messaieed medical center to provide counseling and education about stress, how to reduce the stress on their own and social support. companies where the respondents worked need to make some modifications of the environment such as conducted sport activities, a regular of spiritual tutorial activities, and other positive activities. introduction stress is a very popular terminology and is an inevitable thing in human life. every person has experienced and will experience it with different levels depending on the physical and psychological resistance of the individual. this is the influence of fast-changing social changes as a consequence of modernization, industrialization, advancement of science, and technology that has influenced moral, ethical, and lifestyle values, where not everyone is able to adapt, depending on personality owned by each individual.1 stress arises due to the gap between the demands generated by transactions between individuals and the environment https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.1.2019.27-36&domain=pdf&date_stamp=2019-06-23 south east asia nursing research, vol 1 no 1, june 2019/ page 27-36 28 zaenal mutaqin / factors related work load stress among migrant semi-skilled workers in messaieed qatar with biological, psychological or social systems possessed by these individuals that will affect their cognition, emotions, and social behavior.2 stress caused by environmental and social physical conditions in the form of situations, events, or objects that cause demands in the body and cause psychological reactions called stressors.3 the state of qatar is a small country in the middle east region, in the form of a peninsula which consists mainly of deserts and beaches with a length of about 60 km. compared to indonesia in the tropics, qatar has many differences including: geographical conditions that are mostly composed of barren deserts and beaches, extreme climates where temperatures will reach 50 ° c during summer and 5 ° c in winter , the use of english as a second language and language in the world of work and academics, cultural social life is diverse because this country is one of the countries in the middle east (middle east) which is used as a destination country to find work by migrant workers (migrant workers destination country) from various countries in the world, physical and psychological conditions of competitive work, and enforcement of state regulations and laws based on islamic teachings, and other differences. the differences above can lead to stress on migrants or workers in this country. the indonesian population in messaaieed, one of the provinces in qatar is divided into two, most of which are in the housing complex of oil and gas companies, and the others are in camps for workers (labor camp). indonesian residents who work in the professional sector at messaieed are working for various oil and gas companies, while those who work as semi-skilled workers work for contracting companies that support and support the operations of oil and gas companies. workers in the semi skill and unskill sectors, they only get work visa facilities with a bachelor contract status, which means they do not get family visa facilities. in addition, they also have to live in "labor camp" together with thousands of other semi-skill and non-skill workers. this condition at least raises a variety of problems both in terms of health, social interaction relationships, and certainly has the potential to create interpersonal relationship conflicts between those who can cause stress. stress on indonesian semi-skilled migrant workers in qatar occurs a lot and can cause anxiety. stress that is felt can interfere with the role and function of the worker both in his work or in his daily life. the stress felt by indonesian semi-skilled migrant workers in messaieed qatar can come from oneself (internal) or from outside (external). the stressors need to be identified so that they can be controlled or minimized and modifications to the condition are made to reduce them. based on interviews conducted by the author of 5 indonesian migrant semi-skill workers who work and live in messaieed qatar, found factors that have the potential to trigger stress and depression if prevention is not carried out and modification of existing conditions properly and correctly. the results of the interview stated that all respondents stated that they did not feel comfortable living in qatar, all respondents mentioned internal factors (far from families in indonesia) as stressors, 4 people (80%) mentioned occupational factors as stressors, 4 people (80%) mentioned extreme temperatures as a stressor, and 3 people (60%) mentioned a factor in their lack of ability to adapt to people other than indonesia due to a lack of ability to speak english. based on the description above, both from the results of interviews or the facts and phenomena of differences that exist in qatar, it is necessary to examine whether the factors behind the stress of migrant semi skill workers at messaieed qatar. for this reason, researchers are interested in south east asia nursing research, vol 1 no 1, june 2019/ page 27-36 29 zaenal mutaqin / factors related work load stress among migrant semi-skilled workers in messaieed qatar conducting research to find out and identify what factors are related to stress on indonesian migrant semi-skilled workers in the qatar messaieed region. methods this type of research uses descriptive analytical study methods, this study aims to determine stress-related factors in indonesian semi-skilled migrant workers in the qatar messaieed region. the research design used is a cross-sectional study where observations of research samples are only done once in a certain period or period. the method used in this study is a survey by conducting interviews and distributing questionnaires to respondents. the population in this study were all indonesian semi-skilled migrant workers who were in the qatar messaieed region with around 80 people. sampling in this study was carried out by the total sampling method, namely taking all the population with the inclusion criteria, respondents who were between 20 and 50 years old, willing to be respondents, were at the location when the study was conducted. data collection tool using a questionnaire that has been tested before. the collected data were analyzed univariate with the aim to explain or describe the characteristics of each research variable, and bivariate which aims to determine the relationship between the dependent variables namely stress level with each independent variable namely physical condition, psychological burden, extreme weather, workload, and environmental conditions of residence. the test used is the pearson correlation because the data is normally distributed. results this research was conducted in december 2011 to april 2012, located in the indonesian community in the qatar messaieed region. the number of respondents in this study was 70 people with all respondents being male. of all 70 questionnaires distributed to respondents, all were filled out because the researchers accompanied the respondents at the time of filling out the questionnaire. the distribution of respondents based on age found the youngest age of respondents was 21 years, and the oldest age was 55 years with an average age of respondents was 34.5 years, while the highest number was in the age group 31-40 years as many as 26 people (37.14%). based on the level of education shows that the majority of respondents as many as 29 people (41.45%) have a high school education, and at least are elementary school educated as many as 12 people (17.1%). based on the type of work obtained, most of the respondents, as many as 36 people (51.45%) worked as drivers, while the others worked as laborers (labor/rigger) as many as 17 people (24.3%) and other jobs (welder, pipe fitter, foreman). based on marital status most of the respondents were married as many as 55 people (78.6%), and the rest were still single, 15 people (21.4%). meanwhile, based on the tenure of respondents in qatar, the average working period of respondents in qatar was 2.36 years with the latest working period <1 year, while the longest working period was 7 years, with the highest working period of 1-3 years, which was 34 people (48.6%). the results of the study showed that most experienced severe stress as many as 36 people (51.4%), while the rest experienced mild stress as many as 34 people (48.6%). most of the respondents' perceptions of their physical condition are in good condition as many as 40 people (57.1%), the rest are in a bad condition as many as 30 people (42.9%). most of the respondents felt psychological burden stressors in the weight level as many as 38 people (54.3%), while the rest were in the light level as many as 32 people (45.7%). most of the respondents felt that extreme weather stressors were in bad condition as south east asia nursing research, vol 1 no 1, june 2019/ page 27-36 30 zaenal mutaqin / factors related work load stress among migrant semi-skilled workers in messaieed qatar many as 49 people (70%), and only a small percentage felt it was good, 21 people (30%). the results showed that the majority of respondents felt the condition of heavy workload as many as 36 people (51.4%), and the rest felt it in mild conditions as many as 34 people (48.6%). the results of the study also showed that the majority of respondents felt that the conditions of living conditions were in good condition as many as 43 people (61.4%), and only a small proportion of those who perceived them in a bad condition were 27 people (39.6%). the results showed that there was a relationship between physical conditions and stress levels of respondents (p-value of 0.000 (<0.05) and the value of r = 0.407). graph 1.1 illustrates the direction of the relationship between the variables of physical conditions and stress levels. the direction of a positive linear pattern relationship means that the better the physical condition of the respondent the lighter the stress level. the determinant coefficient of 16.6% means that the physical condition affects stress by 16.6%, the remaining 73.4% is determined by other factors. figure 1 correlation of stressors of physical conditions with stress levels in indonesian migrant semi skill workers at qatar messaieed the results of the study on the correlation of psychological burden stressors with stress levels on semi-skilled migrant workers are described in figure 2. figure 2 scatter plot the correlation of psychological stress with stress levels in indonesian migrant semi skill workers at qatar messaieed figure 2 shows that there is a significant relationship between psychological burden and stress level of respondents (p-value of 0.010 (<0.05) and r = 0.305). the direction of the relationship has a positive linear pattern means that the lighter the psychological burden of the respondent the lighter the stress level. the determinant coefficient of 9.3% means that the psychological burden affects stress by 9.3%, the remaining 90.7% is determined by other factors. the results showed that there was no relationship between extreme weather and stress levels of respondents (p-value of 0.252 (> 0.05) and r = 0.139). the results showed that there was a significant relationship between workload and stress level of respondents (p-value of 0.001 (<0.05) and r = 0.379). the direction of the relationship has a positive linear pattern, which means that the lighter the workload of respondents, the lighter the stress level. the determinant coefficient of 14.4% means that the workload affects stress by 14.4%, the remaining 85.6% is determined by other factors. the results of other studies on environmental conditions with stress south east asia nursing research, vol 1 no 1, june 2019/ page 27-36 31 zaenal mutaqin / factors related work load stress among migrant semi-skilled workers in messaieed qatar levels of respondents are described in figure 3. the results showed that there was a significant relationship between living conditions and stress levels of respondents (p-value of 0.000 (<0.05) and r = 0.541). the direction of the relationship has a positive linear pattern, which means that the better the environmental conditions of respondent living, the lighter the stress level will be. figure 3 scatter plot the correlation of environmental conditions with stress levels in indonesian migrant semi skill workers in qatar messiah the results of the study on figure 3 show the large determinant coefficient of 29.3%, which means that the living conditions of the environment affect stress by 29.3%, the remaining 70.7% is determined by other factors. discussion based on the results of the study showed that the average age of the respondents was 34.5 years, the youngest age was 21 years while the oldest was 55 years. this is in accordance with the regulations of the qatari government regarding the age limit for workers ranging from 20 to 60 years. the results of the study also showed that the majority of respondents' education was high school as many as 29 people (41.45%), junior high school educated as many as 29 people (41.45%) and the rest had elementary education, 12 people (17.1%). the company regulations that employ them require a minimum education of high school or middle / high school, but in reality, there are 12 workers with elementary education who can pass the selection to work in qatar. the level of education of a person is very influential on the ability and performance of his work, especially it will have an effect on his ability to manage the stress he finds when working. based on the type of work, the results showed that the majority of respondents worked as drivers (drivers for large vehicles, such as: employee buses, dump trucks, and long haul trucks / tronton) as many as 36 people (51.4%), who worked as laborers (labor / rigger spread in various divisions such as canteen, construction, oil and gas project, and bridge / road construction) as many as 17 people (24.3%), and worked in other sectors (pipe fitter, welder, foreman) as many as 17 people (24.3%) . determination of semi-skilled workers is in accordance with the criteria set another study which divides the type of worker into three, consisting of non-skilled workers, semiskilled workers, and skilled / professional workers. most of the respondents were married to 55 people (78.6%), meaning that the respondents had a greater risk of being exposed to stress because they were separated from their families. their biological needs certainly get a nuisance because the leave provided by the company is given at least annually. according to the hierarchy of needs established by abraham maslow biological and physiological needs are the most basic in the pyramid. one of the basic needs can influence other needs, including influencing the psychological condition and work.3 the results of the study also showed that the majority of respondents had a working period of 1-3 years, namely 34 people south east asia nursing research, vol 1 no 1, june 2019/ page 27-36 32 zaenal mutaqin / factors related work load stress among migrant semi-skilled workers in messaieed qatar (48.6%). however, there are 28 respondents (40%) who have a working period of <1 year, this means that they are still adapting to the environment and the new work they are currently living. even some people have just come to qatar in less than 2 months. states that the source of stress can be in the form of bioecology such as drastic weather changes, extreme temperatures that can make individuals experience physical and psychological stress, and sources of psychosocial stress such as new jobs, and environment and community atmosphere the new one.4 based on the results of the study showed that the majority of respondents as many as 36 people (51.4%) had stress at a severe level. this can be seen from the frequency distribution of questionnaires which showed that as many as 50 people (71.43%) answered sometimes feeling stiff when hanging out with coworkers and their environment, 46 people (65.71%) answered sometimes losing their appetite, 45 people (64.29%) answer sometimes disagree with colleagues / supervisors, and 42 people (60%) answer sometimes feel bored/bored with their jobs. in fact, there were 19 people (27.4%) who answered always and often thumped when communicating with superiors and 21 people (30%) who answered always and often felt disappointed with the treatment of superiors. the results of this study are in line with the other research, the results of his research show this result is influenced by the company's target that is too high, limited time in completing work, lack of adequate responsibility from the company, heavy workload, and ambiguity role in work. the high level of stress experienced by respondents can occur because the education level of respondents on average is still lacking. the level of education of a person is very influential on the ability and performance in work, especially in managing the stress he finds when working. the severe stress experienced by respondents needs to be given serious attention and needs to be addressed because if it does not interfere.5,6 the results showed that as many as 30 people (42.9%) stated that their physical condition was in bad condition. there were 36 people (51.42%) who said that since coming to qatar their sexual needs were often and always disturbed. this is understandable because most of the respondents were 55 people (78.6%) who were married and lived far from their wives and families. in addition, as many as 18 people (25.52%) consumption of smoking has increased, and as many as 17 people (24.29%) have disturbed sleep patterns. stress has an impact on physical, psychological, health, cognition and organization including being easily saturated and bored, having difficulty resting, and experiencing sleep disorders. this is also in accordance with the other study which states that the body will give a physical reaction to various challenges encountered in life by trying to harmonize it or that the individual will recover quickly enough with the influence of the experience of stress experienced before.7 the results showed that the majority of respondents as many as 38 people (54.3%) stated that their psychological burden was severe. it is seen that as many as 38 people (54.28%) often and always feel anxious/worried about the development of their children, 36 people (51.43%) answered frequently and always felt anxious about their children's education, and as many as 22 people (31.43%) say often and always feel anxious/worried about the loyalty of his wife. this is consistent with another statement that family conditions that are not good can cause a person's condition to become stressed with the burden, the condition of respondents who are far apart from their families shows that their family is in a bad condition.7 the above opinion is also south east asia nursing research, vol 1 no 1, june 2019/ page 27-36 33 zaenal mutaqin / factors related work load stress among migrant semi-skilled workers in messaieed qatar supported by the opinion of gottlieb which states that close and positive attachment to others, especially with family and friends, is consistently found as a good defense against stress.8 the results showed that most of the respondents were 49 people (70%) stated that extreme weather conditions in qatar were in bad condition. this can be seen from the frequency distribution of the questionnaire, of which from 5 questions / statements about extreme weather, where as many as 43 people (61.43%) answered frequently and always felt uncomfortable with dust storms that often occur in qatar, 39 people (55.72%) answered often and always feel insecure when traveling in the midst of dust storms, as many as 39 people (55.72%) answered frequently and always felt the summer weather in qatar was too hot for them, and 37 people (52.86%) answered always and often felt the temperature of the season the cold in qatar is too cold for them. the results showed that the majority of respondents, 36 people (51.4%) stated that the workload was in heavy condition. this can be seen from the frequency distribution of the questionnaire, where out of 8 questions / statements about workload, where as many as 51 people (72.86%) have to answer frequently and always be extra careful in doing their work, 32 people (45.72%) answer frequently and always felt that the work was full of danger/risk, and as many as 29 people (41.43%) answered frequently and always felt their superiors asked for work to be completed on time. work stress is caused by too many tasks, limited time, lack of responsibility, role ambiguity, value differences, frustration, changes in work types, and changes or role conflicts.9,10 the presence of too many tasks is not always a cause of stress, but it will be a source of stress if the number of tasks is not proportional to the ability both physically and skillfully and the time available to individuals. while the limited time in doing work can trigger stress because if someone who usually has the ability to complete the tasks assigned to him. ability is related to expertise, experience, and time owned. under certain conditions, employers often provide assignments with limited time. as a result, individuals are pursued time to complete tasks according to the time set by superiors. based on the results of the study showed that the majority of respondents as many as 36 people (51.4%) had stress at a severe level. this can be seen from the frequency distribution of the questionnaire which shows that 25 respondents (35.72%) answered frequently and always with questions i felt uncomfortable / did not match the housing facilities provided by the company, and as many as 14 people (20%) answered frequently and always with questions i feel uncomfortable with the camp environment that is too many people. according to other research, the absence of social support means that stress will tend to appear in individuals who do not get support from their social environment. social support can be in the form of support from the work environment or family environment. many cases show that individuals who experience work stress are those who do not receive support (especially morale) from their families, such as parents, in-laws, children, friends and the like. likewise, when someone does not get support from their peers, they tend to be more susceptible to stress. this is caused by the absence of social support which causes inconvenience in carrying out their work and duties.11,12 based on the results of the study it was found that there was a significant relationship between physical conditions and stress levels, where (p-value = 0.000 (<0.05) with r = 0.407). this study shows that the better the physical condition of the south east asia nursing research, vol 1 no 1, june 2019/ page 27-36 34 zaenal mutaqin / factors related work load stress among migrant semi-skilled workers in messaieed qatar respondents, the lighter the stress level. this is in accordance with the opinion of potter and perry (2005) which states that one of the factors in the emergence of stress comes from within a person such as physical conditions, psychological conditions or emotional states. the extent to which the level of stress experienced by an individual on his illness is influenced by age and physical conditions and the severity of the disease he experiences.3 the results showed that there was a significant relationship between psychological burden and stress level (pvalue = 0.010 (<0.05) and r = 0.305). this research shows that the lighter the psychological burden of the respondent, the lighter the stress level. this is in accordance with the opinion of others that a person's stress level is shown by one of the symptoms is psychological symptoms which include: anxiety, tension, confusion, anger, sensitivity, feelings, ineffective communication, boredom, job dissatisfaction, mental fatigue, loss of concentration. the condition of respondents who are far apart from their families causes the burden of thought and psychological conflict in themselves to increase, family conditions that are not good can cause a person's condition to become stressed with the burden. this is shown by the psychological symptoms shown by the respondent, namely the results of research stating that the respondents feel anxious about the development of their children (54.28%, 51.43% of their children's education), and the loyalty of their wives left in indonesia (31.43% ) the results of the calculation of the pearson correlation test show that there is no relationship between extreme weather and stress levels (p-value = 0.252 (<0.05) and r = 0.139). actually, based on the distribution of extreme weather questionnaires, it was found that 61.43% of respondents answered frequently and always felt uncomfortable with dust storms that often occur in qatar, 55.72% of respondents answered often and always felt insecure when traveling amid dust storms, 55.72% of respondents answered frequently and always felt the summer weather in qatar was too hot for them, and 52.86% of respondents answered always and often felt the winter temperatures in qatar were too cold for them. it could be that for extreme weather, respondents have adapted and are getting used to the temperature and climate in qatar, so this extreme weather factor does not cause and cause stress for the respondents. based on the results of the study it was found that there was a significant relationship between workload conditions and stress levels, where (p-value = 0.001 (<0.05) with r = 0.379). this research shows that the lighter the workload of respondents, the lighter the stress level. the results of this study indicate 72.86% of respondents answered frequently and always extra carefully in doing their jobs, 45.72% of respondents answered often and always felt the work they were doing was full of danger/risk, and 41.43% of respondents answered often and always felt their superiors asked for work to be completed on time . this result is in line with the research conducted by other research, the results of his research said that much of respondents experienced severe stress because of having a heavy workload, including distance from home to work, large responsibilities, and limitations and predetermined time targets trigger job stress on the office.13 based on the results of the study it was found that there was a significant relationship between workload conditions and stress levels, where (p-value = 0.000 (<0.05) with r = 0.541). this research shows that the better the condition of the environment where the respondent lives, the lighter the stress level. the results of south east asia nursing research, vol 1 no 1, june 2019/ page 27-36 35 zaenal mutaqin / factors related work load stress among migrant semi-skilled workers in messaieed qatar this study were based on noisy living conditions because the respondent's camp was inhabited by thousands of other workers, with a capacity of 8 workers from various ethnic groups placed in one room. in addition, psychological conditions are also very susceptible to misunderstandings among camp residents, and even fights and fights are reported often occurring in the respondent's neighborhood. this result is in accordance with the research conducted by others, the results of his research say that several of respondents said that the conditions of their work environment were stressful for their work. lighting conditions that are lacking, there is noise in the work environment, and a high psychological work environment is the factors that trigger the stress of their work. conclusion based on the results of the above research with existing limitations, it is necessary to give advice to various parties. for health services messaieed medical center qatar is expected to provide counseling services about stress and stress work, how to understand the level of stress experienced, and how to deal with or reduce stress independently. health services, especially nurses, are also expected to provide interactive health education and counseling about stress, how to seek help when dealing with stress, and how to modify conditions to reduce the risk of stress. the education provided is mainly about stress, handling, and prevention for every worker who shows symptoms of stress when visiting health services where he works. for companies that employ migrant semi skill workers to modify conditions that have the potential to cause stress. for indonesian people in messaieed qatar to increase their knowledge about stress, handling and prevention, and to know where to look for help when there are community members or friends who show stress symptoms in their place. suggestions for the indonesian government to pay more attention to the education level of workers who will be sent abroad. because a person's education level is very influential on a person's ability to deal with and manage the stress they experience. the recommendations for further researchers should be able to examine the respondent characteristic variables, especially added characteristics of ethnicity or citizenship other than indonesia, where the results can be used as a comparison, whether there are significant differences regarding the level of stress experienced by semi-skilled migrant workers by citizens other than indonesia. conflicts of interest the author declares that none of him had any conflict of interests. references 1. powell tj, enright sj, enright sj. anxiety and stress management [internet]. routledge; 2015 [cited 2019 jun 21]. available from: https://www.taylorfrancis.com/books/97813 15683867 2. sarafino ep, smith tw. health psychology : biopsychosocial interactions [internet]. [cited 2019 jun 21]. 542 p. available from: https://books.google.co.id/books?hl=id&lr=&i d=ypodbgaaqbaj&oi=fnd&pg=pr6&dq=healt h+psychology:+biopsychosocial+interaction&o ts=17pljg0hev&sig=ewlhgkwnjxcywdeclmi mybhqbem&redir_esc=y#v=onepage&q=healt h psychology%3a biopsychosocial interaction&f=false 3. potter, p. a., perry, a. g., stockert, p., & hall a. fundamental of nursing e-book. elsevier; 2016. 4. watson r, gardiner e, hogston r, gibson h, stimpson a, wrate r, et al. a longitudinal study of stress and psychological distress in nurses and nursing students. j clin nurs [internet]. 2009;18(2):270–8. available from: http://www.ncbi.nlm.nih.gov/pubmed/19120 753 5. lee i, wang hh. perceived occupational stress and related factors in public health nurses. j nurs res [internet]. 2002;10(4):253–60. available from: http://www.ncbi.nlm.nih.gov/pubmed/12522 south east asia nursing research, vol 1 no 1, june 2019/ page 27-36 36 zaenal mutaqin / factors related work load stress among migrant semi-skilled workers in messaieed qatar 738 6. yanto a, rejeki s. the related factors to decreased the new graduate nurses work stress level in semarang. nurscope j penelit dan pemikir ilm keperawatan [internet]. 2017 dec 1;3(2):1. available from: http://jurnal.unissula.ac.id/index.php/jnm/art icle/view/2266 7. singh rg. relationship between occupational stress and social support in flight nurses. aviat sp env med [internet]. 1990;61(4):349–52. available from: http://www.ncbi.nlm.nih.gov/pubmed/23399 71 8. nelson dl, burke rj. gender, work stress, and health. 1st ed. washington, d.c.: american psychological assoc.; 2002. xii, 260 p. 9. adriaenssens j, de gucht v, maes s. determinants and prevalence of burnout in emergency nurses: a systematic review of 25 years of research. int j nurs stud [internet]. 2015;52(2):649–61. available from: http://www.sciencedirect.com/science/article /pii/s0020748914002983 10. greenberg js. comprehensive stress management. 13th ed. new york, ny: mcgrawhill; 2013. xii, 444 p. 11. xie z, wang a, chen b. nurse burnout and its association with occupational stress in a crosssectional study in shanghai. j adv nurs [internet]. 2011;67(7):1537–46. available from: http://www.ncbi.nlm.nih.gov/pubmed/21261 698 12. cooke l. conflict and challenging behaviour in the workplace. j perioper pr [internet]. 2006;16(8):365–6. available from: http://www.ncbi.nlm.nih.gov/pubmed/16939 162 13. gevers j, van erven p, de jonge j, maas m, de jong j. effect of acute and chronic job demands on effective individual teamwork behaviour in medical emergencies. j adv nurs [internet]. 2010;66(7):1573–83. available from: http://www.ncbi.nlm.nih.gov/pubmed/20492 019 tepid sponge and sponge bath to change body temperature children with dengue fever corresponding author: witri hastuti wi3.yahoed@gmail.com south east asia nursing research, vol 2 no 2, june 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.3.2020.15-18 original research tepid sponge and sponge bath to change body temperature children with dengue fever witri hastuti 1, novi murdiana sari2, indah wulaningsih3 1,3 karya husada health college semarang, indonesia 2 ken saras hospital, indonesia article info abstract article history: accepted june 27th, 2020 keywords: tepid sponge; sponge bath; temperature; dengue fever dengue haemorrhagic fever (dhf) is a viral infection transmitted by mosquitoes causing potentially deadly complications. the typical sign of this case is getting high fever until 3-7 days then it drops quickly. to make a lower body temperature, compress the body with warm water by using tepid sponge and sponge bath techniques. the objective of this study to determine the effect of compresses with tepid sponge and sponge bath techniques on changes in children's body temperature with dhf. this study used quantitative research with quasi-experiment design two group pre-test post-test design approach. the population of 30 children with fever, with purposive sampling technique using the lemeshow formula. the analysis used was paired t-test, wilcoxon, and mann whitney at a significance level of 0.05. wilcoxon statistical test results show there is a tepid sponge effect on children body temperature with dhf with a p-value of 0.001. the dependent t-test shows there is an influence of sponge bath in children body temperature with dhf p-value of 0,000. the mann witney test shows that sponge bath is more effective than a tepid sponge in reducing fever with a pvalue of 0,000. the conclusion of this study can be used as a guide for treating children with fever with the issuance of a standard spo. application of this method needs to involve parents to maintain the comfort of children, so it needs to make socialization to parents. introduction fever was one of the body’s defences against natural infections bacteria and viruses that cannot live at a higher temperature.1 the incidence of dengue fever was 433 (84,24 %) in 2017. case fatality rate (cfr) in indonesia was 0,72% and central java province was 0,54%.2 dengue fever disease is still a problem in the province of central java, 35 cities have been proven to have contracted dengue fever. the incidence rate (ir) of dengue fever in the province of central java in 2017 was 21,68 per 100,000 population. semarang regency obtained data 23,65% of the incidence of dengue fever in central java province.3 the under-five mortality rate in the last 3 years in semarang regency shows a decrease from year to year. with infant mortality, this is still caused by infectious diseases. the mortality rate due to dengue fever in semarang regency is 0.8% of the death rate in central java province.2 south east asia nursing research, vol 2 no 2, june 2020/ page 15-18 16 witri hastuti / tepid sponge and sponge bath to change body temperature children with dengue fever non-pharmacological treatment that can be done independently by the room nurse to reduce the body temperature of children with fever is by hydrotherapy. hydrotherapy is a water use therapy to cure & relieve fever.4 one of the usual hydrotherapy nurses do is compress. compresses themselves have various types, one of which is warm water compresses, warm water compressors with tepid sponge technique, warm water compresses with sponge bath techniques.5 the results of other study showed that patients with toddler fever given tepid sponge experienced a decrease in temperature.6 whereas the study of lim, et al (2018) did not make a significant difference between pediatric patients who were given warm massages with antipyretics.7 data obtained for 6 months from august 2018 to january 2019, dengue fever patients treated at ken saras hospital there were 121 children. in dengue fever children always found problems with increasing body temperature, handling for temperatures above 37.5 celsius is by compressing warm water on the folds of the armpits. the results found that there were 80 children (66.1%) out of 121 children (100%), had warm water compresses done and no complaints. however, there were 41 children (33.9%) out of 121 children (100%) who felt cold and shivering because the compress was taken too long.. methods this research is a quantitative study with a quasi-experiment design with a two-group pretest-posttest design approach to determine the effect of tepid sponge and sponge bath treatment on changes in body temperature of children with fever. the sampling technique used is purposive sampling. the technique of dividing sample groups is by drawing with sequence numbers. patients undergoing hospitalization in october-december 2019 who have been diagnosed with dengue fever. starting with the first patient who came in labelled number one, the odd sequence was group 1 tepid sponge respondent. then the second respondent with an even number becomes the sponge bath group 2 respondent until all respondents are met. with a total sample of 15 children in each group. the instruments used in this study were thermometers and compresses. the analysis used was paired t test, wilcoxon and mann whitney results the results showed that the child's body temperature before the tepid sponge technique had the lowest temperature of 37.8 celsius and the highest temperature of 39 degrees celsius. meanwhile, the child's body temperature after the tepid sponge technique had the lowest temperature of 37.5 degrees celsius and the highest temperature of 38.7 degrees celsius. the results of the analysis have shown that there is a significant difference between the child's body temperature before and after the "tepid sponge technique" (p <0.05). it can be concluded that the "tepid sponge technique" is able to reduce the child's body temperature by 0.2 degrees celsius. the results showed that the child's body temperature before the sponge bath technique had the lowest temperature of 37.9 celsius and the highest temperature of 40 degrees celsius. meanwhile, the child's body temperature after the sponge bath technique had the lowest temperature of 37 degrees celsius and the highest temperature of 39.5 degrees celsius. the results of the analysis showed that there was a significant difference between the child's body temperature before and after the sponge bath technique (p <0.05). it can be concluded that the "sponge bath technique" is able to reduce the child's body temperature by 0.09 degrees celsius. therapy effectiveness analysis has been carried out by analyzing the difference south east asia nursing research, vol 2 no 2, june 2020/ page 15-18 17 witri hastuti / tepid sponge and sponge bath to change body temperature children with dengue fever between the reduction in body temperature of children in the two interventions that have been carried out. the analysis results have shown that the sponge bath technique is more effective at lowering the child's body temperature than the tepid sponge technique. child's body temperature before and after the compress is presented in the following table 1. table 1 body temperature before and after treatment (n=15) indicators tepid sponge technique sponge bath technique p body temperature before treatment 38 (±0,47) 38,9 (±0,65) 0,0001*** body temperature after treatment 37,8 (±0,43) 38,08 (±0,71) p 0,001* 0,0001** * paired t-test ** wilcoxon test *** mann-whitney test discussion the results of the research that have been done show that the results of the tepid sponge treatment obtained a median value before the child's body temperature test of 380 c fell to 37.80 c. the statistical test results showed a p-value of 0.001 so that it can be concluded that tepid sponge affects reducing the body temperature of children with a fever at ken saras hospital. the tepid sponge is more effective in lowering the body temperature of children with fever compared to warm compresses because it will accelerate vasodilation of peripheral blood vessels throughout the body so that heat evaporation from the surrounding skin environment will be faster than the results given by warm compresses which only rely on hypothalamic stimulation.8 the results of the research that have been done show that the results of the sponge bath treatment obtained an average value before the child's body temperature test of 38.9º c dropped to 38.08º c. the statistical test results showed a p-value of 0,000 so it can be concluded that sponge bath affects reducing the child's body temperature with fever at ken saras hospital. this is also following hockenberry's theory that the benefits of a sponge bath can provide comfort and lower body temperature in handling cases of clients who have a fever. the skin is an effective heat radiator for balancing body temperature, so rinsing the entire body/skin causes the skin to release heat by sweating, and by sweating the body temperature initially rises to a decrease even to normal temperatures.9 the results of the study showed that the mean rank difference in the decrease in body temperature of children with fever treated by tepid sponge was 8.47 while in the sponge bath group it was 22.5. statistical test results show that the p-value is 0,000 so that it can be concluded that sponge bath is more effective in reducing the body temperature of children with a fever at ken saras hospital. sponge bath is more effective in lowering a child's body temperature. sponge bath technique by wiping the entire body of a child with a warm washcloth is effective hydrotherapy by means of heat evaporation in the body. besides minimizing the body's contact with cold water.10 observation results in this study found that sponge baths are more effective than warm water compresses because on average sponge baths are given faster sweating because the entire surface of the body and skin is rinsed using warm water. conclusion there is an effect of temperature changes in children with dengue fever given compresses of tepid sponge and sponge south east asia nursing research, vol 2 no 2, june 2020/ page 15-18 18 witri hastuti / tepid sponge and sponge bath to change body temperature children with dengue fever bath techniques with p values of 0.001 and 0,000. a sponge bath is more effective than a tepid sponge in reducing body temperature in children with dhf p-value of 0,000. with a mean rank of tepid sponge treatment results of 8.47 while in the sponge bath group of 22.53. acknowledgments the researcher would like to say thank you to all the patients who participated as research respondents. a big thanks would also be expressed to the chairman of karya husada college, director of ken saras hospital, and head of research and community service of karya husada college for the permission and support during the research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. ballestas hc, caico c. pathophysiology of nursing.; 2014. 2. kemenkes ri. profil kesehatan indonesia. in: depkes ri; 2018. 3. dinkes. profil kesehatan dinas kesehatan kota semarang. published online 2016. 4. kozier b. fundamentals of nursing: concepts, process and practice. pearson education, limited; 2014. https://books.google.co.id/books?id=nbzfna eacaaj 5. potter, p. a., perry, a. g., stockert, p., & hall a. fundamental of nursing e-book. elsevier; 2016. 6. hendrawati, elvira m. effect of tepid sponge on changes in body temperature in children under five who have a fever in dr. achmad mochtar bukittinggi hospital. enferm clin. 2019;29:9193. doi:10.1016/j.enfcli.2018.11.029 7. lim j, kim j, moon b, kim g. tepid massage for febrile children: a systematic review and metaanalysis. int j nurs pract. 2018;24(5):e12649. doi:10.1111/ijn.12649 8. wardiyah a, setiawan d, keperawatan malahayati bandarlampung a, akademi keperawatan malahayati bandarlampung m. perbandingan efektifitas pemberian kompres hangat dan tepidsponge terhadap penurunan suhu tubuh anak yang mengalamidemam rsud dr. h. abdul moeloek provinsi lampung. vol 4.; 2016. accessed september 5, 2019. www.jik.ub.ac.id 9. marilyn-eaton h, donna wl, marilyn wl, david w, patricia s. buku ajar keperawatan pediatrik. egc; 2008. 10. el-radhi as. febrile seizures. in: clinical manual of fever in children. springer international publishing; 2018:179-192. doi:10.1007/978-3-319-92336-9_7 the role of volunteers in improving services in elderly integrated service centers corresponding author: edy soesanto edysoes@unimus.ac.id south east asia nursing research, vol 2 no 1, march 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.1.2020.22-26 original research the role of volunteers in improving services in elderly integrated service centers edy soesanto1, naufal najib abdurrahman1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: accepted march 30th, 2020 keywords: volunteer role; service improvement; elderly integrated service centre the elderly attendance rate at the elderly integrated service centre for healthy sources of kangkung village is only 14.31%, this is far from the national coverage rate of 80%. the role of the volunteer is one of the factors supporting the presence of the elderly, through increasing the role of volunteer it is expected to be able to increase elderly visits. the objective of this research to describe the role of the volunteer in the elderly integrated service centre in the village of kangkung. this research used descriptive research with cross-sectional approach. the study population was a cadre of healthy elderly integrated service centre sources kangkung village mranggen district. the research sample uses a total sampling technique. data analysis in this study used univariate. as many as 12 people (60%) volunteer played a good role as coordinators, as many as 12 people (60%) played a good role as community mobilizers, as many as 10 people (50%) played a good role as providers of health promotion, as many as 15 people (75 %) played a good role in terms of basic aid providers, as many as 16 people (80%) played a good role in the documentation. the role of coordinator, community mobilizer, basic assistance provider and documentation has been going well, the role as health promotion provider is still poor. the volunteer is expected to be more active in playing roles in improving the services of elderly integrated service centre. introduction an increase in the morbidity rate for the elderly wherein 2014 the morbidity rate for the elderly was (25.05%) and in 2015 it increased to (28.62%).1 is evidence that the elderly group is one of the community groups risks of disease, when viewed from the region, the health of the elderly living in urban areas tends to be better than the elderly living in rural areas, according to data the morbidity rate for the elderly in urban areas is (26, 89%) while the morbidity rate for the elderly in rural areas is (30.14%).1 kangkung village has an elderly population of 834 people or (11.1%) of the total population of 7488 people. according to data from the health centre mranggen one the year 2018 most diseases suffered by the elderly are hypertension (57%), joint disease (40%), anaemia (30%), cataracts (15%). these diseases are the main causes of decreasing the degree of health and productivity of the elderly. https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.1.2020.22-26&domain=pdf&date_stamp=2020-03-31 south east asia nursing research, vol 2 no 1, march 2020/ page 22-26 23 edy soesanto / the role of volunteers in improving services in elderly integrated service centers one of the efforts of the community in responding to the health problems of the elderly, especially in the village of kangkung is to establish a healthy elderly at the elderly integrated service centre, this elderly integrated service centre has been established in 2009 and now has 20 cadres. the establishment of the elderly integrated service centre must be balanced with efforts to utilize the health facilities both from the role of cadres and the community. the attendance list of elderly in elderly integrated service centre sumber sehat in the past year shows that the coverage number of elderly integrated service centre visits from sources is only 14.31%. the role of cadres is one of the important factors because elderly integrated service centre cadres are responsible for the health of the local community, they work and act as a social actor of an elderly integrated service centre health system, if the cadre's role is carried out maximally then the number of elderly integrated service centre utilization will increase.2 based on preliminary studies and interviews conducted by researchers on may 11, 2019, through interviews of three elderly people, the elderly revealed they were reluctant to come to the healthy source elderly integrated service center because they prioritized their work as farmers, lack of notification of the holding of elderly integrated service center where the announcement of the implementation of elderly integrated service center was only announced once through the mosque so that sometimes the elderly forget or even do not hear, the elderly claim the role of cadres as providers of health promotion is less than the maximum because health promotion tends to often use lecture methods rarely leaflets are distributed to the elderly where due to decreased memory sometimes the elderly forget what delivered at the health center, the elderly stated that the drug given by the midwife was only given for the next three days and sometimes it could not reduce the health complaints of the elderly. the lack of maximum coverage for elderly attendance is also related to the ability of cadres in health examinations and health promotion, the lack of equal capacity of cadres is not matched by the willingness to actively explore the knowledge, in the field implementation cadres have the perception that if there are cadres who are proficient, cadres who have not proficient in health examination and health promotion do not want to explore the hat, because elderly integrated service centre can still run, cadres' unwillingness to explore the material due to the lack of understanding of cadres in understanding the material, and there is no willingness to be able to apply to the community, this phenomenon can affect what elderly integrated service centre services do when implementing elderly integrated service centre, many skilled cadres are absent. from the description above, the researcher is interested in researching the overview of the volunteer role in improving services at elderly integrated service centre sumber sehat, kangkung village, mranggen regency sub-district, to be a reference for improving services in an elderly integrated service centre with healthy sources. methods the research design used by researchers is descriptive with a cross-sectional approach. the study population was a cadre of healthy elderly at elderly integrated service centre sources kangkung village mranggen district. the research sample uses a total sampling technique. the data analysis of this study used univariate. this research was conducted at the elderly integrated service centre sumber sehat kangkung village in march 2020. the data collection tool in this study used a cadre role questionnaire to describe the cadre role. validity test is done by the product-moment correlation test, while the reliability test uses the cronbach alpha statistical test. south east asia nursing research, vol 2 no 1, march 2020/ page 22-26 24 edy soesanto / the role of volunteers in improving services in elderly integrated service centers results based on table 1 shows that of the 20 respondents, namely an average age of 43 years with the youngest age of 32 years and the oldest 56 years, in terms of a long experience being a cadre the average cadre joined since 9 years with the youngest experience of 1 year and the youngest 10 years old, the majority of the male sex is 14 people (70%), the majority cadre education is primary school 8 people (40%). table 1 frequency distribution of respondent characteristics in the elderly integrated service centre, sumber sehat, kangkung village mranggen district (n = 20) characteristics median sd n % age 43,20 7,19 long time as a cadre 9.00 3,22 gender male 14 70% female 6 30% education primary school 8 40% junior high school 5 25% high school 7 35% based on table 2 shows that there are various training cadres ever participated, including training in elderly integrated service centre governance attended by 20 people (100%) or all cadres, health education training attended by 20 people (100%) or all cadres, emergency training the basis was attended by 14 people (70%), 30 people participated in the herbal management training (85%). based on table 3, the role of elderly integrated service centre cadres with healthy sources is that the majority of respondents carry out their duties properly, with 12 respondents (80%) having less than 8 cadres (20%). table 2 distribution of training cadres participated in elderly integrated service centre sumber sehat kangkung village, demak regency (n = 20) training result f % elderly integrated service centre governance attended not attended 20 0 100% 0 health education training attended not attended 20 0 100 0 emergency training attended not attended 14 6 70% 30% the herbal management training attended not attended 17 3 85% 15% table 3 frequency distribution of volunteer roles in elderly integrated service centre sumber sehat kangkung village, demak regency (n = 20) role f % less well 8 12 20% 80% total 20 100% discussion the role of cadres as a good coordinator in terms of, active cadres attend coordination meetings, active cadres propose a division of tasks to the elderly integrated service centre coordinator, active cadres propose plans for achieving goals in coordination meetings, cadres can perform different roles in the implementation of the elderly integrated service centre, and cadres play a role when preparing for the implementation of the elderly integrated service centre. this is because cadres feel there is the greatest pride because they can benefit others.3,4 the role of cadres as good community activists in terms of active cadres attending meetings with village leaders to discuss technical issues and the problem of funding elderly integrated service centre and active cadres to mobilize the presence of the elderly through announcements on the forum and conducting pickup in elderly homes, this is because the village officials are a very open dialogue with cadres and south east asia nursing research, vol 2 no 1, march 2020/ page 22-26 25 edy soesanto / the role of volunteers in improving services in elderly integrated service centers successful organizing in community empowerment.5,6 while those who are not active in the case of cadres do not actively go to the homes of residents to move the elderly to the elderly integrated service centre and cadres do not actively evaluate the elderly who have not been present for the elderly integrated service centre, this is because the number of elderly people is not matched by the number of cadres.7 the role of cadres as providers of health promotion has a balanced value while its role is only half of the active cadres who want to apply their knowledge in counselling and in conducting counselling following sap training on health promotion received by cadres, namely providing leaflets, providing props, practising teaching aids the elderly asked at the end of the session and evaluated the understanding of the elderly. the role of health promotion is not good because cadres feel they lack confidence and are not interested in studying health promotion materials.8 the role of cadres as good basic aid providers in terms of cadres being able to perform tasks at the registration desk, cadres can perform tasks in measuring nutritional status, cadres can perform tasks on blood pressure checks, cadres can perform tasks in simple lab examinations, this is because besides enrichment motivation is also often done by to improve the ability of cadres.4,7 as for what is lacking in examining the mental status of the elderly, this is influenced by the cadre's perception of the difficulty of applying mental status checks to the elderly.8,9 the role of cadres as documentation if cadres can document the presence of the elderly, cadres can document the health problems of the elderly, cadres can complete kms, the kade when evaluating reveals the results of addressing technical problems and provides follow-up recommendations to be documented, this is because the evaluation system has been established. in the elderly integrated service centre so that the management of the evaluation can run well.10 conclusion the role of coordinator, community mobilizer, basic assistance provider and documentation has been going well, the role as health promotion provider is still poor. researchers suggest that posyandu cadres for elderly with healthy sources be more active in their role as cadres so that the interest of older people to attend increases. this research is expected to be a source of literature for future researchers to deepen the elderly integrated service centre by involving other variables such as government support in improving the services of the elderly integrated service centre. acknowledgments the researcher would like to say thank you to all the posyandu cadres who participated as research respondents. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. kemenkes p. profile kesehatan indonesia tahun 2018. jakarta; 2018. https://pusdatin.kemkes.go.id/resources/dow nload/pusdatin/profil-kesehatanindonesia/profil_kesehatan_2018_1.pdf. accessed september 7, 2019. 2. armiyati y, soesanto e, hartiti t. pemberdayaan kader posbindu lansia sebagai upaya peningkatan kualitas hidup lansia di desa kangkung demak (empowerment of elderly posbindu cadre to improv the elderly quality of life in kangkung village demak). vol 0.; 2014. http://103.97.100.145/index.php/psn120120 10/article/view/1232. accessed september 7, 2019. 3. husniyawati yr. analisis pengaruh motivasi, south east asia nursing research, vol 2 no 1, march 2020/ page 22-26 26 edy soesanto / the role of volunteers in improving services in elderly integrated service centers komitmen dan faktor organisasi terhadap kinerja kader posyandu (studi tentang peningkatan partisipasi ibu balita di posyandu wilayah kerja puskesmas sidotopo wetan kota surabaya). 2016. http://lib.unair.ac.id. accessed september 7, 2019. 4. afifa i. kinerja kader dalam pencegahan stunting: peran lama kerja sebagai kader, pengetahuan dan motivasi. j kedokt brawijaya. 2019;30(4):336. doi:10.21776/ub.jkb.2019.030.04.19 5. restuastuti t, zahtamal z, chandra f, restila r. analisis pemberdayaan masyarakat di bidang kesehatan. j kesehat melayu. 2017;1(1):14. doi:10.26891/jkm.v1i1.2017.14-19 6. azwar s. penyusunan skala psikologi. ed. 2, cet. pustaka pelajar; 2015. 7. armiyati y, soesanto e, hartiti t. optimalisasi pemberdayaan kader posbindu lansia sebagai upaya peningkatan kualitas hidup lansia di demak. j keperawatan komunitas. 2014;2(2):57-63. https://jurnal.unimus.ac.id/index.php/jkk/art icle/view/4044. accessed september 7, 2019. 8. sulaiman s, sutandra l, vera y, anggriani a. pendampingan kader posyandu lansia di suka raya. j dedicators community. 2018;2(2):116122. doi:10.34001/jdc.v2i2.712 9. supriyatno. faktor-faktor yang mempengaruhi kineja kader posyandu lansia. jurnal ilmiah kesehatan. https://ejournal.umpri.ac.id/index.php/jik/ar ticle/view/1108. accessed september 7, 2019. 10. soesanto e, sandra fatmawati d. increased the intensity of elderly visit to posyandu with family support. south east asia nurs res. 2019;1(3). doi:10.26714/seanr.1.3.2019.137141 tuberculosis knowledge among university students in indonesia corresponding author: miftahul falah miftahulfalah57@gmail.com south east asia nursing research, vol 1 no 2, september 2019 issn:2685-032x doi: https://doi.org/10.26714/seanr.1.2.2019.95-105 original research tuberculosis knowledge among university students in indonesia miftahul falah1, chun-yi tai2, yu-ying lu2, chieh-yu liu2, lilis lismayanti1 1 university of muhammadiyah tasikmalaya 2 the national taipei university of nursing and health sciences article info abstract article history: accepted september 30th, 2019 key words: tuberculosis; knowledge; indonesia the rising tuberculosis (tb) incidence has become one of the main health issues in the world. the objective of this study is to understand tb knowledge and what factors may predict students’ tb knowledge among university students in indonesia. this study included a total of 200 students. convenient sampling was used to recruit students for the study. univariate analysis utilized, such as t-test and one-way anova and pearson correlations coefficient. stepwise multiple regression analysis was used to understand which factors can predict the tb knowledge. overall, the mean score for tb knowledge among the students was 9.49 out of 14. most of the respondents were male, and included several ethnicities, such as sunda and non-sunda. the variables associated with tb knowledge were gender, education, major field of study, and heard of tb. moreover, the study found that, as predictors, the variables that influenced knowledge about tb ranked according to relevance were: major field of study and educational background. health promotion among students is very important to improve their knowledge related to tb disease. the findings could be used for designing the university strategic programs in measuring the knowledge of tb among their students. students with accurate knowledge of tb can help reduce its prevalence in indonesia. introduction the rising tuberculosis (tb) incidence has become one of the main health issues in the world. although some interventions for the prevention and treatment of tb have been developed, the incidence and mortality rates of tb continue increasing (easwaran et al., 2015; depkes, 2011). according to the world health organization (who) (2017), there were 360,565 patients with tb in indonesia. the indonesian ministry of health also reported that tb was the fourth leading cause of death in indonesia, and 6, 371 patients developed tb in 2014. in addition, most of these new cases were adults aged between 25-34 (17.18 %), 3544 (17.18%), and 45-54 (17.33%) (kemenkes, 2015). furthermore, tb could cause significant mortality and morbidity in a community (murray et al., 2014). the high prevalence of tuberculosis impacts society, economy and the environment. one study from nigeria found that tb patients’ friends frequently https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.1.2.2019.95-105&domain=pdf&date_stamp=2019-09-30 south east asia nursing research, vol 1 no 2, september 2019/ page 95-105 96 miftahul falah / tuberculosis knowledge among university students in indonesia have a discriminatory attitude towards them (asuquo et al., 2014) due to the stigma linked to the disease (dhuria, sharma, & ingle, 2008). the disease has social implications: most patients in one study conducted in mexico reported losing their sense of identity, including loss of productivity and relationships with family, resulting in a severe perception of isolation (morris et al., 2013). moreover, a study found that the costs associated with the illness impoverish many households, because many patients accumulate debt and experience loss of income and productive farm assets. among the 160 cases of tb in this study conducted in china, most of the tb patients were household heads, the primary source of income for their households. after being diagnosed, they lost opportunities to work due to social stigma and the effects of the disease. as a result, 30% of the cases in that study earned incomes below the official poverty line (jackson, sleigh, wang, & liu, 2006). in mexico, patients’ inability to work and their uncertainty about how tb would affect their ability to survive financially appeared to reduce their sense of worth (morris et al., 2013). the reason tb patients gave most frequently to explain their non-adherence to treatment in indonesia was lack of money to pay for fees and transportation (widjanarko, gompelan, dijkers, & der werf, 2009). a study aiming to estimate a patient’s cost for tuberculosis diagnosis and treatment from the patient’s perspective found that these costs are a significant economic burden on patients in zambia. moreover, the three largest predictors of patient costs are treatment supervision strategy, patients’ delays in seeking care and gender (amsler et al., 2008). furthermore, tb has a significant impact on quality of life of patients in several domains, including patient’s environment and their psychological wellbeing (dhuria et al., 2009). many studies have shown that the environment has a great impact on tb transmission. for example, a study from brazil demonstrated that the transmission of tb is directly linked to the community’s living conditions (farias et al., 2013). therefore, the condition of patients' homes needs to be investigated, prioritizing those cases with inappropriate ventilation and overcrowding, as closed environments facilitate transmission and domestic contacts put potential patients at greatest risk of catching the disease (kemenkes, 2014). conversely, other studies have reported that tb negatively affects quality of life in the environmental domain, such as sense of safety, transportation, financial security, quality and accessibility of health and social care, and opportunities for leisure activities. other studies also found that tb’s impact was the greatest on quality of life in the environmental and psychological domains (dhuria et al., 2009; sule et al., 2014). students’ lack of knowledge about tb is one factor that causes the high incidence of tb in indonesia. specifically, lack of knowledge about the cause, prevention, transmission, and symptoms of tb result in poor behavior seeking treatment. for example, the national tb team program of indonesia reported that many tb patients stop taking medication before they fully recover, as they do not know that the disease can become latent and that improvement in symptoms does not necessarily indicate a cure (depkes, 2011). seeking proper treatment mainly depends on peoples’ knowledge about tb and their perception of risks associated with it (uchenna et al., 2014). for instance, patients in many countries believe that tb is hereditary and incurable. due to such false perceptions regarding tb, patients may have less motivations to manage their symptoms (dewi, barclay, passey, & wilson, 2016; hoa, chuc, & thorson, 2009). one study of 748 participants with suspected tb in indonesia found that 11.3% had not yet sought care and approximately 33% would rather seek care from traditional health practitioners than south east asia nursing research, vol 1 no 2, september 2019/ page 95-105 97 miftahul falah / tuberculosis knowledge among university students in indonesia health professionals (ahmad, richardus, & de vlas, 2012). moreover, adherence to isoniazid preventive therapy (ipt) for tb in indonesia is low (rutherford et al., 2012). conversely, patients who have accurate knowledge of tb may seek more care. the more frequent they seek care, the more knowledge they have about tb. this is because patients can be given correct information while getting treatment from health care providers (yousif, donaldson, & husseynova, 2011). hossain et al. (2015) reported that accurate knowledge is an important factor in predicting patients’ care seeking behaviors. therefore, it is essential for governments to develop intervention programs that promote knowledge, prevention, and treatment of tb. the indonesian government recommends conducting more research on tb prevention in indonesia (depkes, 2011). a number of studies have been done in indonesia about prevention of and rehabilitation from tb. some have screened people for tb (lock et al., 2011; triasih et al., 2016). few studies have focused on patients’ knowledge about tb. these revealed that knowledge among people suspected of having tb living in yogyakarta had a moderate level of knowledge about the disease, whereas others had low knowledge (ahmad, richardus, & de vlas, 2012; lock et al., 2011). patients with inadequate knowledge of tb were at higher risk of getting inadequate treatment compared to patients who had acquired more information about tb (fatiregun, ojo, & bamgboye, 2009). therefore, this study is investigating knowledge about tb among students in indonesia. this will be one of the first studies to evaluate knowledge about tb in a non-patient population. methods this study used a cross-sectional descriptive study design. this study was conducted at the university of muhammadiyah tasikmalaya in indonesia. total population of this study were all students who study at the university of muhammadiyah tasikmalaya in indonesia, numbering 1.500 students in total. the sample of this study was students with health-related and non-health-related major at the university of muhammadiyah tasikmalaya in indonesia. the sample size was 200 students. a convenience sample method used in this study. in this study, the researcher used a tb knowledge questionnaire developed by dr. lock and his colleagues in 2011. then this instrument asked participants to provide demographic information, including age, gender, educational background, residential area, ethnicity, marital status, major field of study, tb experience, tb xray, tb screening, wearing a mask, and family history of tb. prior to implementing the study, the researcher trained a research assistant to collect data. after obtaining permission from the institutional review board (irb), the research assistant collected the questionnaire. after collecting the questionnaires, the researcher went through the questionnaire to ensure completeness and examined the number of eligible students. each participated student was then assigned a study id for data entry, and then the researcher calculated a total score based on the participants’ responses, then enter the data to spss. univariate analyses utilized, such as t-test and oneway anova were used to test the knowledge score between different levels of categorical variables. pearson correlations coefficients were used for investigating correlation between continuous variables. furthermore, multiple linear regressions were used to understand which factors can predict tb knowledge. results this chapter describes the characteristics of the study population, which aims to present the principle findings of the study related to differences in knowledge among south east asia nursing research, vol 1 no 2, september 2019/ page 95-105 98 miftahul falah / tuberculosis knowledge among university students in indonesia university students in muhammadiyah university of tasikmalaya, indonesia. different statistical methods were used to ascertain the features of the studied population and to display tendencies in the data gathered. descriptive statistics of the study population a total of two hundred students were recruited and interviewed for this study. all participated students were studying in muhammadiyah university of tasikmalaya, indonesia at the time of recruitment. the mean age of the students was 21.46 (sd± 1.982) at the time of data collection ranging from 18 to 27 years old. the majority of the respondents were male, with 124 (62%) males and 76 (38%) females. among several ethnicities, students of sunda ethnicity outnumbered the others. of the students included in the study population, 163 (81.5%) were sundan ethnicity, 30 (15%) were javans, 3 (1.5%) were betawis and 4 (2%) were malays. regarding educational background, the majority of the students (n = 161, 80.5%), had completed senior high school (sma). a total of 36 (19.5%) students had specific high school (smk) education. most of the students were single or widowed (n = 162, 81%), and about 38 (19%) were married. more than half of the students (n = 106, 53%) lived in rural areas, and 94 (47%) lived in urban areas. according to their major field of study, the majority of the students (n = 130, 65%) were pursuing health related studies, with 47 (23.5%) in education and 23 (11.5%) in engineering. most of the students (n =191, 95.5 %), had heard about tb, and only 9 (4.5%) had not heard about the disease. more than half of the students (n = 165, 82.5%) had not had an x-ray for tb, and only 35 (17.5%) students had one. the same number of students had been screened for tb. according to the students, about 120 (60%) students had worn masks, and 80 (40%) had not. the majority of the students (n = 166, 83%), did not have a family member with tb, and only 34 (17%) did have family with tb. table 1 demographic characteristics of the students indicators n % mean ± sd range age 21.46±1.982 18-27 gender male 124 62.0 female 76 38.0 ethnicity sunda 163 81.5 java 30 15.0 betawi 3 1.5 malay 4 2.0 educational background senior high school (sma) 161 80.5 specific high school (smk) 39 19.5 marital status single or widowed 162 81.0 married 38 19.0 residential area urban 94 47.0 rural 106 53.0 major field study health-related studies 130 65.0 education 47 23.5 engineering 23 11.5 heard of tb no 9 4.5 yes 191 95.5 had x-ray for tb no 165 82.5 yes 35 17.5 had tb screening no 165 82.5 yes 35 17.5 wear masks no 80 40.0 yes 120 60.0 family member with tb no 166 83.0 yes 34 17.0 note. tb, tuberculosis. south east asia nursing research, vol 1 no 2, september 2019/ page 95-105 99 miftahul falah / tuberculosis knowledge among university students in indonesia statistically significant differences between demographic characteristics and students’ knowledge this study used pearson correlation, t-test, and one-way anova to determine the relationships among demographic factors and students' knowledge (table 2). an independentsample t-test showed that gender [male (m=9.81, sd=2.38), female (m=8.95, sd=2.61)] was significantly associated with knowledge [t (198) = 2.40, p= .017]. these results suggest that gender has an effect on knowledge. similarly, there was a significantly related between educational background [sma (m=9.28, sd=2.53), smk (m=10.33, sd= 2.20)] and knowledge [t (198) = -2.39, p= .018]. likewise, major field of study and knowledge showed a significant relationship [f (2, 197) = 21.82, p= .000]. in addition, students who have heard of tb [yes (m= 9.57, sd= 2. 40), no (m=7.67, sd= 3.70)] was significantly associated with having knowledge about tb [ t (198) = 2.25, p=.025]. on the other hand, most variables included in this study showed no statistically significant association with tb knowledge. for example, pearson correlation test found there was no correlation between age and tb knowledge (r = .138, n=200, p= .052). similarly, ethnicity had no statistically significant association with tb knowledge [t (198) = 1.09, p= .277]. moreover, no statistically significant relationship was found between marital status [single or widowed (m=9.49, sd= 2.40), married (m=9.45, sd= 2.89)] and tb knowledge [t (198) = .103, p= .918]. similarly, the results showed there was no significant association between residential area [urban (m=9.38, sd= 2.76), rural (m=9.58, sd= 2.26) and knowledge [t (198) = -.542, p= .588]. surprisingly, a family member having tb [yes (m= 10.1, sd= 2.49), no (m=9.35, sd= 2.49)] did not correlate with tb knowledge [t (198) = 1.703, p=.090]. furthermore, having had an x-ray for tb [yes (m=10.1, sd= 2.46), no (m=9.35, sd= 2. 50)] was not statistically significant related with knowledge about tb [t (198) = -1. 65, p= .101]. the same result found in having tb screening. moreover, there was no statistically significant association found between having wear masks [yes (m=9.62, sd= 2.40), no (m= 9.29, sd= 2.64) and tb knowledge [t (198) = -.912, p= .363]. predicting knowledge of students at muhammadiyah university of tasikmalaya (umtas). a stepwise multiple regression analysis was conducted to determine the best linear combination of sub-dimensions of sociodemographic factors related to tb knowledge among university students in indonesia. the result found major field of study and educational background were recognized as predictive factors. specifically, as shown in table 3 that major field of study (standardized coefficients β = .409, p = .000) and educational background (standardized coefficients β = .181, p = .005) significantly predicted knowledge about tb among muhammadiyah university students in indonesia. the unstandardized coefficient for major field of study was (β = -1.475), which indicated that students who were not pursuing health-related studies were more likely to have lower knowledge scores. for educational background, the unstandardized coefficient score was positive (β = 1.141), which indicates that students who had a specific high school (smk) education had greater knowledge than senior high school (sma). south east asia nursing research, vol 1 no 2, september 2019/ page 95-105 100 miftahul falah / tuberculosis knowledge among university students in indonesia table 2 mean knowledge scores of students with demographic characteristics variables n mean ± sd t/f/r p lsd age 21.46±1.982 .138c .052 gender 2.40b .017** male 124 9.81±2.380 female 76 8.95±2.612 ethnicity 1.09b .277 sunda 163 9.58±2.454 non-sunda 37 9.08±2.691 educational background -2.39b .018** senior high school (sma) 161 9.28±2.530 specific high school (smk) 39 10.33±2.204 marital status .103b .918 single or widowed 162 9.49±2.409 married 38 9.45±2.892 residential area -.542b .588 urban 94 9.38±2.756 rural 106 9.58±2.259 major field of study 21.82a <.001*** 1>2 1>3 2>3 health-related studies 130 10.26±1.895 education 47 8.15±2.750 engineering 23 7.83±3.070 heard of tb -2.25b .025** no 9 7.67±3.708 yes 191 9.57±2.409 had x-ray for tb and had tb screening no 165 9.35±2.496 -1.65b .101 yes 35 10.11±2.459 wear masks -.912b .363 no 80 9.29±2.649 yes 120 9.62±2.398 family member with tb no 166 9.35±2.488 -1.70b .090 yes 34 10.15±2.488 note. **p < .05. ***p < .01; tb, tuberculosis; a f-values from one-way anova; b independent t-test; c pearson correlation; lsd = post hoc. table 3 predictors of tb knowledge variables unstandardized coefficients standardized coefficients t p b seb beta constant 10.282 .600 17.142 <.001*** major field of study -1.475 .230 -.409 -6.399 <.001*** educational background 1.141 .403 .181 2.836 .005** note: a. dependent variable: knowledge b. predictors in the model: major field of study, educational background ***p < .01; **p < .05; b, beta; seb, std. error. r= .509, r2= .25, adjusted r2=.215 south east asia nursing research, vol 1 no 2, september 2019/ page 95-105 101 miftahul falah / tuberculosis knowledge among university students in indonesia discussion this study explored knowledge of tuberculosis among university students in indonesia. the respondents were students at the muhammadiyah tasikmalaya university, indonesia. the mean age of the students was 21.46 years at the time of data collection. their ages ranged from 18 to 27 years. a majority of the students, 124 (62%), were male. the mean tb knowledge score among the students was 9.49 (sd±2.500) out of 14 possible points. knowledge scores ranged from 2 to 14 items correctly answered. demographic factors associated with tb knowledge this study findings showed that there are several factors, such as gender, educational background, major field of study and having heard about tb, related to knowledge about tb. in addition, major field of study and educational background were predictors of tb knowledge levels among students in muhammadiyah university of tasikmalaya. gender associated with knowledge with few exceptions, studies worldwide find gender is a significant factor in knowledge about disease, although the patterns differ. results from vancouver, canada showing no significant relationship between gender and knowledge about hepatitis b, are exceptional (leung et al., 2006). the study found that gender had a statistically significant relation with knowledge of tb among university students in indonesia. according to the results, men had greater knowledge about tb than women. the difference in knowledge between male and female students might be attributed to differences in access to information, media and participation in different social groups. these results are supported by those of other studies in some developing countries. a study by wang and colleagues (wang, fei, shen, & xu, 2008) about knowledge of tb in the rural chinese population found differences tb knowledge among males and females. females had lower knowledge about tb health services and were comparatively unwilling to receive information about tb than males. moreover, females did not seem to get information about tb and share it with other people. however, females were more likely to seek health care and go to village clinics, yet males preferred to seek health care at high-level hospitals. this pattern of greater knowledge about disease among men does not break down neatly according to a society’s level of economic development. one can see this pattern in developing countries, for example, a study in vietnam showed that, of a total sample of 559, most of women 82% did not know that tb is caused by bacteria (hoa, thorson, long, & diwan, 2003). likewise, males had significantly higher knowledge scores about tb disease than females in sudan (mohamed, yousif, ottoa, and bayoumi, 2007). in contrast, some studies in developing countries have found women to have more health knowledge than men. for example, in a study about hiv/aids knowledge in ghana, results consistently showed significant gender differences among undergraduate university students, with women having greater knowledge than men (asante & boadi, 2013). in colombia, a study found that women more frequently had correct responses to questions about dengue fever and its transmission. this could suggest that women in columbia may be more interested in or sensitive to acquiring skills that allow them to recognize the disease and prevent its transmission (diaz-quijano et al., 2018). in malaysia, a study about factors associated with knowledge related to hepatitis b and c found that a significantly higher proportion south east asia nursing research, vol 1 no 2, september 2019/ page 95-105 102 miftahul falah / tuberculosis knowledge among university students in indonesia of female respondents had better knowledge of hepatitis c, compared with males (ahmad, sann, & rahman, 2016). in bangladesh, men had greater awareness than women about tb disease, tb latency and directly observed treatment, while on the other hand, bangladeshi women had more knowledge about the bacterial cause of the disease and its curability than men. this gender difference may reflect the culture and lifestyles in bangladesh. much of the time, mothers and daughters stay at home and are more prone to enjoy tv, which, however is a relatively poor source of information. they are comparatively less exposed to markets or public places. on the other hand, men are more exposed to markets, hospitals and other public places. so, they have more chances to gain information from varied sources, such as billboards, posters and friends, in addition to tv (rana et al., 2015). worldwide, differences in knowledge about transmissible disease between men and women are common. however, follow few obvious patterns. in both developed and developing countries, one sex or the other was better informed. the reasons for these differences in knowledge levels among men and women remain mostly unproven and speculative. yet are understood to be social in origin. education associated with knowledge this study found that educational background was significantly associated with knowledge about tb among university students in indonesia. results from the students show that students who had a specific high schools (smk) education had greater knowledge than those who went to senior high school (sma). this result might be influenced by the courses that they got from the school. for example, specific high school (smk) had more courses related to the health knowledge and they do also practice how to prevent some disease. this finding supported by others studies. for example, a study about tb knowledge and factors affecting case detection under the national tb control program (ntp) in bangladesh found that low education was related with poor knowledge about tb. it shows that information of tb is not reaching less educated people in an effective method (hossain et al., 2015). moreover, a study by yin et al. (2013) showed that elderly participants who had finished high school education or above had better odds of possessing adequate health knowledge than those whose highest education level was below junior high school. this finding is similar with other studies, for example, a study by freitas et al. (2015) and hoa, chuc, & thorson (2009), reported that higher education levels were related with greater awareness and willingness to seek information about tb. moreover, the sudanese study on knowledge of tuberculosis and its treatment among tb patients found a general low of awareness of the disease and its treatment, but higher educational levels will increase the level of satisfactory knowledge (mohamed, yousif, ottoa, and bayoumi, 2007). similarly, a study of knowledge and misconceptions about tb in the general population in serbia found that education level was a predictor of right understanding about modes of transmission (vukovic, obradovic, & bjegovic, 2008). a study in nigeria found that the educational status of participants and their spouses was linked with tbrelated knowledge, attitudes and practices (uchenna et al., 2014). moreover, people who had post-secondary education were more likely to be knowledgeable about the importance of completing tuberculosis treatment in kenya (ndwiga, kikuvi, & omolo, 2016). in tanzania, schooling likewise proved to have a significant positive effect on tb knowledge (haasnoot, boeting, kuney, & roosmalen, 2010). also, another study in the usa, patients who had completed six or more years of schooling south east asia nursing research, vol 1 no 2, september 2019/ page 95-105 103 miftahul falah / tuberculosis knowledge among university students in indonesia were significantly to have sufficient knowledge about tb (mondal, nazrul, chowdhury, & howard, 2014). the relationship between education and adequate knowledge about tb is straightforward: none of these studies reported that people with more formal schooling knew less than others about tb, its causes, transmission and treatment. associations between major field of study and tb knowledge major field of study had a significant association with knowledge about tb among university students in indonesia. results from the students show that students who were not pursuing healthrelated studies were less likely to have high knowledge scores. this may be attributed to the fact that education and engineering majors do not have lectures in heath topics that could convey knowledge about tb. but students pursuing health-related majors necessarily have lectures that include knowledge related to tb. this association between major field and health knowledge has been proven in several studies. for example, a study in the usa about knowledge appropriate to metabolic syndrome reported that, among university students, health science majors had greater knowledge than non-health science majors. in fact, it could be explained that courses in health sciences would have covered the topic of metabolic syndrome more than in other fields (yahia, brown, rapley, & chung, 2014). similarly, a study that compared medical and nonmedical students using samples from three universities in northeastern china found that the level of knowledge about appropriate use of antibiotics was greater among medical students than non-medical students. it showed that medical students could get information about antibiotics more easily than other students or the general public (huang et al., 2013). however, there are distinctions in knowledge levels within the health science. for example, a study about tb knowledge in italy found that medical students were better informed than nursing students; the medical students in their study provided correct answers in most cases (from 62.2% to 99%), and the medical students’ level of knowledge was significantly higher than that of the nursing students (montagna et al., 2014). such studies show that major field of study influences participants’ knowledge about health and medical treatments. association between having heard of tb and knowledge “heard of tb” refers to information obtained by knowing someone who has tb or through word-of-mouth, media, and attending seminars and educational programs. in this study, having heard of tb was significantly associated with knowledge about tb among university students in indonesia. the results of the study show that most of the students had heard about tb. it could be explained by the fact that students at the muhammadiyah university of tasikmalaya had some seminars that related to the disease. this finding is consistent with a study in bangladesh that found that most students stated that they had heard of tb from various sources, such as electronic media, print media, relatives and friends (rana et al., 2015). however, interestingly, results from serbia showed all non-medical university students in one study had heard about tb, with the majority describing it as a disease or specifically a pulmonary disease. nonetheless, their knowledge about tb was uneven and inadequate, especially relating to the cause of the disease, mode of transmission and the sites affected (smolovic et al., 2012) studies drawing participants from the general public have assessed the accuracy of knowledge obtained from different information sources. specifically, the study from malaysia mentioned above found that south east asia nursing research, vol 1 no 2, september 2019/ page 95-105 104 miftahul falah / tuberculosis knowledge among university students in indonesia most respondents had previously encountered information about tb. however, knowledge of tb transmission was insufficient and the participants had some inaccurate knowledge about the disease. comparing exposure to different types of traditional mass media, those who listened frequently to radio were more likely to have correct knowledge about tuberculosis transmission (sreeramareddy et al., 2013). another study in nigeria, awareness of tuberculosis was highest among people who had learned about it from television, radio, and community members (uchenna et al., 2014). conclusion this study identifies the factors that influence students’ knowledge about tb in indonesia. health promotion among students at muhammadiyah university of tasikmalaya is very important to improve their knowledge related to tb disease, especially about the cause, transmission, and symptom of the disease. the findings could be used by the university design strategic programs that measure knowledge about tb among their students. the further study could be developed to look for other factors, such as culture, information/mass media, job, and economy, that may influence knowledge of different population groups or in different areas. these results can provide evidence for the field of academic nursing to devise programs about tb prevention for university students in indonesia. acknowledgements we wish to express our appreciation to all respondents who participated in this study for valuable assistance during data collection. conflicts of interest neither of the authors have any conflicts of interests that would bias the findings presented here. references 1. ahmad, r. a., richardus, j. h., & de vlas, s. j. 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(2010). knowledge,attitude and practice regarding tuberculosis : communitybased study in al-anbar governorate; iraq. middle east journal of family medicine, 7(1), 223-230. effectiveness of slow deep breathing exercise on decreasing stress levels for patients with diabetes mellitus corresponding author: warsono warsono@unimus.ac.id south east asia nursing research, vol 2 no 2, june 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.2.2020.10-14 original research effectiveness of slow deep breathing exercise on decreasing stress levels for patients with diabetes mellitus warsono warsono1, arief yanto1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: accepted may 7th, 2020 keywords: slow deep breathing; diabetes mellitus; stress level the prevalence of diabetes mellitus patients increases in semarang province every year. whereas, it reached 120 numbers of patients in kedungmundu public health center by 2020. one of the psychological problems encountered by patients with diabetes is a high risk of stress levels. the condition of stress, anxiety, and fear influence the production of adrenaline hormones which aggravate the capability of patients to perform daily living activities. slow deep breathing exercise is a nonpharmacologic method to reduce stress levels on diabetes mellitus patients. this study aimed to investigate the effect of slow deep breathing exercises on decreasing stress levels for patients with diabetes mellitus. this study used a quasiexperiment pretest-posttest with a control group design was conducted at kedungmundu public health center, semarang. all of 32 samples were recruited in this study. wilcoxon test analysis calculated a value of p=0.000 < ɑ 0,005. the statistical analysis found significantly different results between the pretest and posttest in the experimental group. slow deep breathing exercise is effective to decrease the stress levels for patients with diabetes mellitus. slow deep breathing exercise is strongly suggested for patients with diabetes mellitus as self-intervention to reduce stress levels. introduction diabetes mellitus (dm) is a disease of metabolic disorder that occurs when the pancreas can not produce insulin with a marked presence of impaired metabolism of carbohydrates, proteins, and fats caused due to the increase in insulin levels in relative terms. damage to the pancreas is due right of the swelling in the pancreas which is usually caused by digestive enzymes become active inside the pancreas, so that attack and destroy pancreatic tissue and causes diarrhea and even weight loss.1,2 the level of prevalence globally patient dm in the year 2016 amounted to 11.3% of the total population of the world and experiencing an increase in the year 2017 into 677 million cases. indonesia is a country that occupies the order of the 6th with patients dm number of 12.5 million people after china, india, united states, brazil, russia, and mexico. prevalence of dm by the data results in 3 showed the prevalence of the disease is not contagious experience hike when compared with riskesdas (2013) among others dm occurs an increase of 6.9% in the year 2013 https://doi.org/10.26714/seanr.2.2.2020.10-14 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.2.2020.10-14&domain=pdf&date_stamp=2020-06-30 south east asia nursing research, vol 2 no 2, june 2020/ page 55-59 56 warsono / effectiveness of slow deep breathing exercise on decreasing stress levels for patients with diabetes mellitus increased into 8.5% in the year 2018 with the number of cases reaching 46,174. stress is the body's reaction that occurs when a person is faced with a threat, pressure, or a change. stress is also caused by environmental, economic, and unhealthy living factors, which are one of the triggers for diabetes mellitus. in times of stress, the pituitary gland in the brain decreases the production of the hormone serotonin. serotonin is a mood-regulating hormone that affects the pancreas gland to secrete insulin. when stressed, the production of the hormone serotonin is produced in small amounts, insulin automatically decreases and can reduce its ability to neutralize blood sugar. because blood lacks insulin production, blood glucose will remain in the bloodstream without being able to enter the cell wall, so there is an increase in blood sugar. 4,5 treatment diabetes or diabetes mellitus in general only be given treatment in the form of drug pharmacological such as metformin, and insulin therapy while nonpharmacological administration was not considered in nursing when one nurse handling to note that non-pharmacological therapy. nonpharmacological therapy has not been widely applied by nurses in a hospital such as therapy in handling stress on diabetes mellitus. the method of slow deep breathing is one of the nursing actions that can reduce the stress that occurs a decrease in anxiety and automatically can lower blood sugar levels. relaxation can influence the hypothalamus to regulate and decrease sympathetic nervous system activity. stress can not only increase blood sugar levels physiologically. patients in a state of stress can also change their good habit patterns, especially in terms of eating, exercise, and medication. 6 the research entitled sdb (slow deep breathing) on anxiety levels and blood sugar levels in people with diabetes mellitus. slow deep breathing research 2 times a week for 4 weeks, the results of the level of anxiety obtained by the p-value of the intervention group were (0.000) <0.005 and the results of the control group test obtained the p-value (0.0830> 0.05, while on examination blood glucose obtained by the p-value of the intervention group was decreased and the results of the control group test showed that the p-value was increased but not significant.7 another research showed that the reduction in blood sugar levels was very significant in the intervention group after relaxing for seven days, and doing it twice a day. the highest decrease was on the seventh day (p = 0.000). different sexes did not differ the mean reduction in kgd in the two groups (p = 0.730). and it can be concluded that relaxation can reduce blood sugar levels in type 2 dm patients.6 from patient data for the last 3 months, january-march 2019, it was found that there were 120 people with diabetes mellitus, both male and female, where respondents were still taking drugs such as metformin. researchers aim to provide non-pharmacological therapy, namely slow deep breathing (sdb) therapy. methods this study used a quasi-experimental research design. the study design using pre-post-test control group design by using the instrument hamilton anxiety rating scale (hars), which is done by providing a pre-test before treatment is given and do the re-measurement (post-test) after the treatment given to the intervention group while the control group did not give any therapy. therapy or intervention is carried out after 7 hours to avoid the effect of the work of the drug that is consumed by the respondent. the sampling in this study by using a sampling probability technique random sampling with criteria inclusion of patients with diabetes mellitus for ± 1 year, a patient who experiences anxiety with a score of 95-141 moderate stress, p ria and women ages 30-50 35-55 years, suffering south east asia nursing research, vol 2 no 2, june 2020/ page 55-59 57 warsono / effectiveness of slow deep breathing exercise on decreasing stress levels for patients with diabetes mellitus can communicate well and b willing to be a respondent. the population in the study were all people with diabetes mellitus at kedungmundu public health center semarang, and data were obtained for the last 3 months from january to march 2019 with a total population of 120 people with diabetes mellitus at kedungmundu public health center semarang area. the sample used in this study was 32 respondents consisting of an experimental group of 16 respondents and a control group without treatment of 16 respondents, this study was conducted on 22 september 6 october 2019. univariate and bivariate analysis data using the wilcoxon test. results characteristics and general description of respondents age, gender, last education of respondents, occupation of respondents, and stress level of respondents, which are presented in the central tendency in the form of frequency values. the number of respondents was 32 people (n = 32). the results of the study have shown that the mean age of the respondents is in the late adulthood category. the mean age of the respondents was 43.19 years, with the youngest being 30 years old and the oldest being 55 years old. based on the levene's statistics test, it is known that the stress experienced by respondents before the intervention has the same baseline (p = 0.104). the effectiveness of the slow deep breathing exercise is known by comparing the stress values before and after the action. the results of the study have shown that there is a significant difference between the average stress values before and after the intervention. whereas in the control group there were no similar results. so it can be concluded that slow deep breathing exercise intervention can reduce stress in diabetes mellitus patients. table 1 characteristic of respondents at kedungmundu public health center, semarang (n=32) indicators f (%) gender male 15 46.9 women 17 53.1 occupation does not work 15 46.9 pns / polri / tni 6 18.8 entrepreneur 11 34.4 education elementary school 8 25.0 junior high 9 28.1 high school 10 31.1 bachelor 5 15.6 level of stress mild stress 9 28.1 moderate stress 2 3 71.9 table 2 differences in stress before and after the intervention indicators intervention group control group stress score before intervention 71.88 (±7,182) 126.69 (±3,772) stress score before intervention 69.06 (±7,280) 129.50 (±4,719) 0,0001* 0,425* * wilcoxon test discussion in the adult age range related to behavior and lifestyle, a person tends to not pay attention to their food intake so that it can affect blood sugar levels and stress levels because the food content is not following diabetes mellitus suffered.8–10 women have a higher risk of suffering neuropathic complications related to parity and pregnancy, large body mass index, and menstrual cycle syndrome as well as during menopause which results in inhibition of the transport of gnocchi into cells, leading to diabetes mellitus.11 the level of education is very influential in changes in attitudes and behavior in healthy living. patients who have a low level of education will find it difficult to accept and understand the health messages conveyed south east asia nursing research, vol 2 no 2, june 2020/ page 55-59 58 warsono / effectiveness of slow deep breathing exercise on decreasing stress levels for patients with diabetes mellitus so that it affects the patient's ability to respond to a problem he faces. conversely, sufferers who have higher education will have broader knowledge also allow the patient to control himself in overcoming the problems at hand, have high selfconfidence, experience, and have the right estimate, how to deal with events, and easily understand what recommended by health workers in providing therapy.12 the level of employment of respondents as the motherhouse ladder includes sweeping, washing dishes, cooking including the activity of the physical light that has a risk of 4.36 times is great for people with diabetes mellitus in comparison with those that have activity moderate and severe.13,14 levels of stress experienced by the response can be controlled by the treatment of slow deep breathing for therapy that is one of the independent nursing interventions that can be used to overcome the psychological symptoms of patients. it is important to teach patients to remember the conditions they face are uncertain, for example experiencing psychological symptoms. this relaxation can be useful for improving health conditions and inhibiting stress and anxiety. because of the very strong connection between the body and the mind, it not only has a calming effect on the body but is also beneficial in giving calm to the mind. until now, deep breathing relaxation is still one of the most widely used therapies because it is easy and does not require tools when performed. it only requires full concentration, a comfortable position, and can use imagination.6,15,16 the results of these data indicate that the provision of slow deep breathing therapy reduces stress levels so that this study is proven. conclusion slow deep breathing exercise intervention can reduce the stress of diabetes mellitus patients. nurses can use this therapy to reduce stress in diabetes mellitus patients, to reduce the impact caused by stress. acknowledgments we would like to express our appreciation to all patients who participated in this research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. haq t, ahmed t, latif za, sayeed ma, ashrafuzzaman sm. cardiac autonomic neuropathy in patients with type 2 diabetes mellitus having peripheral neuropathy: a cross-sectional study. diabetes metab syndr clin res rev. 2019 mar;13(2):1523–8. 2. schvarcz e, palmer m, aman j, horowitz m, stridsberg m, berne c. physiological hyperglycemia slows gastric emptying in normal subjects and patients with insulindependent diabetes mellitus. gastroenterology. 1997 jul;113(1):60–6. 3. kesehatan k, penelitian b, kesehatan p. hasil utama riskesdas 2018. 2018. 4. hegde s v., adhikari p, subbalakshmi nk, nandini m, rao gm, d’souza v. diaphragmatic breathing exercise as a therapeutic intervention for control of oxidative stress in type 2 diabetes mellitus. complement ther clin pract. 2012 aug;18(3):151–3. 5. fiskin g, sahin nh. effect of diaphragmatic breathing exercise on psychological parameters in gestational diabetes: a randomised controlled trial. eur j integr med. 2018 oct;23:50–6. 6. chaddha a, modaff d, hooper-lane c, feldstein da. device and non-device-guided slow breathing to reduce blood pressure: a systematic review and meta-analysis. vol. 45, complementary therapies in medicine. churchill livingstone; 2019. p. 179–84. 7. noble ka. the stressed patient with diabetes mellitus. j perianesthesia nurs. 2005 oct;20(5):354–60. 8. rochmawati dh. makna kehidupan klien dengan diabetes melitus kronis, di kelurahan south east asia nursing research, vol 2 no 2, june 2020/ page 55-59 59 warsono / effectiveness of slow deep breathing exercise on decreasing stress levels for patients with diabetes mellitus bandarharjo semarang sebuah studi fenomenologi. 2013. 9. noorratri ed. peningkatan kualitas hidup pasien diabetes mellitus dengan terapi fisik. j ilmu keperawatan komunitas. 2019 may;2(1):19. 10. anissa m, amelia r, dewi np. gambaran tingkat depresi pada lansia di wilayah kerja puskesmas guguak kabupaten 50 kota payakumbuh. heal med j. 2019 aug;1(2):12– 6. 11. ph l, sari ip, hermanto h. gambaran tingkat stres pasien diabetes mellitus. j perawat indones. 2018 may;2(1):41. 12. brunetti l, kalabalik j. management of type2 diabetes mellitus in adults: focus on individualizing non-insulin therapies. p t. 2012 dec;37(12):687–96. 13. im hj, kim yj, kim hg, kim hs, son cg. kouksundo, a traditional korean mind-body practice, regulates oxidative stress profiles and stress hormones. physiol behav. 2015 mar;141:9–16. 14. bhati p, hussain me. sleep duration is a significant predictor of cardiac autonomic neuropathy in type 2 diabetes mellitus. prim care diabetes. 2019 oct;13(5):452–61. 15. jones cu, sangthong b, pachirat o. an inspiratory load enhances the antihypertensive effects of home-based training with slow deep breathing: a randomised trial. j physiother. 2010 jan;56(3):179–86. 16. cant s, watts p, ruston a. the rise and fall of complementary medicine in national health service hospitals in england. complement ther clin pract. 2012 aug;18(3):135–9. therapeutic effect of al-quran murattal (surah yusuf) on blood pressure level in pregnant women with preeclampsia corresponding author: sri rejeki srirejeki@unimus.ac.id south east asia nursing research, vol 2 no 1, march 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.1.2020.27-32 original research therapeutic effect of al-quran murattal (surah yusuf) on blood pressure level in pregnant women with preeclampsia sri rejeki1, sumastia trimuliani1, machmudah machmudah1, nikmatul khayati1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: accepted march 4th, 2020 keywords: surah yusuf murattal therapy; blood pressure; pre-eclampsia pre-eclampsia was recorded as a cause of maternal death in indonesia in 2017, which was 28.8%. hypertension is a sign of pre-eclampsia. murattal therapy letter yusuf is a non-pharmacological therapy that can be used to reduce blood pressure. the purpose of this study is to determine the effect of murattal therapy in reducing blood pressure in pregnant women with pre-eclampsia. the design of this study used the quasy experiment design with one group pretest and posttest design. as the population are pregnant women who are diagnosed with pre-eclampsia. 15 respondents were selected using purposive sampling. data collection tool with an observation sheet and tensimeter. the data collection technique was carried out using the respondent placed in a conditioned room, then listening to the letter of joseph for 15 minutes using a tape recorder and then his blood pressure was measured. from the 15 respondents after murotal therapy, the result of a decrease in blood pressure with a statistical test using a paired t-test obtained a p-value of systolic blood pressure of 0,000 and diastolic blood pressure of 0,000. murattal therapy can stimulate a controlled autonomic nerve and cause secretion of epinephrine and norepinephrine by the controlled adrenal medulla. control hormones epinephrine and norepinephrine will inhibit the formation of angiotensin which can reduce blood pressure. surah yusuf's murattal therapy can reduce the blood pressure of pregnant women with pre-eclampsia. introduction the main complications that cause almost 75% of maternal deaths are heavy bleeding, infection, high blood pressure during pregnancy (preeclampsia or eclampsia) and complications from unsafe abortion.1 based on the distribution of the causes of maternal mortality, it is known that the cause of maternal death is 30.3% bleeding, 28.8% hypertension, 7.3% infection, 1.8% prolonged labour, 1.6% abortion and 40.8% others.2 the causes of maternal death in central java are hypertension in pregnancy i.e. 32.97% (pre-eclampsia), bleeding 30.37%, circulatory system disorders 12.36%, infections 4.34%, metabolic disorders 0.87% and others 19.09%.3 pre-eclampsia is one of the highest causes of maternal death besides bleeding and infection with a significant incidence. preeclampsia is a collection of symptoms that arise in pregnant and puerperal women https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.1.2020.27-32&domain=pdf&date_stamp=2020-03-31 south east asia nursing research, vol 2 no 1, march 2020/ page 27-32 28 sri rejeki / therapeutic effect of al-quran murattal (surah yusuf) on blood pressure level in pregnant women with preeclampsia consisting of increased blood pressure, oedema, and proteinuria that appear in pregnancy from 20 weeks until the end of the first week after delivery.4 the impact of pre-eclampsia-eclampsia on the fetus can result in low birth weight, impaired placental function, fetal hypoxia, intrauterine growth restriction (iugr), prematurity, dysmaturity, and iufd or fetal death in the womb. the impact of preeclampsia-eclampsia on the mother is placental abruption, hypofibrinogenemia, hemolysis, brain haemorrhage, damage to the capillaries of the eye to blindness, pulmonary oedema, liver necrosis, heart damage, hellp syndrome, kidney disorders. the most severe complication of pre-eclampsia-eclampsia is maternal death.5 al-qur'an is one method of treatment that has all kinds of programs and data needed to treat various kinds of disorders of the body's cells. murattal (listening to the reading of the qur'an) is one of the healing methods using the qur'an. listening to the murattal of the qur'an can affect emotional intelligence (eq), intellectual intelligence (iq), as well as one's spiritual intelligence (sq). listening to murattal will have a calming and relaxing effect on a person so that it will also contribute to the reduction in blood pressure.6 according to kartini, the murattal alqur'an technique is proven to provide a calm and relaxing effect because it provides a positive perception response which can further stimulate the hypothalamus to release endorphins which are hormones that make a person feel happy so that they can reduce the blood pressure.7 kartini's research is also supported by the results of research from diki8. there is an effect of murattal therapy on blood pressure or there is a difference in blood pressure before and after getting the treatment.6 the murattal used in this study was surah yusuf. surah yusuf consists of 111 verses, where surah contains the story of the prophet joseph. surah yusuf is believed to have virtue as a means (washilah) to get offspring who have a face and character as beautiful as the prophet yusuf.9 based on the above information, the present research deals with the therapies that can reduce blood pressure in pregnant women with pre-eclampsia. the effect of murattal surah yusuf's therapy was examined on the blood pressure of preeclamptic pregnant women. methods population and sample this research is a quantitative study with a quasy experiment research design with one group pretest and posttest design. the population is pre-eclampsia pregnant women who check their contents in the poly content of rowosari puskesmas and kedungmundu puskesmas. the method of taking samples uses purposive sampling so that the number of samples is 15 respondents. this research was conducted in the working area of rowosari community health center and kedungmundu health center. data collection tool with an observation sheet and tensimeter as a blood pressure gauge. the research process takes place from march-april 2019. statistic analysis descriptive analysis is performed for all variables. data were analyzed univariately and bivariate. bivariate analysis using paired t-test. the statistical significance test is defined by p ≤ 0.05. all data were analyzed using spss version 17. values for measurements are presented as mean ± sd. results the respondents are with an average age of 34.47 years, most mothers with 3rd pregnancy status were 6 respondents (40%) and, the average gestational age was 27 weeks, and there was no risk of south east asia nursing research, vol 2 no 1, march 2020/ page 27-32 29 sri rejeki / therapeutic effect of al-quran murattal (surah yusuf) on blood pressure level in pregnant women with preeclampsia depression as many as 15 respondents (100%). table 1 the characteristics of respondents by age and gestational age (n=15) indicators min max mean sd age 27 46 34.47 5.055 gestational age 21 38 27 4.405 based on table 2 it could be seen the average systolic blood pressure and diastolic blood pressure of respondents on the 1st, 2nd and 3rd day before being given murattal surah yusuf therapy. the mean systolic blood pressure of the respondents before the highest treatment was on the first day of 148 mmhg and the standard deviation was 5.815 with the highest systolic blood pressure of 160 mmhg and the lowest of 140 mmhg. the average of systolic blood pressure on the second day was 144 mmhg and the standard deviation was 5.499 with the highest blood pressure of 155 mmhg and the lowest was 140 mmhg. the average diastolic blood pressure of respondents before the highest treatment on day 1 was 95 mmhg and the standard deviation was 4.805 with the highest diastolic blood pressure of 100 mmhg and the lowest was 90 mmhg. the lowest diastolic blood pressure was on the 3rd day of 92 mmhg and the standard deviation was 4.169 with the highest diastolic blood pressure of 100 and the lowest of 90 mmhg. based on table 2, it can be found that the average systolic blood pressure and diastolic blood pressure of respondents on the 1st, 2nd and 3rd day after being given murattal surah yusuf therapy. the mean systolic blood pressure of the respondents after treatment on the first day was 136 mmhg and the standard deviation was 5.815 with the highest systolic blood pressure of 150 mmhg and the lowest was 130 mmhg with the highest diastolic blood pressure of 100 mmhg and lowest of 80 mmhg. the mean systolic blood pressure of the respondents after treatment on the second day was 134 mmhg and the standard deviation was 4.952 with the highest systolic blood pressure of 140 mmhg and the lowest was 130 mmhg with the highest diastolic blood pressure of 90 mmhg and lowest of 80 mmhg. the average systolic blood pressure of the respondents after treatment on the 3rd day was 134 mmhg and the standard deviation was 4.419 with the highest systolic blood pressure of 140 mmhg and the lowest was 130 mmhg. the average diastolic blood pressure of the respondent after treatment on the 3rd day was 86 mmhg and the standard deviation was 4.499 with the highest diastolic blood pressure of 90 mmhg and lowest of 80 mmhg. based on table 2, it can be said that the mean systolic blood pressure from 3 treatments before performing the murattal therapy of surah yusuf was 145 mmhg with a standard deviation of 4.355 with the highest systolic blood pressure of 153 mmhg and the lowest systolic blood pressure of 140 mmhg. the average of diastolic blood pressure before performing murattal therapy surah yusuf was 93 mmhg with a standard deviation of 3.241 with the highest diastolic blood pressure of 100 mmhg and the lowest diastolic blood pressure of 90 mmhg. based on table 2, it can be found that the average of systolic blood pressure from 3 treatments after the murattal surah yusuf therapy was 134 with a standard deviation of 4.024 with the highest systolic blood pressure 143 mmhg and the lowest systolic blood pressure of 130 mmhg. the average of diastolic blood pressure after performing murattal surah yusuf therapy was 86 with a standard deviation of 3.360 with the highest diastolic blood pressure of 93 mmhg and the lowest diastolic blood pressure of 82 mmhg. south east asia nursing research, vol 2 no 1, march 2020/ page 27-32 30 sri rejeki / therapeutic effect of al-quran murattal (surah yusuf) on blood pressure level in pregnant women with preeclampsia table 2 average of blood pressure before and after being given murattal surat yusuf therapy days 1, 2 and 3 (n=15) indicators day 1 day 2 day 3 before therapy systolic, mean (sd) 148 (±5,815) 144 (±5,499) 145 (±4,577) diastolic, mean (sd) 95 (±4,806) 93 (±4,082) 92 (±4,169) after therapy systolic, mean (sd) 136 (±5,815) 134 (±4,952) 134 (±4,419) diastolic, mean (sd) 86 (±6,114) 85 (±4,169) 86 (±4,499) discussion as a result of this study, it was found that the respondents' blood pressure measurements carried out 10 minutes before the murattal surah yusuf therapy. it was carried out on all respondents experiencing high blood pressure. the highest blood pressure was 153/100 mmhg and the lowest was 140/90 mmhg. while the average respondent's blood pressure was 145.67 / 93.80 mmhg. an increase in the blood pressure of respondents who were pregnant women with a womb >2 weeks of age had a pregnancy-specific syndrome which was mainly related to the lack of organ perfusion due to vasospasm and endothelial activation, which manifests with blood pressure and proteinuria or socalled preeclampsia.8 after the respondent was given murattal surah yusuf therapy treatment, the respondent was remeasured for blood pressure in 10 minutes after the murattal surah yusuf therapy was performed. the result showed that all respondents (n=15) experienced a decrease in blood pressure either in systolic or diastolic pressure after murattal surah yusuf therapy. the highest blood pressure became 143/93 mmhg, while the lowest blood pressure was 130/82 mmhg. the average blood pressure of the respondent became 134.56 / 86.22 mmhg. listening to the murattal of the qur'an gave influence on emotional intelligence, (eq) intellectual intelligence (iq), and spiritual intelligence (sq) of a person. listening murattal would cause a calm and relaxing effect on a person so that it would also contribute to reducing the blood pressure, anxiety levels and pain intensity.6 the result showed that murattal surah yusuf therapy influenced blood pressure causing reduction of blood pressure among pregnant women who had pre-eclampsia. the result showed a significant decrease in blood pressure seen from the difference in average blood pressure before and after the murattal surah yusuf therapy for 15 minutes, which amounted to 11.104 mmhg at systolic pressure and 7.578 mmhg at diastolic pressure. a paired t-test of systolic pressure obtained p-value=0.000. while the test on the paired diastolic pressure t-test resulted in p-value=0.000, ha was accepted, and ho was rejected, and it meant that there was an influence of murattal surah yusuf therapy in the blood pressure of pregnant women with pre-eclampsia at community health center of rowosari and kedungmundu. based on these results, it could be concluded that murattal surah yusuf therapy could reduce the blood pressure in pregnant women who got pre-eclampsia. the positive perception obtained from the murattal al-quran would stimulate the hypothalamus to release endorphins, as we know that this hormone would make someone feel happy. furthermore, the amygdala would stimulate the activation and control of the autonomic nerve which consists of the sympathetic and parasympathetic nerves. the parasympathetic nerves are connected to the heart, and it made the heart work slowly. meanwhile, parasympathetic nerves played vice versa role. controlled autonomic nerve stimulation would cause south east asia nursing research, vol 2 no 1, march 2020/ page 27-32 31 sri rejeki / therapeutic effect of al-quran murattal (surah yusuf) on blood pressure level in pregnant women with preeclampsia epinephrine secretion and norepinephrine by the adrenal medulla. controlled by epinephrine hormone and norepinephrine would inhibit the formation of angiotensin which could further reduce the blood pressure.9 before giving murattal surah yusuf therapy, the blood pressure of all respondents was mean of 145.67 / 93.80 mmhg with the highest blood pressure of 153/100 mmhg and the lowest of 140/90 mmhg. after the respondent was given treatment, the result showed that all respondents (n=15) experienced a decrease, the highest blood pressure being 143/93 mmhg and the lowest was 130/82 mmhg. so, the average blood pressure of the respondent becomes 134.56 / 86.22 mmhg. surah yusuf murattal therapy is effective in lowering the blood pressure of pregnant women who got pre-eclampsia both in the case of systolic blood pressure (p=0.000) and diastolic blood pressure (p=0.000). the nurses are expected to apply murattal surah yusuf therapy in providing comprehensive and holistic nursing care to pregnant women who got pre-eclampsia. the recommendation for nursing education is expected to be one of the treatment discussions to reduce blood pressure in preeclampsia pregnant women in counselling activities to the wider community. it is expected that future research should be carried out by considering the adequacy of the research sample and can also by comparing other therapies such as seft, acupuncture or acupressure therapy. conclusion the nurses are expected to apply murattal surah yusuf therapy in providing comprehensive and holistic nursing care to pregnant women who got pre-eclampsia. the recommendation for nursing education is expected to be one of the treatment discussions to reduce blood pressure in preeclampsia pregnant women in counselling activities to the wider community. it is expected that future research should be carried out by considering the adequacy of the research sample and can also by comparing other therapies such as seft, acupuncture or acupressure therapy. acknowledgments we would like to express our appreciation to all patients who participated in this study and to the heads and nurses of rowosasi and kedung mundu puskesmas who provided valuable assistance during data collection. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. world health organization. maternal mortality. [accessed 6 march 2020]. available at: https://www.who.int/en/news-room/factsheets/detail/maternal-mortality 2. kementerian kesehatan republik indonesia. 2015 profil kesehatan indonesia. [accessed 6 march 2020]. available at: https://www.kemkes.go.id/resources/downloa d/pusdatin/profil-kesehatan-indonesia/profilkesehatan-indonesia-2015.pdf 3. dinas kesehatan kota semarang. profil kesehatan kota semarang tahun 2017. [accessed 6 march 2020]. available at: https://dinkes.semarangkota.go.id/asset/uploa d/profil/profil/profil%20kesehatan%202017.p df 4. sukarni i. patologi: kehamilan, persalinan, nifas dan neonatus resiko tinggi. yogyakarta: nuha medika; 2014. 5. kurniasari d, arifandini f. hubungan usia, paritas dan diabetes mellitus pada kehamilan dengan kejadian preeklamsia pada ibu hamil di wilayah kerja puskesmas rumbia kabupaten lampung tengah tahun 2014. jurnal kesehatan holistik. 2015;9(3):142-150. 6. yuliani dr. terapi murattal sebagai upaya menurunkan kecemasan dan tekanan darah pada ibu hamil dengan preeklampsia: literature review dilengkapi studi kasus. jurnal kebidanan. 2018;8(2):79-98. south east asia nursing research, vol 2 no 1, march 2020/ page 27-32 32 sri rejeki / therapeutic effect of al-quran murattal (surah yusuf) on blood pressure level in pregnant women with preeclampsia 7. kartini k, fratidhina y, kurniyati h. pengaruh mendengarkan murattal terhadap penurunan tekanan darah pada ibu hamil preeklamsi di rsia pku muhammadiyah tangerang. jurnal jkft. 2016;2(2):40-47. 8. lalenoh dc. preeklampsia berat dan eklampsia: tatalaksana anastesia peioperatif. yogyakarta: deepublish: 2018. 9. erlina e, raharjo sb. terapi murattal ar-rahman terhadap perubahan tekanan darah pasien hipertensi di rsudza banda aceh. bandung: ruangkata imprint kawan pustaka: 2016. the first 24 hours postpartum mother’s breast milk production at hospital corresponding author: menik kustriyani menikkustriyani@gmail.com south east asia nursing research, vol 2 no 4, december 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.4.2020.20-24 original research the first 24 hours postpartum mother’s breast milk production at hospital menik kustriyani1, priharyanti wulandari1 1 universitas widya husada semarang, indonesia article info abstract article history: submit nov 5th, 2020 accepted nov 15th, 2020 published dec 30th 2020 keywords: breast-milk production; postpartum breast milk is ideal baby food, various kinds of breast milk content are needed by the baby. factors affecting breastmilk production among others: mother's food intake, mind, physiological anatomy, baby suction factors, rest factors and drug factors. the purpose of this study was to determine the production of postpartum mother milk in the first 24 hours. the research was conducted in descriptive quantitative with a time-series approach. the research subjects were obtained through consecutive sampling. data were obtained at 2 hours postpartum, 16 hours postpartum and 24 hours postpartum using measuring cups and observation sheets. the subjects of this study were 21 normal postpartum mothers. the research data were analyzed using univariate analysis. the study was conducted in july 2020 at ungaran hospital. respondents have explained the study. researchers guarantee the confidentiality of respondents from the beginning to the end of the study. the results showed parity of postpartum multiparous mothers was 52.4%, primiparous 47.6%. postpartum mothers with the early adult category were 66.7%. postpartum mother breastmilk production at 2 hours with an average ± 0.155 cc, the mother experienced an increase in the amount of milk production at 16 hours postpartum by an average of ± 1.272 ml and at 24 hours postpartum experienced an increase in the amount of mother's milk production on average ± 1.369 ml. it can be concluded that physiologically normal post-partum mother milk production has increased gradually, the increase is because the more often the mother empties the breast, the more breast milk production. introduction breast milk (asi) is the ideal food for babies, various kinds of breast milk are needed by babies. breast milk contains protein, carbohydrates, vitamins, minerals, fat and water as the suitable component suitable the needs the baby. breast milk begins to be produced by the breasts on the 16th week where the breasts begin to synthesize the components of milk by being influenced by human placenta lactogen so that the milk is still retained. colostrum will generally come out from the 3rd trimester or around 34-36 weeks.1 breastfeeding rates in egypt vary due to several factors, such as social, economic, political and cultural factors.2 likewise in indonesia, the ministry of health in indonesia has a program of 10 steps towards successful breastfeeding, several ways that must be done as a health worker in the hospital to help mothers start https://doi.org/10.26714/seanr.2.4.2020.20-24 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.4.2020.20-24&domain=pdf&date_stamp=2020-12-30 south east asia nursing research, vol 2 no 4, december 2020/ page 151-155 152 menik kustriyani / the first 24 hours postpartum mother’s breast milk production at hospital breastfeeding their babies within 60 minutes after giving birth in the delivery room, helping mothers to understand how to breastfeed correctly and how to maintain breastfeeding even if the mother is separated from the baby on medical indications. performing combined care by getting the mother to be with the baby 24 hours a day. helping the mother to breastfeed as much as the baby wants, without restrictions on the length and frequency of breastfeeding. optimal breastfeeding will reduce the risk of various baby health problems.3 several factors affect the production of breastmilk, the mother's food intake, peace of mind and soul, physiological anatomy, baby suction factors, rest factors and drug factors.4 previous research stated that 66,7 % of postpartum mothers breastfeed smoothly, 60,2% of postpartum mothers provide sufficient breast milk. the fluency of breastfeeding in postpartum mothers is influenced by the early initiation of breastfeeding and baby suction.4,5 this study aims to determine the production of breast milk during the first 24 hours postpartum. methods this research used a descriptive quantitative method with a time-series approach. this study wanted to measure the amount of normal postpartum breast milk production at three measurements, at 2 hours postpartum, 16 hours postpartum and 24 hours postpartum (wulandari et al., 2018). respondents in this study were normal postpartum mothers with the inclusion criteria of 2 hours postpartum normal mothers, primipara and multiparous postpartum mothers, normal nipple forms, normal postpartum mothers, postpartum mothers with no systemic disease, the mother that was not taking drugs to facilitate expulsion. breastfeeding, baby weight ≥ 2500 grams, respondent with a good psychological condition, mother and baby were in joint care and mother was willing to be the respondent. respondents were 21 postpartum mothers. the sampling technique used was consecutive sampling. breast milk production was measured using a measuring cup for three measurement periods, namely at 2 hours postpartum, 16 hours postpartum and 24 hours postpartum. researchers provided explanations to respondents about the objectives and benefits of the study and its consequences. respondents were asked to sign an informed consent before conducting the study. the researcher did not include the identity of the respondent in the study. this research has received approval from the ethics committee with number 20 / kepk-rsud / ec / vi 2020. the research data was presented using univariate analysis, the study was conducted in july 2020 at the ungaran hospital. results the research data were analyzed using univariate analysis, the study was conducted in july 2020, at the ungaran hospital. the results showed that the respondents consisted of mothers who had given birth to a live baby for the first time (primipara) and mothers who had given birth two to four times (multiparous). the youngest was 18 years old and the oldest was 37 years old. there was an increase at 2 hours postpartum with a mean (± 0.155) ml, the increase also occurred at 16 hours postpartum with an average (± 1.272) ml, the increase at 24 hours postpartum with an average (± 1.369) ml. south east asia nursing research, vol 2 no 4, december 2020/ page 151-155 153 menik kustriyani / the first 24 hours postpartum mother’s breast milk production at hospital table 1 respondent characteristics (n=21) indicator normal post-partum mother f % parity primipara multipara 10 11 47,6 52,4 age late teens early adulthood late adulthood 6 14 1 28,6 66,7 4,8 table 2 production of normal post-partum mother breastmilk (n=21) indicator breast milk production breast milk production at 2 hours post-partum 0,171 (±0,155) ml breast milk production at 16 hours post-partum 0,662 (±1,272) ml breast milk production at 24 hours post-partum 0,852 (±1,369) ml discussion respondent characteristics age is one of the physiological factors that may affect milk production, mothers who are younger or less than 35 years of age will produce more milk than older mothers (biancuzo, 2000). for some mothers who are over 35 years of age, their milk production is smooth6. mothers who are younger or less than 35 years of age produce more than older mothers. meanwhile, mothers aged 19-23 years can generally produce enough breast milk compared to those in their thirties because of their good physiology.7 the age of the breastfeeding mother affects milk production. younger mothers produce more breast milk than older mothers. mothers aged 19-23 years can generally produce enough breast milk compared to 30 years old mothers.8 the age of 35 is risky because it is closely related to nutritional anaemia that may affect milk production. in primiparous mother with 35 years of age, there is a decrease in hormone production so that it decreases the lactation process.4 another thing that can affect breast milk production is parity, multiparous mothers show more milk production than primiparous in the first 24 hours postpartum. in the process of breastfeeding, many factors influence it, including parity. meanwhile, for mothers who gave birth more than once, the milk production is more than the birth of their first child.9,10 several deliveries that have been experienced by mothers provides experience in giving breast milk and know how to increase milk production so that there are no problems for mothers in breastfeeding. mothers who have given birth for the first time and mothers who have given birth more than two times often find problems in breastfeeding. problems that often arise are sore nipples due to inexperience or not ready to breastfeed physiologically and changes in the shape and bad condition of the nipples.4,11 mothers who gave birth more than once can produce more milk than those who gave birth for the first time. a person who has given birth for the first time usually has less knowledge and experience in terms of breastfeeding, while a mother who has given birth more than once certainly has experience in breastfeeding so that lactation management will be carried out properly. furthermore, the psychological preparedness between primiparous and multiparous is very different. a primiparous person feels anxious and psychologically unstable more easily, it will affect the production of hormones that play a role in breast milk production.4 at the time of the study, it was found that more successful multiparous parity in breastfeeding, due to previous experience south east asia nursing research, vol 2 no 4, december 2020/ page 151-155 154 menik kustriyani / the first 24 hours postpartum mother’s breast milk production at hospital of breastfeeding with children, knowledge from family and the surrounding environment and sources of information. primiparous parity that succeeds in breastfeeding is because the mother has received knowledge about breastfeeding from the family when the family is breastfeeding the mother is concerned about breastfeeding. besides, successful primiparous mothers are mothers with a background in health education, so that they already know about the correct way of breastfeeding.12 in primiparous parity, there were more fail to breastfeed because the mother still lacks experience in breastfeeding, they experienced the mistake in breastfeeding techniques so that there is no proper attachment between mother and baby and causes the baby to not suckle properly.13 the mother failure to breastfeed her baby immediately after birth will affect the mother milk production because the firsttime breastfeeding after birth will stimulate the pituitary to release oxytocin. oxytocin works to stimulate the smooth muscle to express milk in the alveoli, lobes and ducts that contain milk that will be excreted through the nipples. this situation forces the prolactin hormone to continue producing breast milk. so that the more often the baby sucks the nipple, then breastfeeding will also be smoother.14 normally the first day of breastfeeding comes out on the first day of birth until the third day.15 production and discharge of breast milk occur after the baby born, it is followed by a decrease in estrogen levels which stimulate the increase in prolactin levels for milk production. even if only a little milk comes out on the first day, the mother must continue to breastfeed. this action besides the provide nutrition to the baby teaches the baby to breastfeed or get used to sucking the mother nipple and supports milk production.16 during pregnancy and the first postpartum days, milk production is affected by the prolactin hormone (the breast milkproducing hormone) and other reproductive hormones. as long as these hormones are present and balanced, the mother will begin to produce colostrum / first milk from the second trimester of pregnancy (lactogenesis i) that increases the numbers about 30-40 hours after delivery (lactogenesis ii).17–19 in the final trimester of pregnancy, even though the breasts have produced colostrum, their secretion is inhibited by high levels of the hormone progesterone. during labor, the discharge of the placenta causes the levels of the hormones progesterone, estrogen, and human placental lactogen (hpl) to drop significantly. this condition is accompanied by high levels of the hormone prolactin marking the beginning of lactogenesis ii (production of large amounts of breast milk). breastmilk production in the first 24 hours after delivery is usually not seen much. after 48-72 hours, the mother will feel a full sensation in the breast. it occurs when breast milk is produced a lot.9 both of these processes are purely driven by hormones that come from the centre (glands in the brain) and still occur even if the mother does not breastfeed her baby. after lactogenesis ii, there is a shift in controlling milk production that is centred in the brain transferred to the breast. this stage is called lactogenesis iii. at this stage, the release of breast milk is the main control for milk production. although hormonal disturbances can affect milk production, the role of hormones at this stage is much reduced. under normal conditions, the breasts will continue to produce milk as long as the process of expressing milk continues.17 conclusion based on the results of the study, there was an increase of breast milk production in south east asia nursing research, vol 2 no 4, december 2020/ page 151-155 155 menik kustriyani / the first 24 hours postpartum mother’s breast milk production at hospital postpartum mothers at 2 hours as much as 0.171 ml, at 16 hours postpartum as much as 0.662 ml and 24 hours postpartum as much as 0.852 ml. acknowledgments researchers would like to thank the ministry of research and technology / the national research and innovation agency for providing financial support in research implementation. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. lawrence r, lawrence r. breastfeeding 8th edition. 8th ed. philadelphia: elsevier; 2016. 2. demir f, ghosh p, liu z. effects of motherhood timing, breastmilk substitutes and education on the duration of breastfeeding: evidence from egypt. world dev. 2020 sep;133:105014. 3. yanto a, rochayati r, wuryanto e. decreased the risk of hyperbilirubinemia incidence with the initiation of early breastfeeding. media keperawatan indones [internet]. 2018 jun 18;1(2):25. available from: https://jurnal.unimus.ac.id/index.php/mki/ article/view/3446 4. pranajaya r, rudiyanti n. determinan produksi asi pada ibu menyusui. j ilm keperawatan sai betik. 2017 jan;9(2):227– 37. 5. yanti hf, yohanna ws, nurida e. kelancaran produksi asi pada ibu post partum ditinjau dari inisiasi menyusu dini dan isapan bayi. j aisyah j ilmu kesehat. 2018 jun;3(1):39–46. 6. budiati t, setyowati s, cd nh. peningkatan produksi asi ibu nifas seksio sesarea melalui pemberian paket “sukses asi.” j keperawatan indones. 2010 jul;13(2):59–66. 7. firmansyah n. pengaruh karakteristik (pendidikan, pekerjaan), pengetahuan dan sikap ibu menyusui terhadap pemberian asi eksklusif di kabupaten tuban. universitas airlangga; 2012. 8. pudjiadi. keluarga dan anak. jakarta: kawan pustaka.; 2005. 9. kari ik. seri gizi klinik, asi ; petunjuk untuk tenaga kesehatan. soetjiningsih, editor. jakarta: egc; 1997. 10. bonuck ka, trombley m, freeman k, mckee d. randomized, controlled trial of a prenatal and postnatal lactation consultant intervention on duration and intensity of breastfeeding up to 12 months. pediatrics. 2005 dec;116(6):1413–26. 11. impartina a. hubungan pengetahuan ibu nifas tentang teknik menyusui dengan kejadian bendungan asi. medisains. 2017;15(3):156–60. 12. victora cg, bahl r, barros ajd, frança gva, horton s, krasevec j, et al. breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. lancet. 2016;387(10017):475–90. 13. mcfadden a, gavine a, renfrew mj, wade a, buchanan p, taylor jl, et al. support for healthy breastfeeding mothers with healthy term babies. cochrane database syst rev. 2017;(2). 14. nugroho t, nurrezki, warnaliza d, wilis. buku ajar asuhan kebidanan. 3rd ed. yogyakarta: nuha medika; 2014. 15. astuti i. determinan pemberian asi eksklusif pada ibu menyusui. j heal qual. 2013;4(1):1– 76. 16. rahayu d, yunarsih. penerapan pijat oksitosin dalam meningkatkan produksi asi pada ibu postpartum. journals ners community. 2018;9(1):08–14. 17. mannel, r., martens, pj., walker, m. m. core curriculum for lactation consultant practice. 2nd editio. massachusets: jones and barlett; 2012. 18. roesli u. panduan konseling menyusui. iv. jakarta: pustaka bunda; 2012. 19. ballestas hc, caico c. pathophysiology of nursing. 2014. handover nurse monitoring and evaluation in meeting the snars accreditation standards 1.1 corresponding author: kurnia yuliastanti kurniayuliastanti@gmail.com south east asia nursing research, vol 2 no 4, december 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.4.2020.43-47 case study handover nurse monitoring and evaluation in meeting the snars accreditation standards 1.1 kurnia yuliastanti1,2, vivi yosafianti pohan2, tri hartiti2 1 nursing department, sultan agung islamic hospital semarang, indonesia 2 master of nursing program, universitas muhammadiyah semarang, indonesia article info abstract article history: submit dec 10th, 2020 accepted dec 30th, 2020 published dec 30th 2020 keywords: monitoring and evaluation; nurse handover; nursing management sultan agung islamic hospital semarang as one of the providers of health, education and research services must be supported by a strong organization and good management. the nurse plays an important role regarding the clinical outcome of the client, especially during the handover the process which has an impact on patient safety and the quality of the hospital. the implementation of monitoring and evaluation of handover in this hospital has never been implemented because there are no working tools and regulations that regulate it as a reference for implementation. this study uses the interviews and observations with the approach carried out on 7 19 december 2020. participants consisted of the responsible person / head of the room, the responsible nurse (ppja) and the implementing nurse (pp) in the baitul izzah 2 room of the sultan agung islamic hospital semarang. this study found 3 themes were found, namely the absence of monitoring and evaluation of handover nurses, lack of understanding of nurses regarding the implementation of handover monitoring and evaluation, the absence of regulations and work tools regarding the handover monitoring and evaluation. work tools and regulations are very helpful in the implementation of monitoring and evaluation of handover in providing nursing care in the inpatient room. as well as fulfilling snars 1.1 accreditation standards. introduction sultan agung islamic hospital semarang as one of the providers of health, education and research services, aims to improve health status and is always oriented towards the interests of the community. for that, the hospital needs to be supported by the existence of a strong organization and good management oriented towards the quality of service for the community. nursing management is a process of working through members of the nursing staff to provide nursing care professionally. it is a special task that must be carried out by nursing managers to plan, organize, direct and supervise existing resources, both human resources, tools and funds so that they can provide effective nursing services to patients, families and communities.1 meanwhile, a nursing service is a form of professional service that is an integral part of health services based on https://doi.org/10.26714/seanr.2.4.2020.43-47 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.4.2020.43-47&domain=pdf&date_stamp=2020-12-30 south east asia nursing research, vol 2 no 4, december 2020/ page 173-177 174 kurnia yuliastanti / handover nurse monitoring and evaluation in meeting the snars accreditation standards 1.1 nursing knowledge and tips for individuals, families, groups or communities, both healthy and sick. nursing practice is a service provided by nurses in the form of nursing care.2 nurses as an integral part of health services are required to have strong managerial abilities so that the services provided can increase patient satisfaction. nurses' managerial abilities can be achieved in many ways. one of them is by increasing reliable managerial skills based on innovation and evidence-based.3 the nurse must know the concept correctly and have a positive attitude and be prepared to apply the evidence-based practice. in the inpatient installation, the nursing staff are in the forefront of the health service system with the first and longest contact with the patient, which is 24 hours per day and 7 days per week, therefore nurses hold a key position in building the image of the hospital. nursing services in the hospital are the biggest activity producers so that they reflect the quality of hospital services. this quality can be seen from one of them through the implementation of handover nurses when weighing receipts between shifts.4 national hospital accreditation standards (snars) 1.1. the patient safety goal (skp.2.2) requires that the hospital establish and implement a communication process “handover” and develop effective, timely, accurate, complete, clear and understandable communication methods for recipients.5 weigh-acceptance is a technique used to convey and receive reports in connection with the client's condition, which is carried out between nurses and nurses and between nurses and clients in an accurate and more real way, it must be clear, concise and complete. acceptance weighing is carried out starting from preparation, implementation at the nurse station and continued beside the patient's bed or bedside handover, as well as post-consideration. 1 patient handover is designed as a method to provide relevant information to the nursing team at each shift, as a practical guide providing information about the patient's current condition, treatment goals, treatment plans and determining priority services that are carried out in a timely, accurate, complete, and clear manner, so that it can be understood, and will reduce errors, and result in increased patient safety.6 handover implementation in several hospitals in indonesia is still not optimally implemented. this shows that the handover condition still requires a lot of improvement and recommendations to become a better process. therefore, if the communication in handover is not effective, it can cause errors in the continuity of services and improper treatment and result in potential losses for patients.7 baitul izzah 2 room is an adult inpatient room led by a person in charge / head of room with 4 (four) nurses in charge of care (ppja). ppja in implementing nursing care is assisted by 17 implementing nurses (associate nurse / pa). the room designated as a practice place for nursing management applications, is an adult care room for classes i and iii with cases of internal medicine, eyes, nerves, ent, skin and genitals, and teeth and mouth. has a capacity of 26 patient beds (tt). bor for the last 3 (three) months averaged 73.5%. the number of nurses is 21 (twenty-one) with d3 nursing education amounting to 17 and nurse education: amounting to 4. based on the results of the assessment, through interviews and observations made to the head of the baitul izzah 2 room at the sultan agung islamic hospital, semarang revealed that in the application of the second patient safety goal, namely increasing effective communication, manifested in the implementation of nurse handover between shifts. handover is carried out at the nurse station then proceed to the patient's bedside (bedside south east asia nursing research, vol 2 no 4, december 2020/ page 173-177 175 kurnia yuliastanti / handover nurse monitoring and evaluation in meeting the snars accreditation standards 1.1 handover). for the handover the material, the nurse uses the patient's medical record data and uses a tool in the form of an sbarbased handover form (situation, background, assessment, recommendation). the handover is routinely carried out and runs smoothly, however so far there has never been any monitoring or evaluation related to the implementation of the handover. this study aims to determine the implementation of handover nurse monitoring and evaluation in meeting the snars accreditation standards 1.1. methods the scientific way to obtain data with specific purposes and uses.8 activities carried out in obtaining data through observation and interviews, started with problem identification, then continued with problem analysis, determination of problem priorities, preparation of plans of action, implementation, and evaluation of structures, processes and results. the data is used in determining the problems identified using a fishbone diagram. the method used to determine the priority of several problems using the car method, which consists of: c = capability, namely the availability of resources (funds, facilities and equipment) a = accessibility, namely convenience, the existing problem is easy to solve or not. convenience can be based on the availability of methods/methods/technology as well as implementation support such as regulations or implementation guidelines. r = readiness, namely the readiness of the executive staff and the readiness of targets, such as expertise or ability and motivation. l = leverage, namely how much influence the criteria have on one another in solving the problems discussed. to get the priority value, that is by multiplying the value of each criterion. the higher the value of the product, the more priority the problem is to solve. results in determining the problem according to the carl method, there are 2 (two) problems, namely: 1. not yet implemented monitoring and evaluation of handover by the head of the room (score 256) 2. not yet implemented nursing supervision activities by the head of the room, the team leader in a structured manner (score 96) based on the highest score, the priority of the problem in the baitul izzah 2 room is "the head of the room has not carried out monitoring and evaluation of handover". intervention implemented by conducting socialization/ refreshing about handover through zoom meeting. followed by coordination and consultation with the head of nursing and the head of the room for making work tools in the form of monitoring forms, evaluation forms and making spo monitoring and spo evaluation handover. on december 10, 2020, the form and spo were socialized directly to the head of the room, ppja and pp continued with implementation on december 11, 2020. form and spo were well received by all baitul izzah room nurses 2. implementation was carried out with continuous assistance interviews and observations to the head of the room and ppja obtained data on the implementation of the monitoring form, evaluation form, spo monitoring and spo evaluation can be carried out smoothly. the form is filled in completely, the nurse also does not feel burdened in filling out the complete form. with this form, it makes it south east asia nursing research, vol 2 no 4, december 2020/ page 173-177 176 kurnia yuliastanti / handover nurse monitoring and evaluation in meeting the snars accreditation standards 1.1 easier for nurses to handover. nurses are more able to focus and be structured on what things will be handed over to the next shift. the information provided is more accurate, which can minimize errors in communication that can harm patients. discussion based on the results of interviews and observations, the patient's overall handover from the preparation, implementation, and post-consideration stages constitutes a unified process that becomes one of the activities that support nursing services on an ongoing basis and with integrity through reporting and documentation.1 following the purpose of the consideration and acceptance based on the spo of the sultan agung islamic hospital semarang which was issued on january 7, 2020, among others, is to improve communication skills between nurses so that there is a responsible collaborative relationship between members of the nursing team and can follow the complete development of clients and the implementation of nursing care towards clients on an ongoing basis. efforts to improve service quality following standards and following the latest hospital accreditation provisions handover, in baitul izzah 2 room have been implemented following the existing spo. handover is carried out every shift change at the nurse station then continued to the patient's bedside (bedside handover). for the handover the material, the nurse uses the patient's medical record data and uses a tool in the form of an sbar-based handover form (situation, background, assessment, recommendation). the method of implementing this weigh-and-receipt has been implemented since the issuance of the spo as a reference for the implementation of the handover. there were no obstacles in its implementation. it was found that the handover had never been monitored and evaluated in its implementation. whereas in the snars 1.1 accreditation standard.5 the head of the room, ppja and pp do not carry out monitoring and evaluation due to lack of understanding and understanding, that handover must always be monitored and evaluated to find out any obstacles in its implementation for quality assurance and patient safety. the impact if this happens continuously and there is no improvement or improvement, it will have a negative impact on the implementation of the consideration itself, for the staff or nurses who carry out these activities and for the institution which is the container and provider of the facilities, and especially for patients as clients who involved in this activity. thus, this activity will ultimately have an impact on patient safety goals which ultimately lead to patient satisfaction with the service and quality of the hospital institution. with the existence of forms, spo monitoring and evaluation handover, monitoring and evaluation are always carried out in every handover implementation. in interviews and observations to the head of the room and ppja, the monitoring form, evaluation form, monitoring spo and spo evaluation were carried out properly. the form is filled in completely and the nurse finds it easy to carry out the contents of the form. nurses can be more focused and structured on what things will be handed over to the next shift. the information provided is more accurate, which can minimize errors in communication that can harm the patient the positive impact felt by the nurses themselves is to motivate to improve communication skills between nurses, to establish a cooperative and responsible relationship between nurses and to be able to follow the patient's development comprehensively 9. nurses' job satisfaction in nursing practice is achieved when the nurse feels that she has contributed, is considered important, has received support from existing sources, and many nursing outcomes are achieved.10 south east asia nursing research, vol 2 no 4, december 2020/ page 173-177 177 kurnia yuliastanti / handover nurse monitoring and evaluation in meeting the snars accreditation standards 1.1 conclusion activities run well and can increase the knowledge and skills of nurses in the application of monitoring and evaluation of handover nurses. it was shown from the results of the mentoring evaluation that the implementation of monitoring and evaluation of handover nurses had been carried out well with 100% achievement which previously did not exist. this was supported by the joint commitment of all nurses in the baitul izzah 2 care room to always carry out monitoring and evaluation of handover. acknowledgments the author is thankful to sultan agung islamic hospital semarang and the nurses who took part in this study. conflicts of interest the author disclosures no potential conflicts of interest, financial or otherwise. references 1. nursalam. manajemen keperawatan aplikasi dalam praktik nursalam. (2011). manajemen keperawatan aplikasi dalam praktik keperawatan profesional edisi 3. salemba medika. https://doi.org/10.1001/archinte.165.22.2659 keperawatan profesional edisi 3. salemba medika. 2011. 2. budiono. konsep dasar keperawatan. kementrian kesehatan republik indonesia; 2016. 3. legita t. pengetahuan, sikap dan kesiapan perawat klinisi dalam implementasi evidencebase practice. ners j keperawatan. published online 2012. doi:10.25077/njk.8.1.84-97.2012 4. triwibowo c, yuliawati s, husna na. handover sebagai upaya peningkatan keselamatan pasien (patient safety) di rumah sakit. j keperawatan soedirman. published online 2018. doi:10.20884/1.jks.2016.11.2.646 5. komisi akreditasi rumah sakit. standar nasional akreditasi rumah sakit. kars; 2017. 6. faisal f, syahrul s, jafar n. pendampingan handover pasien dengan metode komunikasi situation, background, assesment, recommendation (sbar) pada perawat di rsud barru kabupaten barru sulawesi selatan. j terap abdimas. published online 2019. doi:10.25273/jta.v4i1.3807 7. kamil h, keilmuan b, dasar k, et al. handover dalam pelayanan keperawatan. idea nurs j. published online 2011. 8. sugiyono. metodologi penelitian. univ pendidik indones. published online 2003. 9. aiken lh, clarke sp, sloane dm, et al. nurses’ reports on hospital care in five countries. health aff. published online 2001. doi:10.1377/hlthaff.20.3.43 10. marquis bl, huston cj. leadership roles and management functions in nursing: theory and application.; 2017. doi:10.1097/00006216200407000-00013 the influence of parenting patterns on the personal social development of preschool children corresponding author: sholahudin ghozali sholahudin_ghozali@yahoo.com south east asia nursing research, vol 2 no 2, june 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.2.2020.70-73 original research the influence of parenting patterns on the personal social development of preschool children sholahudin ghozali1 1 dukhan medical center qatar petroleum, qatar article info abstract article history: accepted june 28th, 2020 keywords: parenting style; child stimulation; preschool age the child's personal social development is greatly influenced by the environment and interactions between the child and the parents or other adults around them. the type of parenting style of parents towards their children will affect the attainment of the level of education, social skills and overall development of the child. the purpose of this study was to determine the effect of parenting style on the personal social development of preschool children. the method used in this research is descriptive correlation method and cross-sectional approach. the respondents of this study were 39 parents who have preschool children aged 3-5 years in dukhan qatar. sampling was taken by total sampling. the results showed that the parenting style of preschoolers affected the personal social development of preschoolers (p = 0.028). it is recommended that parents of preschool-age children provide more encouragement to their children in terms of independence and socializing with the environment. introduction childhood is a very important period because during this period a person's personality and attitudes are being formed. during this period the child shows the ability to move more activities, develop curiosity, and explore the surrounding environment.1,2 the ability for wider social interaction and self-concept has also begun during this period.3 optimal growth and development can be achieved if there is the interaction between children, parents and the surrounding environment where children interact socially.4,5 children's social development is the stage of a child's ability to behave following environmental expectations.2 one of the parameters of child development is social personality (social personality) which is related to the ability to be independent, socialize and interact with the environment.6 parenting style is a combination of several elements that create a climate or emotional atmosphere in which parents communicate their attitudes towards their children.7 at preschool age, parenting patterns have more influence on children's ability to carry out activities and understanding of lessons.8 the results also state that the type of parenting style of parents towards their children will affect the attainment of education level, social skills and overall development of children.9 parenting styles are classified into three types, namely: https://doi.org/10.26714/seanr.2.2.2020.70-73 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.2.2020.70-73&domain=pdf&date_stamp=2020-06-30 south east asia nursing research, vol 2 no 2, june 2020/ page 70-73 71 sholahudin ghozali / the influence of parenting patterns on the personal social development of preschool children authoritarian, authoritative and permissive.10 qatar society is very heterogeneous from various ethnic groups. each of them has its own rules and culture. therefore they will influence the adaptation process and social development of children.11 based on the results of the preliminary study, it is known that in the dukhan area 10 children aged 3– 4 years 4 are less independent in terms of socializing with their surroundings. like they still have to be watched by their parents to play with their playmates. the results of an interview with a teacher at dukhan english school showed that some of the children in the nursery did not want to play together with classmates of different ethnicities. this may be due to a lack of encouragement or parenting styles from parents in terms of socializing with new environments. the purpose of this study was to determine the effect of parenting style on the personal social development of preschool children. methods this research has used a descriptive quantitative design. this study describes the parenting style and personal-social development of pre-school children. the approach that has been taken is a crosssectional approach. measurement of children's upbringing and social personal development is measured at the same time. the respondents of this research are parents who have pre-school age children. the inclusion criteria for research respondents included: residents of dukhan and having children aged 3–5 years. research respondents totalled 39 people. the sampling technique that has been used is a total sampling. this research was conducted in the city of dukhan, qatar for one month starting from january 20, 2020, to february 20, 2020. the research was conducted by visiting the homes of each of the research respondents. the instrument that has been used for data collection is a questionnaire. the questionnaire on indicators of parenting style has been adapted from instruments developed by robinson, mandleco, olsen, and hart. the instrument to determine children's development is the denver development screening test version ii (ddst ii). researchers have provided explanations to the research respondents before collecting data. the explanation contains the objectives, benefits, and consequences that must be carried out during the research. the involvement of research respondents was voluntary and without coercion from the researcher. after the respondent agreed, he was asked to sign an informed consent sheet. researchers have given rewards to respondents in the form of souvenirs. researchers maintain the confidentiality of research subjects by not including the respondent's name on the research report. the data from the research results were analyzed using the chi-square test and fisher's exact test to determine the influence of parenting styles on children's social development. results the results showed that the mean age of the respondents was 37.44 years with a standard deviation of 4.42. the youngest was 26 years old, while the oldest was 48 years old. the education level of the most respondents is diploma level as many as 15 people (38.5%), the remaining 14 respondents have a bachelor degree (35.9%) and at least 10 people have high school education (25.6%). the average length of a marriage of respondents' parents with pre-school children in dukhan qatar is 10.03 years with a standard deviation of south east asia nursing research, vol 2 no 2, june 2020/ page 70-73 72 sholahudin ghozali / the influence of parenting patterns on the personal social development of preschool children 4.094. the longest marriage is 20 years, while the fastest is 4 years. the results of research on the type of parenting style of indonesian preschoolaged parents in dukhan qatar, it is known that most of the respondents have authoritative parenting types, namely 37 respondents (94.9%). the study also showed that only 2 respondents had the permissive parenting type (5.1%) and there were no respondents who had the authoritarian parenting type. the results of the study on children's personal social development showed that there were 32 children (82.1%) whose social personal development was normal, and only 7 children (17.9%) had less social personal development. the results of the bivariate analysis in this study showed that as many as 2 parents (4.4%), with the permissive parenting type, had children with less social personal development. as 32 parents (82.1%) with authoritative parenting type had children with normal social personal development. table 1 the relationship between parenting style and children's personal social development indicators children's personal social development coefficient (95% ci) p less pass f % f % parenting patterns 0.135 (0.060-0.305) 0.028 permissive 2 4.4 0 0 authoritative 5 13.5 32 82.1 discussion the results showed that there was a significant effect of parenting styles on the personal social development of pre-school children. the results of this study are supported by the results of other studies that the type of parenting style of parents towards their children will affect the attainment of education level, social skills and overall development of children. this study also shows that few parents with the permissive parenting type have children with less social personal development. and more parents with the authoritative parenting type have children with normal social personal development. this result is different from previous research which explains that authoritative parenting style is not related to pre-school prosocial behavior.12 this shows that authoritative parenting is good parenting. this type of parenting, parents try to direct their children rationally and appreciate communication that gives and takes each other and directs the child to be independent so that it will help the child's personal social development in a positive direction. meanwhile, permissive parenting parents tend to allow children to regulate their own activities, do not control and are not trained to be responsible, even though preschoolers should be introduced to good and bad norms so that if parents allow children too much it will affect personal social development in a negative direction.10 parents who use authoritative parenting have higher emotional regulation than parents who use permissive parenting.13 the results of other studies have shown that parenting styles for tau people can affect children's mental health and self-esteem.14 the results of other studies show that authoritative parenting is able to enhance one's personal growth initiatives.15 another study suggests that the most beneficial parents (with authoritative parenting) are people high in extraversion, openness to experience, and awareness, and low in neuroticism.16 good parenting can affect a child's ability to communicate with others.17 south east asia nursing research, vol 2 no 2, june 2020/ page 70-73 73 sholahudin ghozali / the influence of parenting patterns on the personal social development of preschool children conclusion parents' parenting influences the personal social development of pre-school children in dukhan qatar. authoritative parenting styles are better at stimulating pre-school children's personal social development. researchers suggest especially for the indonesian people in qatar dukhan to be able to use proper parenting in caring for children, one of which is by implementing autoritative parenting to optimize children's social development. in addition, it is hoped that parents will give more encouragement to preschool children in terms of independence and socializing with a multinationality environment by participating in community activities that involve the entire community of dukhan residents. acknowledgments we would like to thank all respondents who were willing to be involved in this research. and to all those who have helped complete this research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. wilson mhcrd. wong’s essentials of pediatric nursing. tenth edit. elsevier health sciences; 2016. 2. little sg, swangler j, akin-little a. defining social skills. in: handbook of social behavior and skills in children. springer; 2017:9-17. 3. meadow kp. deafness and child development. university of california press; 2020. 4. maleki m, chehrzad mm, kazemnezhad leyli e, mardani a, vaismoradi m. social skills in preschool children from teachers’ perspectives. children. 2019;6(5):64. 5. maleki m, mardani a, mitra chehrzad m, dianatinasab m, vaismoradi m. social skills in children at home and in preschool. behav sci (basel). 2019;9(7):74. 6. legkauskas v, magelinskaite-legkauskiene s. importance of social competence at the start of elementary school for adjustment indicators a year later. issues educ res. 2019;29(4):12621276. 7. elliott l, bachman hj. how do parents foster young children’s math skills? child dev perspect. 2018;12(1):16-21. 8. ling j, robbins lb, wen f, zhang n. lifestyle interventions in preschool children: a metaanalysis of effectiveness. am j prev med. 2017;53(1):102-112. 9. garcia of, serra e. raising children with poor school performance: parenting styles and short-and long-term consequences for adolescent and adult development. int j environ res public health. 2019;16(7):1089. 10. kuppens s, ceulemans e. parenting styles: a closer look at a well-known concept. j child fam stud. 2019;28(1):168-181. 11. strand ps, vossen jj, savage e. culture and child attachment patterns: a behavioral systems synthesis. perspect behav sci. 2019;42(4):835850. 12. arifiyanti n. relationship between authoritative parenting style and preschools prosocial behavior. j obs j pendidik anak usia dini. 2019;3(2):311-319. 13. bahrami b, dolatshahi b, pourshahbaz a, mohammadkhani p. parenting style and emotion regulation in mothers of preschool children. pract clin psychol. 2018;6(1):3-8. 14. singh s. parenting style in relation to children’s mental health and self-esteem: a review of literature. indian j heal wellbeing. 2017;8(12). 15. hirata h, kamakura t. the effects of parenting styles on each personal growth initiative and self-esteem among japanese university students. int j adolesc youth. 2018;23(3):325333. 16. bahrami b, dolatshahi b, pourshahbaz a, mohammadkhani p. comparison of personality among mothers with different parenting styles. iran j psychiatry. 2018;13(3):200. 17. bingham ge, jeon h, kwon k, lim c. parenting styles and home literacy opportunities: associations with children’s oral language skills. infant child dev. 2017;26(5):e2020. analysis of nursing documentation implementation in outpatient room corresponding author: muhamad nurudin mbrodin731@gmail.com south east asia nursing research, vol 2 no 2, june 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.2.2020.25-30 case study analysis of nursing documentation implementation in outpatient room muhamad nurudin1, vivi yosafianti pohan2, tri hartiti3 1,2,3 master of nursing program, universitas muhammadiyah semarang, indonesia article info abstract article history: accepted june 27th, 2020 keywords: nursing care; documentation; outpatient care the quality of nursing care is a key element of service quality in hospitals. to realize good quality nursing service and quality in the outpatient institution, qualified human resources are also needed and good nursing management skills are needed from a manager or head of the service unit. for the implementation of nursing care documentation in outpatient installations to be carried out optimally, it is necessary to carry out management activities in the form of supervision by carrying out nursing support activities in stages. the purpose of this analysis is to determine the implementation of outpatient nursing medical record documentation. the use of action methods in this analysis aims to develop new skills or new approaches and be applied directly and reviewed the results. from the results of the assessment found several nursing management problems and the priority is the completeness of outpatient nursing medical record documentation which is still low. the action taken is by providing refresher activities or material refreshing on nursing documentation, initial assessment of outpatients, simulations of filling out initial outpatient assessment documentation, making and disseminating supervision forms and techniques for tiered supervision using the supervision form. the activity was attended by 23 participants consisting of the head of the room, the team leader and the nurse executing from the polyclinic or outpatient installation. evaluation after carrying out activities on the completeness of outpatient nursing medical record documentation was 70% (14 of 20 samples). introduction a hospital is a form of a health service organization that provides comprehensive health services covering promotional, preventive, curative, and rehabilitative aspects for all levels of society. to maintain and improve the quality of service, one aspect that needs attention is the quality of nursing services. nursing as a form of professional service is an integral part that cannot be separated from the overall health service effort. nursing is the backbone in a health facility because the proportion of nurses is the majority compared to other health workers and it determines the picture of the quality of health services. this is supported by seeing the proportion of nursing personnel, the time nurses interact fully for 24 hours with patients, and will be one of the determining factors for the good and bad quality and image of the hospital.1 https://doi.org/10.26714/seanr.2.2.2020.25-30 south east asia nursing research, vol 2 no 2, june 2020/ page 25-30 26 muhamad nurudin / analysis of nursing documentation implementation in outpatient room good nursing care management is needed in providing nursing care to clients in a systematic and organized manner. nursing care management is a resource arrangement in carrying out nursing activities by using the nursing process method to meet client needs or solve client problems.2 nursing care management is indispensable in providing nursing services to patients. the management of care carried out by a nursing manager has the strongest influence on the sustainability of nursing in health services 3. the management process starts with planning, organizing, personnel, directing, and controlling human resource factors, finance, materials, methods, and facilities.3 manager nursing will affect the performance of nursing staff, create a conducive work environment, and will have an impact on patient safety, organizational sustainability, and quality. nursing care.1 nurses in carrying out their services use the nursing care approach which aims to improve the health status of patients and families and provide professional care. nursing care is a process or series of activities in nursing practice that is directly provided to clients in various health service settings, to fulfil human basic needs (kdm), by using the nursing process methodology and guided by nursing standards, based on the code of ethics and nursing ethics, within the scope of authority and responsibility of nursing.4 in providing nursing care, nurses use a nursing process with five stages because by using the nursing process, care becomes comprehensive. the nursing process is a systematic method for assessing, diagnosing, planning, implementing and evaluating the condition of the patient in a healthy or sick condition so that it becomes the basis for scientific breakdown, and becomes the basis for nursing practice.5 the nursing process is a systematic problem-solving approach in providing nursing care. the nursing process is a guide for providing professional nursing care, for individuals, groups, families and communities.6 nursing documentation is a record that contains all the data needed to determine nursing diagnoses, nursing planning, nursing actions, and nursing assessments that are systematically compiled, valid, and can be accounted for morally and legally.7 nursing documentation is very important for nurses, documentation is part of the nurse's overall responsibility for patient care. clinical records facilitate the generosity of services provided to patients and help coordinate the treatment and evaluation of patients.7 nursing documentation must meet the requirements: fact-based, accurate, concise, complete, organized, timeliness, and easy to read. the benefits of completing nursing documentation for nurses and clients include communication tools, accountability mechanisms, data collection methods, nursing service facilities, evaluation facilities, means of enhancing cooperation between health teams, continuing education facilities and used as audits of nursing services.8 roemani muhammadiyah hospital is a private hospital that was founded in 1975. roemani muhammadiyah hospital seeks to improve service quality by following the snars 1.0 accreditation standard roemani muhammadiyah hospital seeks to improve service quality following the hospital's vision and mission by optimizing existing facilities for good care inpatient and outpatient. outpatient services at roemani muhammadiyah hospital are services provided to patients with cases that can still be handled without requiring inpatient care and post-treatment patient services as a control of the progress of healing for the disease suffered by these patients. south east asia nursing research, vol 2 no 2, june 2020/ page 25-30 27 muhamad nurudin / analysis of nursing documentation implementation in outpatient room outpatient care is a part of hospital services with short service delivery, which is about 15 minutes per patient on average. the average outpatient visits at roemani muhammadiyah hospital are 600 patients per day with various specialist medical services as well as subspecialists. to provide quality nursing services, roemani muhammadiyah hospital is in the form of carrying out service processes following predetermined standards, one of which is the implementation of nursing care documentation on outpatients. the results of the initial assessment showed that the completeness of outpatient nursing medical record documentation was still low, namely 45%, the tiered nursing supervision activities on the implementation of nursing documentation were not optimal, were still situational and there was also no documentation of the results of supervision. the purpose of this analysis is to determine the implementation of outpatient nursing medical record documentation. methods the method used is the action method, which is a method that aims to develop new skills or new approaches and is applied directly and the results are reviewed. where this analysis is prepared based on the assessment of 8 nursing management functions, namely the function of organizing, personnel, directing, monitoring, care management, logistics management, quality assurance programs and patient safety. the results of the assessment in an outpatient installation based on the 8 nursing management functions found 3 problems, namely: completeness of record documentation medical outpatient care which is still low, the implementation of tiered nursing supervision is not optimal, the implementation of patient or family education is not optimal. of the 3 problems above, a priority order of problems was carried out according to the hanlon theory and agreement with the head of the outpatient polyclinic room, namely the problem of completing outpatient nursing medical record documentation is still low. from this problem then the action is taken by holding activities to provide refresher or refreshing of material on nursing documentation, initial assessment of outpatients, simulations of filling out initial outpatient assessment documentation, making and disseminating supervision forms and techniques for conducting tiered supervision using the supervision form organized. on december 10, 2020. the activity was attended by 23 participants consisting of the head of the room, the team leader and implementing nurses from the polyclinic or outpatient installation. after the activity was evaluated on december 18, 2020, of the implementation of outpatient nursing medical record documentation and the results obtained from 20 samples of outpatient medical records, there were 14 (70%) medical records whose documentation was filled. results the results of the assessment in the outpatient installation based on the 8 nursing management functions found 3 problems, namely: first is the completeness of outpatient nursing medical record documentation which is still low (45%), second is the implementation of tiered nursing supervision is not optimal and the third is the implementation of education. patient or family is not optimal (43%). of the 3 problems above, a priority order of problems was carried out according to the hanlon theory and agreement with the head of the outpatient polyclinic room, namely the problem of completing outpatient nursing medical record documentation is still low. from this problem then action is taken by holding activities to provide refresher or refreshing of material on nursing documentation, initial assessment of outpatients, simulations of filling out initial outpatient assessment documentation, making and disseminating supervision forms and south east asia nursing research, vol 2 no 2, june 2020/ page 25-30 28 muhamad nurudin / analysis of nursing documentation implementation in outpatient room techniques for conducting tiered supervision using the supervision form organized. on december 10, 2020. the activity was attended by 23 participants consisting of the head of the room, the team leader and implementing nurses from the polyclinic or outpatient installation. after the activity was carried out an evaluation on december 18, 2020 of the implementation of outpatient nursing medical record documentation and the results obtained from 20 samples of outpatient medical records, there were 14 (70%) medical records whose documentation was completely filled. thus the documentation of outpatient nursing medical records experienced a significant increase after being given a refresher on the material related to nursing documentation, patient assessment and monitoring through nursing supervision activities. discussion nursing documentation is a record that contains all the data needed to determine nursing diagnoses, nursing planning, nursing actions, and nursing assessments that are systematically compiled, valid, and can be accounted for morally and legally7. nursing documentation is a series of activities carried out by nurses starting from the assessment process, nursing diagnosis, action plans, nursing actions, and evaluations which are recorded either electronically or manually and can be accounted for by the nurse. the results of observations made by students who practice application during the implementation stage, during the initial assessment of outpatients at the outpatient clinic of the roemani muhammadiyah hospital, obtained data that the implementing nurse had done complete documentation during the initial assessment of the patient. outpatient care, the executive nurse records the coverage of the amount of documentation that has been done into the document supervision implementation form. the results of observations made also obtained data that the orphans were able to carry out the task of supervising the nurse executing on the initial assessment documentation of outpatients, the orphans were able to validate the completeness of the initial outpatient assessment documentation through e'rm and the orphans were able to record or document the validation results into the form / instrument to supervise the completeness of outpatient initial assessment documents. the data from the next observation is that the head of the room is able to carry out supervisory duties to the staff / supervisor and also the head of the room is able to validate results of supervision activities from orphans / supervisors. based on the results of the evaluation on 18 december 2020 the completeness of outpatient nursing medical record documentation after implementation was 70% (14 out of 20 samples). the results of mursida9 research conducted at the h. hanafie muara bungo regional hospital, showed that most of the nurses (60%) stated that the leadership was not effective and the nurses (40%) stated that the leadership was effective. some of the nurses (50.1%) stated that supervision was ineffective and as much as (42.9%) indicated that supervision was effective. some of the nurse administrators (54%) had poor performance in documenting nursing care and as many (45.7%) had a good performance in documenting nursing care. the results of bivariate analysis were obtained (p value <0.05), thus it can be concluded that there is a significant relationship between leadership and supervision with the performance of nurses in documenting nursing care. andriani10 research results showed the results of a survey on 20 march 2016 in the internal, surgical, and child inpatient room south east asia nursing research, vol 2 no 2, june 2020/ page 25-30 29 muhamad nurudin / analysis of nursing documentation implementation in outpatient room at rsi ibnu sina bukittinggi for 10 documenting physical examinations only filled with 3 documentation, the diagnoses written from the time the patient entered until returned only used 1 diagnosis. and filling out the intervention was only filled in 2 documentation. the results of the analysis showed that more than half (53.3%) of the head of the room carried out the supervision and documentation which was done completely and incompletely, the same amount (50%) was carried out by the executive nurse. the results of bivariate analysis with chi-square were obtained (p = 0.021), it can be concluded that there is a relationship between the supervision of the head of the room and the documentation of nursing care in the inpatient room of rsi ibnu sina bukittinggi. the implementation of medical record documentation during the initial outpatient assessment at the polyclinic / outpatient installation of the roemani muhammadiyah hospital was carried out according to standards. nurses already understand the importance of completing medical record documents after being given refresher material about nursing documentation, initial assessment of outpatients, simulating filling out initial outpatient assessments through e'rm and techniques for supplying completeness of medical record documentation. the head of the room and the team leader understand and are able to conduct supervision in stages after being given technical material perform tiered supervision of the completeness of medical record documentation. conclusion the results of the evaluation of the implementation of the provision of material refreshes on nursing documentation, the initial assessment of outpatients, simulations of filling out the initial assessment of outpatients, the implementation of tiered supervision using the supervision form gave positive effects and results in the implementation of outpatient nursing medical record documentation. the results of the evaluation obtained data from 20 samples of outpatient initial assessment medical records, 14 medical records (70%) were completely filled in. when compared before the intervention, the completeness of outpatient nursing medical records was only 45%, so this result has a significant increase. completeness of documenting medical records requires support from all caregiving professionals (ppa) in hospitals including nurses. good management is needed in an effort to get professional and quality patient care, including through complete and quality medical record documentation. acknowledgments our thanks go to 1) dr. vivi yosafianti p, m.kep as the academic supervisor of the master of nursing in the practical application of kmk ii, 2) ns. bekti rahayu, m. kep as the clinical supervisor, 3) ns. suryati, s.kep as head of the outpatient polyclinic room, 4) all nurses in the outpatient installation of roemani muhammadiyah semarang hospital. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. zendrato mv, sri hariyati rt. optimalisasi pengelolaan asuhan keperawatan di instalasi rawat jalan rumah sakit x. j persat perawat nas indones. 2018;2(2):85. doi:10.32419/jppni.v2i2.86 2. keliat ba. manajemen keperawatan. egc. 3. marquis bl. kepemimpinan dan manajemen keperawatan. egc; 2010. 4. bidang organisasi pp-, ppni. standar praktik persatuan perawat nasional indonesia (ppni). ppni. 2010;(15):1-65. south east asia nursing research, vol 2 no 2, june 2020/ page 25-30 30 muhamad nurudin / analysis of nursing documentation implementation in outpatient room 5. nursalam. manajemen keperawatan aplikasi dalam praktik keperawatan profesional edisi 4. 4th ed. salemba medika; 2014. 6. mugiarti s. manajemen dan kepemimpinan dalam praktek keperawatan.; 2017. 7. yustiana. dokumentasi keperawatan. vol 66. pusdik sdm kesehatan; 2012. 8. andri f, indra r, susmarini d. analisis faktor faktor yang mempengaruhi perawat dalam memenuhi kelengkapan dokumentasi keperawatan di igd rumah sakit wilayah pontianak kalimantan barat. j med respati. 2015;x:49-60. 9. dewi m, zestin r. hubungan kepemimpinan dan supervisi dengan kinerja perawat pelaksana dalam pendokumentasian asuhan keperawatan. manag keperawatan. 2014;2 no.1:13-21. 10. jaune l. hubungan gaya kepemimpinan kepala ruang dengan kinerja perawat pelaksana di instalasi rawat inap a dan c rumah sakit stroke nasional kota bukittinggi. 2020;6(parcelle 1):13. monitoring analysis of filling the informed consent of blood transfusion corresponding author: ati rusyda ruhana rusydaruhana@gmail.com south east asia nursing research, vol 3 no 1, march 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.1.2021.40-44 case study monitoring analysis of filling the informed consent of blood transfusion ati rusyda ruhana1,2, vivi yosafianti pohan2, tri hartiti2 1 master of nursing, universitas muhammadiyah semarang, indonesia 2 universitas muhammadiyah semarang, indonesia article info abstract article history: submit jan 23rd, 2021 accepted march 20th, 2021 published march 28th 2021 keywords: informed consent; monitoring; documentation informed consent is evidence of the accountability of health service providers in the hospital. it is carried out in every carrying out the procedure of actions that have the risk of causing disability or death. incomplete documentation of patient informed consent can reduce the quality of hospital services. the implementation of informed consent documentation in hospitals often faces obstacles. this is due to the lack of human resources and the high workload available. this case study aims to determine the filling of informed consent documentation in the patient's blood transfusion. this study uses interviews, observation and document study by developing approaches to the nursing management function, organizing functions, personnel, direction, supervision, care management, logistics management, quality assurance programs and patient safety. the results showed that in one month there were 20 patients with blood transfusions, and 11 out of 20 patients did not have informed consent. the problem that arises is the incomplete documentation of medical records at the time of carrying out blood transfusions to patients. supervision that is not optimal is the cause of this problem. introduction hospital is a health service unit of the health service system and is a strategic element seen from the context of the number of costs incurred, where most of the health funds are absorbed in the hospital management sector, both in developed and developing countries. medical and care services are a subsystem of the existing service system in the hospital. the form of service provided is adjusted to the patient's condition so that it is more individual.1 public demand for the quality of nursing services in hospitals is felt as a phenomenon that must be responded to by nurses. therefore, this nursing service needs to be given top priority in future development. nurses must be willing to develop their knowledge and change according to the demands of society and become professional nurses. development in various aspects of nursing is interconnected, interdependent, influencing and having mutual interest. therefore, innovations in nursing education, nursing practice, nursing science and professional life are the main focus of indonesian nursing in the professional process. the professionalization process is a process of recognizing something that is https://doi.org/10.26714/seanr.3.1.2021.40-44 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.1.2021.40-44&domain=pdf&date_stamp=2021-03-28 south east asia nursing research, vol 3 no 1, march 2021/ page 40-44 41 ati rusyda ruhana / monitoring analysis of filling the informed consent of blood transfusion felt, assessed and accepted spontaneously by the community, so it is required to develop itself in the health service system. because of the reasons above, nursing services must be managed professionally, therefore it is necessary to have nursing management.2 management is a dynamic and proactive approach in carrying out an organizational activity. meanwhile, nursing management is the process of working through members of the nursing staff to provide professional nursing care. the nursing management process is in line with the nursing process as a method of implementing nursing care professionally so that it is hoped that both of them will support each other. as happens in the nursing process, nursing management also consists of data collection, problem identification, planning, implementation and evaluation of results. because nursing management is specific to the majority of an employee, each stage in the management process is more complicated than the nursing process. nursing management must be applicable in real service settings in the hospital so that nurses need to understand how the concept and application are in the nursing organization itself.3 from the results of observations carried out for one week, starting from november 24 to december 1, it was found that in 1 month there were 20 patients with blood transfusions, 9 patients had complete informed consent, while 11 patients had no informed consent. from the results of the interview with the head of team, it was found that, for information, the information had been given to the patient orally, but often forgot to write down the patient's medical record, because there were too many actions to be done while the nursing staff was limited. this can be seen from the records of the patient's status with the action of giving blood transfusions where there was no agreement sheet for giving blood transfusions as much as 55%. from this, students concluded that the patient's completeness of informed consent was incomplete, this could reduce the quality of the hospital. methods this study has used a descriptive study design. the variable that has been researched in this case study is the documentation of informed consent by the nurse. the approach that has been used in this study is a case study. the subject of this case study is a nurse who performs blood transfusion therapy for patients. the subject of this study was taken using the total sampling method. this study was conducted in the baitussalam room of the sultan agung islamic hospital, semarang. measurement of study variables that have been carried out are: observation, interviews, and study documentation. observations have been carried out on nurses who are carrying out blood transfusions to patients. interviews have been conducted directly to the nurse after completing the action. documentation studies were carried out by looking at the patient's medical record documents. all study subjects have expressed their consent and have signed a consent form to be the subject of this study. the researcher did not include the identity of the study subject. researchers guarantee that the data that has been collected will not affect the work performance assessment of the subject of this study. results the results of the study have shown that there are 4 out of 8 implementation of the nursing management function. some of these problems include: 1. informed consent for blood transfusion was not included in the patient's medical record. south east asia nursing research, vol 3 no 1, march 2021/ page 40-44 42 ati rusyda ruhana / monitoring analysis of filling the informed consent of blood transfusion 2. supervision of the completeness of patient medical records is not optimal, especially in monitoring the completeness of blood transfusion informed consent documents. 3. the number of nurses is still limited 4. there are still many nurses who have a nursing diploma level. based on these problems, it can be concluded that the problem has been prioritized, namely: not optimal monitoring of the completeness of patient medical records. researchers have formulated actions to solve these problems. action taken is to conduct socialization and re-education to nursing supervisors at the hospital. this activity was carried out in december 2020. socialization actions were carried out virtually through virtual meetings. this activity was attended by room leaders and team leaders for the baitussalam room nurse, sultan agung islamic hospital, semarang. the results of the evaluation of the success of these actions indicated that there had been an increase in documentation of informed consent on blood transfusion actions by nurses by 25%. this shows that it is necessary to re-educate the completeness of patient medical records, especially blood transfusion informed consent. discussion based on the results of the study that was carried out in the baitussalam 2 room, there were problems in nursing management, that the evaluation of filling in informed consent in the provision of blood for transfusions was not optimal. informed consent is consent that is given to the patient on the actions to be carried out by doctors and nurses after getting a full description. the implementation of informed consent begins with the doctor planning what actions to give to the patient to what risks the patient will experience. from a legal point of view, documents that are not filled in completely will be weak as evidence, this was expressed by patient in completeness of filling informed consent documents.4 this is as stated in the results of research by sisca adina purnama, namely documents that are not filled in yet cannot fulfil legal aspects and are weak in physical evidence.5 informed consent is also very much needed by patients because patients have the right in their medical information and actions to be taken against them so that it will support decision-making and can build a trusting relationship, this is in line with research conducted by gong n. in gong n's research, states that from the patient's point of view, informed consent that is not conveyed to them is an obstacle to decision making for actions to be carried out on them.6 in the research, n. bowers revealed that a very good and regular explanation during the informed consent process can increase the patient's understanding of the procedure to be performed so that it will be beneficial to the patient and the procedure carried out will run well.7 re-education on informed consent and form filling informed consent was implemented on december 10, 2020, through internet meeting, which was attended by 37 participants, and running smoothly. during the meeting, the participants were very enthusiastic. on 11 december in the conduct interviews with the staff back baitussalam room 2 on informed consent that is the result: staff room baitussalam 2 has been explained by either concerning the action of platelets along with the risks that would be received by the patient. after the interview with the staff, the students checked the patients who needed blood transfusions, with the results: the patient's family and the patient had understood well the explanation given by the nurse and had signed the informed consent form for giving blood for transfusions. in cases that are not south east asia nursing research, vol 3 no 1, march 2021/ page 40-44 43 ati rusyda ruhana / monitoring analysis of filling the informed consent of blood transfusion well documented, it is because at the time of giving the education they are in the patient's ward, while the patient's medical records are in the nurse station so that the signing is often forgotten. in other cases, the family members described were different from the family members who were present at the time of the blood transfusion. yawi sasmita hasibuan's research on the factors that cause incompleteness of filling in informed consent in hospitals, namely: the knowledge of nurses about actions or procedures to be carried out on patients, nurses with good knowledge, so the informed consent is filled in completely 8. in another study conducted by susanto primananda dewangga et al, also mentioned that the factors affecting informed consent of patients are medical information that was conveyed to the patient is not complete, so that patients do not understand what is meant by good.9 nurses play an important role in filling out the informed consent because the one who interacts most with patients is the nurse. for that, a nurse is required to have good knowledge of the procedures and actions that will be given to patients. a nurse is required to be creative and innovative in taking action and providing education to patients. as did n. bowers. in his journal, providing educational procedures to be carried out to patients in the form of multimedia, namely videos. in their research, it was found that 62% of all respondents understood better all procedures than those that were only explained orally.7 barriers to completing informed consent are time, knowledge and coordination between management systems in hospitals or inpatient rooms, this was expressed by sisca adina purnama and sary in a legal perspective: completeness of filling in the informed consent form in the inpatient room.5 pdsa implementation of monitoring completeness informed consent administer blood transfusions in baitussalam space 2, as follows: 1. data analysis of monitoring implementation: not optimal evaluation regarding informed consent for giving blood for transfusion 2. pdsa table 1 planning of action indicators detail plan a. re-education on informed consent b. socialization back on charging informed consent do a. implementation of seminars on informed consent b. evaluation of filling in the informed consent of blood transfusion study a. the staff has a good understanding of informed consent b. the staff understands the importance of documenting informed consent action evaluated the filling of informed consent for giving blood in the baitussalam room 2 the problems that were found during the implementation of the nursing management application in the baitussalam 2 room apart from the inadequate evaluation of informed consent for giving blood for transfusions, namely: lack of need for nursing personnel. implementation: discuss with the head of the room to optimize the existing nursing staff. evaluation: the existing nursing staff can be well optimized. conformity theory: good leadership and good communication will make staff feel more motivated and feel happy to make suggestions for service improvement.10 conclusion the management problem that arose in the baitussalam room rsi sultan agung semarang was the incompleteness of south east asia nursing research, vol 3 no 1, march 2021/ page 40-44 44 ati rusyda ruhana / monitoring analysis of filling the informed consent of blood transfusion documenting informed consent for giving transfused blood. the staff has explained it well and has been understood by the family and patient, but the documentation is still incomplete. after re-educating the informed consent and filling in the informed consent form for giving blood for transfusions, the medical records of patients who need blood transfusions have been filled. from 55% of patients' medical records, there was a significant increase, namely as many as 80% of patients who required complete blood transfusion. this is not apart from the monitor headspace in the completeness of informed consent administer blood transfusions. apart from that, optimizing the nursing staff has gone well. acknowledgments the researchers would like to thank all those who have helped carry out this study. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. depkes. standar tenaga keperawatan di rumah sakit. edisi ke-1. ri dd, editor. direktorat pelayanan medik; 2002. 2. priharjo r. praktek keperawatan profesional : konsep dasar dan hukum. jakarta: egc; 2008. 3. gillies d. nursing management : a system approach. philadhelpia: w.b. saunders; 2004. 4. samino s. kelengkapan pengisian dokumen informed consent di provinsi lampung 2013. j dunia kesmas. 2015;4(1). 5. purnama sa, sary l. perspektif hukum: kelengkapan pengisian formulir informed consent di ruang rawat inap bedah rsud menggala kabupaten tulang bawang provinsi lampung tahun 2014. j dunia kesmas. 2015;4(1). 6. gong n, zhou y, cheng y, chen x, li x, wang x, et al. practice of informed consent in guangdong, china: a qualitative study from the perspective of in-hospital patients. bmj open. 2018 oct;8(10):20658. 7. bowers n, eisenberg n, jaskolka j, roche-nagle g. using a multimedia presentation to improve patient understanding and satisfaction with informed consent for minimally invasive vascular procedures: a pilot study. j vasc surg. 2013 may;57(5):59s-60s. 8. hasibuan as, sasmita d. faktor-faktor penyebab ketidaklengkapan pengisian informed consent di rumah sakit kesrem binjai tahun 2017. jipki. 2017; 9. susanto dp, pratama bs, hariyanto t. analisis faktor -faktor yang mempengaruhi pemahaman pasien terhadap informed consent di rumah sakit. j manaj kesehat indones. 2017 aug;5(2):73–81. 10. fatihah dc, darmawanti n. pengaruh kepemimpinan dan komunikasi terhadap motivasi serta dampaknya pada kinerja perawat di rs amn subang ptpn viii. j e-bis. 2018 jul;2(1):35–52. implementation of the tiered supervision as a supervision function corresponding author: retno wahyu nugrahini retnowahyu2408@gmail.com south east asia nursing research, vol 2 no 1, march 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.1.2020.33-39 case study implementation of the tiered supervision as a supervision function retno wahyu nugrahini1,2, vivi yosafianti pohan2 1 rumah sakit islam sultan agung semarang, indonesia 2 universitas muhammadiyah semarang, indonesia article info abstract article history: accepted march 4th, 2020 keywords: nursing supervision; nursing management; supervision function tiered supervision that supports improving the quality of nursing services in the field of nursing at sultan agung islamic hospital has not been carried out in a structured and documented manner. baitul izzah 1 room as a disease treatment room in class iii, the head of the room has not yet supervised the person in charge of care (ppja) and so on ppja to the associate nurse (pp). the supervision that has been carried out so far is only to ask directly about existing problems to the head of the room and directly observe the activities of implementing nursing care by ppja and pp. tiered supervision does not go well, because there are no references and standards for its implementation. the purpose of this study was to determine implementation of the tiered supervision as a supervision function. it was found that the implementation of tiered supervision instruments improved the performance of the head of the room, ppja and pp, then the patient's medical record document increases in completeness chargingespecially the patient's islamic education document. in conclusion, tiered supervision instruments are very helpful in the implementation of the supervisory function as well as monitoring and evaluation in nursing management in the implementation of nursing care in the inpatient room. the recommendation for the role of the nursing field that is most important in controlling the quality of nursing care is to actively involve staff to jointly ensure the continuity of the implementation of tiered nursing supervision. introduction nursing management is a process of planning, organizing, managing staff, directing, supervising and controlling each other. the role of the nursing manager cannot be separated from the management process carried out, including applying attention to material resources and nursing human resources. the role of the manager that is actually applied is able to bring transformation for other nursing staff to apply nursing quality standards. standards are set to measure the performance of objective, measurable and achievable nursing care and services.1 the nursing management process is carried out with an open systems approach, where each component is interconnected, which includes input, process, output, control and feedback. nursing managers are required to plan (plan), organize (organize), lead and evaluate (evaluate) the facilities and infrastructure available to be able to provide nursing care that is as effective and https://doi.org/10.26714/seanr.2.1.2020.33-39 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.1.2020.33-39&domain=pdf&date_stamp=2020-03-31 south east asia nursing research, vol 2 no 1, march 2020/ page 33-39 34 retno wahyu nugrahini / implementation of the tiered supervision as a supervision function efficient as possible for individuals, families and communities.2 supervision or controling is the application of methods and tools to ensure that the plan has been implemented according to what has been determined. supervision through communication, namely supervising and communicating directly with the team leader and executor regarding the nursing care provided to patients. supervision in nursing management through supervision with direct and indirect supervision. nursing supervision is a supervision and guidance activity carried out continuously by supervisors covering nursing service problems, manpower and equipment problems so that patients receive quality service at all times.3 supervision or controling is the application of methods and tools to ensure that the plan has been implemented according to what has been determined. supervision through communication, namely supervising and communicating directly with the team leader and executor regarding the nursing care provided to patients. supervision in nursing management through supervision with direct and indirect supervision. tiered nursing supervision at sultan agung islamic hospital in semarang has not been implemented. the head of the nursing department carries out supervision of the head of the room in completing his duties, only asking things that have problems in the treatment room. the head of the room in monitoring and evaluating ppja's duties in providing nursing care to patients does not have standardized tools or references, as well as ppja evaluating ppja is not well documented. the absence of supervision through supervision from nursing management, the head of the room and ppja in a documented and structured manner so that the evaluation cannot be carried out continuously because there are no records used as evaluation material. the supervision instrument as a reference in the implementation of tiered supervision as a form of supervision activities, if it is carried out and documented in a structured manner and there is a clear supervision assessment format, the supervisory function will run smoothly. the assessment format is the nurse's performance record for further improvement and the supervised nurse will also have a performance record as material for self-evaluation. thus it will be easy to make improvement efforts in nursing services. however, if the supervision activities are not carried out in a structured and well-documented manner and there is no evaluation format for standard supervision, then the form of evaluation that is carried out cannot be carried out continuously because there are no notes used as material for a structured evaluation.4 the purpose of this research is to find out the extent of the supervisory function of nursing management through tiered supervision, providing solutions by making supervision instruments and evaluating the implementation of supervision instruments at sultan agung islamic hospital semarang. increased supervision by the head of the room, the nursing committee, and the nursing department needs to be improved, by means of an organizational structure approach in order to motivate the performance of the nurse executing.5 the importance of clinical supervision apart from managerial supervision is therefore, that an effective clinical surveillance support system is strengthened to support managerial supervision.6 the purpose of this study was to determine implementation of the tiered supervision as a supervision function. methods south east asia nursing research, vol 2 no 1, march 2020/ page 33-39 35 retno wahyu nugrahini / implementation of the tiered supervision as a supervision function the research design uses descriptive qualitative methods, namely the research method is basically a scientific way to obtain data with specific purposes and uses as well as to determine how to find, collect, process and analyze research data.7 the method was chosen to obtain natural data about the understanding of the supervisory function through tiered supervision and its implementation using the supervision instrument through interviews. results assessment according to the priority of the problem in the baitu izzah 1 room obtained 2 (two) problems, namely: the frequency of islamic education with the number of 96, and the number of 256 tiered nursing supervision activities that have not been implemented. tiered. tiered supervision activities have not been carried out because there is no reference for implementation, so that the completion of routine work has no target. supervision is a coaching activity that is planned to assist nursing personnel in doing their job effectively.8 the intervention was carried out by conducting socialization on nursing supervision, making supervision instruments, and making supervision of standard operating procedures (sop). socialization about supervision material with focus group discussion (fgd), socialization carried out directly to the head of nursing, head of department of education, ppja and pp continued with the implementation of supervision instruments on december 9, 2020. tiered supervision instruments can be implemented properly from the field of nursing, head of department and ppja well .. group clinical supervision as an intervention to support nurse resilience in the hospital as a recommendation for practice, to improve development through clinical supervision.9 evaluation of the implementation of tiered supervision instruments by conducting interviews and observations to three participants, namely the head of nursing, the head of the room and the ppja. …. with the supervision instrument it makes it easier for me to monitor the memnitor of the head of the room… ”(p1) …. this supervision instrument turned out to make it easier to complete supervisory tasks for ppja and my duties as head of the room .. (p2) … .after there are supervision instruments, all of which become my job as ppja to monitor and evaluate pp in providing nursing care to be better and more directed… .. (p3) observations are made by looking at the filling of the supervsisi instrument. the supervision instruments are well implemented and fully stocked. clinical nursing supervision has an influence on nurses' experiences of well-being and in relation to their psychosocial work environment. nurses attending clinical nursing supervision reported increased satisfaction with their psychosocial work environment.10 discussion the supervisory function will run well with the implementation of supervision. tiered supervision is carried out as an effort to observe and monitor the implementation of nursing management or the provision of nursing care on an ongoing basis including nursing service problems, workforce problems, and care so that patients receive quality service at all times.2based on the evaluation of the implementation of tiered supervision through the supervsisi instrument, the performance of the head of the room, ppja and pp is different from the previous one which was seen only providing routine nursing care. supervision of the head of the room has a positive and significant effect on nurse performance. this means that the better the supervision of the head of the room, the nurse's performance will increase. conversely, the south east asia nursing research, vol 2 no 1, march 2020/ page 33-39 36 retno wahyu nugrahini / implementation of the tiered supervision as a supervision function less good the supervision of the head of the room, the lower the performance of the nurse. supervision of the head of the room, workload, and motivation simultaneously (together) have a significant effect on the performance of nurses. this means that the better the supervision of the head of the room, workload, and motivation together, the nurse's performance will increase. on the other hand, the supervision of the head of the room is not good.11 completeness of the documentation found in the second priority problem is the islamic education medical record document, with the implementation of supervision, it is hoped that it can be completely filled.existencesupervision by documenting nursing care indicates that the need for supervision action for hospitals that have not implemented supervision and for hospitals that have implemented supervision is expected to further improve the implementation of the supervision. because with this supervision, a nurse will feel that someone is accompanying her and this will have a positive impact on the nurse's own performance.12 the description of the supervision of the head of the room that is perceived by the nurse states and the description of how 53% of the nursing care documents are completely filled. a good head of the room increases the documentation of nursing care so that the head of the room should carry out the supervision properly and schedule to continue to improve the quality of nursing care documents.13 in asmawati's research, yuanita ananda, alkafi (2018), in her research it can be concluded that from 12 nurse respondents before being given supervision, the average development of nursing care documentation was 34.56 with a standard deviation of 4,912. furthermore, it appears that the minimum value of 20 is classified as incomplete documentation and the maximum value of 32 is classified as complete documentation. of the 12 nurse respondents after being given supervision, the average development of documentation of nursing care was 28.38 with a standard deviation of 4.773. furthermore, it can be seen that the minimum value of 21 is classified as complete documentation and the maximum value of 38 is classified as complete documentation. there is a difference in documenting nursing care before and after being given supervision with a p value of 0,000.14 supervision or supervision material is adjusted to the job descriptions of each supervised nursing staff. for the head of the room, supervision material includes managerial skills and nursing care. the team leader is supervised regarding team management skills and the ability to provide nursing care. implementing nurses undergo supervision related to the ability of nursing care carried out. some of the activities that can be supervised by the person in charge of the room / head of the room for the orphans are: a. conducting pre conference and post conference b. implementation of patient consideration c. implementation of nursing assessments d. implementation of nursing diagnoses e. implementation of nursing plans f. implementation of nursing implementation g. implementation of nursing evaluation h. implementation of nursing care documentation i. implementation of universal precautions j. implementation of patient safety k. implementation of case reflection discussions l. implementation of discharge planning m. compliance with spo n. implementation of the nursing round south east asia nursing research, vol 2 no 1, march 2020/ page 33-39 37 retno wahyu nugrahini / implementation of the tiered supervision as a supervision function some of the activities that can be supervised by the orphan of the implementing nurses are: a. implementation of nursing care for patients b. implementation of nursing care documentation c. compliance with spo d. implementation of universal precautions e. implementation of patient safety nursing interventions are oriented towards 14 (fourteen) basic nursing components including: a. meet the needs of oxygen. b. meet the needs of nutrition, fluid and electrolyte balance c. meet the needs of elimination. d. meet security needs. e. meet the needs of cleanliness and physical comfort. f. meet the needs of rest and sleep. g. meet the needs of movement and physical activity. h. meet spiritual needs. i. meet emotional needs. j. meet communication needs k. prevent and overcome physiological reactions. l. meet medical needs and help the healing process. m. meet extension needs. n. meet rehabilitation needs supervision in hospital hospital accreditation is also an element in the assessment, as a basis for monitoring evidence of implementation, namely at access to hospitals and service continuity (ahsc) in access to hospitals and service continuity (ahsc) 3.3, it is stated "if the patient is in the management of the patient service manager (mps), the continuity of the above process is monitored, followed, and the transfer is supervised by the patient service manager (mps)". competence and authority of staff (cas) in staff competency and authority (cas) 5, it is stated that "all staff are supervised and evaluated periodically to ensure continuity of competence in their position". hospital governance (hg). a. in hospital governance (hg) 8.6. stated "the organizational structure can support the control process on the quality of clinical services". b. in hospital governance (hg) 11, it is stated that "the head of the service unit improves the quality and safety of patients by participating in the quality improvement and patient safety program of the hospital, monitoring, and improving specific patient care in his unit. the head of the service unit involves all his staff in quality improvement and patient safety activities that reflect the overall priorities of the hospital and conducts monitoring of clinical and non-clinical activities specific to the service unit ”.15 theory conformity: supervision is a professional process carried out by supervisors through a continuous process of direction, guidance and evaluation to supervisees (supervisory participants) to increase the ability of supervisees in carrying out their work in order to achieve professional service quality and protection of patient safety. nursing management activities will run well and improve service quality by approaching management functions must always be carried out optimally, including planning, organizing, directing, and controlling (monitoring and evaluation). nursing service management focuses on the 5 m components (man, money, material, south east asia nursing research, vol 2 no 1, march 2020/ page 33-39 38 retno wahyu nugrahini / implementation of the tiered supervision as a supervision function method, machine). in every management activity, it always begins with planning and ends with control which is a recurring cycle. conclusion the results of the evaluation of the implementation of the supervision instrument are very helpful in the implementation of tiered supervision in the nursing management of sultan agung islamic hospital semarang. the implementation of nursing leveled supervision is quite effective in increasing the insight in the field of nursing, the head of runag, ppja and pp. a good perception from the head of the room about the importance of nursing clinical supervision is a good initial capital to make changes and improvements in carrying out its functions. this supervisory function requires hospital support in its implementation. the recommended suggestion is that the role of nursing is most important in controlling the quality of nursing care is to actively involve staff to jointly ensure the continuity of the application of nursing leveled supervision. development into an online application is the task of the nursing field. acknowledgments special thanks to dr. ms. vivi yosafianti pohan, m.kep for their guidance and motivation in completing this task. may allah bestow good deeds and blessings. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. julianto m. peran dan fungsi manajemen keperawatan dalam manajemen konflik. fatmawati hosp j. published online 2016:1-7. 2. nursalam. manajemen keperawatan: aplikasi dalam praktik keperawatan profesional. 5th ed. salemba medika; 2015. 3. marquis b, huston c. kepemimpinan dan manajemen keperawatan teori & aplikasi. manag keperawatan. published online 2010. 4. nursalam. manajemen keperawatan aplikasi dalam praktik nursalam. (2011). manajemen keperawatan aplikasi dalam praktik keperawatan profesional edisi 3. salemba medika. https://doi.org/10.1001/archinte.165.22.2659 keperawatan profesional edisi 3. salemba medika. 2011. 5. zahara y, sitorus r, sabri l. faktor-faktor motivasi kerja: supervisi, penghasilan dan hubungan interpersonal. j keperawatan indones. 2011;14(2011):73-82. 6. cutcliffe jr, hyrkäs k. multidisciplinary attitudinal positions regarding clinical supervision: a cross-sectional study. j nurs manag. published online 2006. doi:10.1111/j.1365-2934.2006.00720.x 7. sugiyono. metode penelitian kuantitatif kualitataif dan kombinasi (mixed methods). j chem inf model. published online 2016. 8. cope v, murray m. leadership styles in nursing. nurs stand. published online 2017. doi:10.7748/ns.2017.e10836 9. francis a, bulman c. in what ways might group clinical supervision affect the development of resilience in hospice nurses? int j palliat nurs. published online 2019. doi:10.12968/ijpn.2019.25.8.387 10. bégat i, severinsson e. reflection on how clinical nursing supervision enhances nurses’ experiences of well-being related to their psychosocial work environment. j nurs manag. published online 2006. doi:10.1111/j.13652934.2006.00718.x 11. hastuti at. hubungan persepsi perawat pelaksana tentang kemampuan supervisi kepala ruang dengan kinerja perawat di instalasi rawat inap rumah umum daerah kota semarang. fikkes j keperwatan. published online 2014. 12. publikasi n, studi p, keperawatan i, kedokteran f, tanjungpura u. hubungan supervisi dengan pendokumentasian asuhan keperawatan di ruang rawat inap rumah sakit tk ii kartika husada kubu raya. published online 2017. 13. alidosti m, delaram m, dehgani l, maleki moghadam m. relationship between selfefficacy and burnout among nurses in behbahan city, iran. women’s heal bull. published online 2016. doi:10.17795/whbsouth east asia nursing research, vol 2 no 1, march 2020/ page 33-39 39 retno wahyu nugrahini / implementation of the tiered supervision as a supervision function 30445 14. ananda yuanita, asmawati a, alkafi a. pengaruh supervisi kepala ruangan terhadap pelaksanaan pendokumentasian asuhan keperawatan di ruang rawat inap rsu aisyiyah padang tahun 2018. jikj ilmu kesehat. 2018;2(2):108-112. doi:10.33757/jik.v2i2.125 15. kars. standar nasional akreditasi rumah sakit (snars). 1.1. komisi akreditasi rumah sakit; 2019. the analysis of factors influencing exclusive breastfeeding given by working mothers corresponding author: biyanti dwi winarsih zidanina1706@yahoo.com south east asia nursing research, vol 2 no 3, september 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.3.2020.7-11 original research the analysis of factors influencing exclusive breastfeeding given by working mothers yayuk fatmawati1, biyanti dwi winarsih1, hirza ainin nur2 1 stikes cendekia utama kudus, indonesia 2 akper krida husada kudus, indonesia article info abstract article history: submit july 15th, 2020 accepted sept 5th, 2020 published sept 30th 2020 keywords: breastfeeding; exclusive; working mothers breast milk is a food source for infants with essential nutrition for their health, growth, and development. breast milk has various benefits including preventing children from a variety of conditions that can inhibit their growth and development such as malnutrition. malnutrition is associated with 45% of deaths and illnesses of children. exclusive breastfeeding is considered to be able to help overcome nutritional problems such as stunting and malnutrition. a report from the ministry of health republic of indonesia in 2015 showed that 18.8% of toddlers suffer from malnutrition while 12.7% experience stunting. this study aimed to analyse factors influence breastfeeding given by working mothers. this was a quantitative descriptive study with a cross-sectional approach. the study involved 101 respondents who were working mothers of children aged 7-24 months old. the respondents were selected using questionnaire measurement tools. data analysis used the chi-square test with an alpha value of 0.05. the results show that there was no relationship between knowledge of breastfeeding and exclusive breastfeeding. however, there was a significant relationship between family support and exclusive breastfeeding. good knowledge must be followed by a good attitude and family support, especially from the husband, so that the mother will give exclusive breastfeeding to the baby. introduction the benefits of breast milk should be known by every mother. breast milk is a food source for babies with essential nutrition for the health, growth, and development of infants. the content of breast milk cannot be replaced with any type of baby food since its contents, such as anti-oxidants, some vitamins, and inflammatory agents are very beneficial for babies. moreover, breast milk is a natural food that is easily digested with a balanced nutritional composition1–3. breast milk is not only beneficial for babies but also the mothers. the benefits of breast milk for mothers and babies include preventing some diseases, obesity in children, asthma, allergies, hypertension, and diabetes in children and their mothers, as well as increasing infants’ cognitive abilities.4 who reports that 800,000 toddlers can be saved every year if breastfeeding is given optimally from ages 0-23 months. breast milk has many benefits that can reduce the morbidity and mortality rates of infants and children.5 meanwhile, https://doi.org/10.26714/seanr.2.3.2020.7-11 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.3.2020.7-11&domain=pdf&date_stamp=2020-09-30 south east asia nursing research, vol 2 no 3, september 2020/ page 7-11 8 biyanti dwi winarsih / the analysis of factors influencing exclusive breastfeeding given by working mothers other benefits of breast milk include preventing obesity in children, providing antibodies and emotional closeness between mother and baby to improve the psychomotor development and social abilities of the baby. kudus regency is an industrial regency where there are many industries with a high number of female employees. exclusive breastfeeding for 6 months cannot be given especially from female workers in indonesia due to the company policy where the workers are only given 1 – 3 months of maternity leave. besides, the lack of knowledge regarding the importance of exclusive breastfeeding also influences the decision of the mothers to not give exclusive breastfeeding to their infants. is supported by ignorance about management about the condition and lack of knowledge of the importance of breastfeeding. several studies explain that infants who do not get exclusive breastfeeding will have a lower nutritional status and cognitive function. malnutrition is associated with 45% of deaths and illnesses of children.5,6 exclusive breastfeeding is considered to be able to help overcome nutritional problems such as stunting and malnutrition in toddlers, which also occur in indonesia according to a report from the indonesia ministry of health in 2015.7 research conducted by the millenium challenge account (mca-indonesia) in 10 provinces in 2014 showed that 55 % of mothers in indonesia did not provide exclusive breastfeeding for a variety of reasons. 43 % of mothers still considered breast milk is not enough to provide the nutrition of their children. meanwhile, if not resolved, stunting will have a broad impact on children’s growth and development. stunting is associated with suboptimal intelligence or, from an economic perspective, stunting is also associated with a decrease in productivity of up to 20 %.7 this study aimed to determine the factors that influence exclusive breastfeeding in working women. these factors are analyzed to find a solution to improve the lack of exclusive breastfeeding in working women. methods this was a quantitative descriptive study with a cross-sectional approach, where the cause and effect variables that occurred in the research object were measured and collected simultaneously. this was a quantitative descriptive study with a crosssectional approach. the study involved respondents who were obtained by purposive sampling techniques using a questionnaire consisting of sociodemographic of the mothers (age, education level, and employment status), respondent's level of knowledge, and the support of their spouse. the study involved 101 respondents who were working mothers of children aged 7-24 months old and live in the working area of ngemplak health center. the respondents were selected using questionnaire measurement tools. data analysis used the chi-square test with an alpha value of 0.05. the study was conducted in june 2019. results the result of this study explains respondents characteristics, namely working mothers with children under 2 years consist of the respondent's age, respondent's educational background, respondent's occupation and the age of the last child owned by the respondent. table 1 shows that more than half of respondents aged between 21-30 years as many as 52 respondents (51.4%), age <20 years and age> 40 years is the age with the lowest %age of respondents as much as 2 respondents or 2% and age 31-40 years as many as 45 (44.6%) respondents. the educational background of most respondents was high school education by 40 respondents or 43.6%, elementary school education 38 (37.6%) respondents south east asia nursing research, vol 2 no 3, september 2020/ page 7-11 9 biyanti dwi winarsih / the analysis of factors influencing exclusive breastfeeding given by working mothers and only 18.8% or 19 respondents had a university education. the types of work owned by the most respondents were labourers (44.6%) or 45 respondents and the occupation with the lowest %age was farmers namely 5 (5%) respondents while self-employed and other occupations were 29 respondents or 28.7% and 13 (12.9%), followed with work as teachers as many as 9 (8.9%) respondents. most children’s age of respondents was 13-24 months (55.5%) or as many as 56 respondents and aged 712 months were 45 respondents or 44.5%. table 1 respondents characteristics (n=101) indicators f % age <20 years old 21 – 30 years old 31 – 40 years old > 40 years old 2 52 45 2 2 51.4 44.6 2 educational background elementary school high school university 38 44 19 37.6 43.6 18.8 occupation labor entrepreneur farmer teacher other 45 29 5 9 13 44.6 28.7 5 8.9 12.9 toddler’s age 7 12 months old 13 24 months old 45 56 44.5 55.5 table 2 is a table about exclusive breastfeeding analysis, which was obtained from 101 respondents 52 respondents (51.5%) gave exclusive breastfeeding and 48.5% or 49 respondents did not give exclusive breastfeeding. while the respondent's knowledge about exclusive breastfeeding 96 (95%) of respondents was well-informed and only 5 (5%) of respondents were adequate-informed. most family support that is owned by respondents is enough family support as many as 48 respondents or 46.5%, 44 respondents or 43.5% of respondents get good family support, while a small proportion of respondents namely 9 respondents or 9% have less family support. table 2 exclusive breast feeding analysis (n=101) indicators f % exclusive breastfeeding given not given 52 49 51.5 48.5 knowledge of breastfeeding adequate good 5 96 5 95 family support poor moderate good 9 48 44 9 46.5 43.5 table 3 will explain the analysis of factors that influence exclusive breastfeeding for working mothers, where the results show that the factors that influence exclusive breastfeeding are family support with significant value. while respondents' knowledge about exclusive breastfeeding does not affect exclusive breastfeeding in working mothers with significant values. table 3 influence factors analysis (n=101) indicators exclusive breastfeeding p given not given knowledge of breastfeeding adequate 40% 60% 0.672 good 52.1% 47.9 family support poor 22.2% 77.8% 0.001 moderate 37.5% 62.5% good 72.7% 27.3% discussion the results show that most of the respondent (52.1%) with good knowledge of breastfeeding gave exclusive breastfeeding. the chi-square analysis results obtained a p-value of 0.672 which was higher than α=0.005, meaning there was no significant relationship between the knowledge of breastfeeding with exclusive breastfeeding. the finding is in line with previous research where the results showed that there was no influence of knowledge of breastfeeding and the mothers’ behaviour of giving exclusive breastfeeding in padalangan village, south east asia nursing research, vol 2 no 3, september 2020/ page 7-11 10 biyanti dwi winarsih / the analysis of factors influencing exclusive breastfeeding given by working mothers banyumanik district, semarang with a pvalue of 0.300.8 mother's behaviour in exclusive breastfeeding is influenced by knowledge and is supported by a good attitude. this is consistent with green's theory that knowledge will form good behaviour if it is based on a good attitude and selfawareness. another study also obtained similar results where there was no relationship between knowledge and exclusive breastfeeding of mothers in the community health centre in sebapai, pemengkat district, sambas regency, with a p-value of 0.054.9 other factors that influence exclusive breastfeeding are occupation and mother's age. in this study, most working mothers who have babies aged 12-24 months are labourers (44.6%) aged 21-30 years old. this is in line with the research that found the age of the child and mother influence the exclusive breastfeeding in the legal amazon and northeast, brazil.10 the results show that the majority of respondents who gave exclusive breastfeeding (72.2%) had good family support. the chi-square test results obtained a p-value of 0.001, which means that there was a significant relationship between family support and exclusive breastfeeding. previous research explains that most mothers who gave exclusive breastfeeding had good family, superior, and coworker supports, with the %age reached 75.5%, 65.7%, and 68.8%, respectively. their study found that factors that influence the exclusive breastfeeding of working mothers are age, knowledge, attitude, availability of facilities, as well as support from family, superiors, and coworkers.11 another study conducted obtained similar results where the majority of mothers who gave exclusive breastfeeding (75.4%) had good family support with a p-value of 0.000.12 family support, especially from the husband, and community support for nursing mothers include providing advice and space for mothers to breastfeed quietly. lack of family support can cause mothers to be less motivated in breastfeeding and switch to infant formula or other complementary feedings.13 another research conducted found that there was a significant relationship between family support and exclusive breastfeeding with a p-value of 0.003.14 the form of husband support to a breastfeeding mother includes motivating and accompanying the mother while breastfeeding, giving praise, taking care of the baby, and looking for information on breastfeeding. these will make the wife motivated and enthusiastic about breastfeeding.15 another research conducted in 2013 found that there is a relationship between the support of closest people with exclusive breastfeeding in the working area of tuladenggi community health centre in telaga biru sub-district with a p-value of 0.016.16 conclusion there was no significant relationship between the knowledge of breastfeeding and the exclusive breastfeeding given by mothers working. there was a significant relationship between the family support and the exclusive breastfeeding given by mothers. acknowledgments the researcher would like to say thank you to all respondents who participated in this research. south east asia nursing research, vol 2 no 3, september 2020/ page 7-11 11 biyanti dwi winarsih / the analysis of factors influencing exclusive breastfeeding given by working mothers conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. bobak, lowdermilk j. buku ajar keperawatan maternitas. 6th ed. jakarta: egc, 2010. 2. prakoso h. pengguanaan asi dan rawat gabung dalam ilmu kebidanan. jakarta: yayasan bina pustaka sarwono prawirohardjo, 2002. 3. masoara s. manfaat asi untuk bayi, ibu dan keluarga. program manajemen laktasi. jakarta: perkumpulan perinatologi indonesia, 2003. 4. alimoradi f et all. an overview of importance of breastfeeding. j compr pediatr; 2. 5. giri m. k. w. hubungan pemberian asi eksklusif dengan status gizi balita usia 6-24 bulan di kampung kajanan. j sains dan teknol; 2. 6. novita l. et all. perbandingan fungsi fognitif bayi usia 6 bulan yang mendapat dan yang tidak mendapat asi eksklusif. sari pediatr; 6. 7. dinas kesehatan. profil kesehatan provinsi jawa tengah tahun 2012. semarang: dinas kesehatan provinsi jawa tengah, 2014. 8. rahmawati m. d. faktor-faktor yang mempengaruhi pemberian asi eksklusif pada ibu menyusui di kelurahan pedalangan kecamatan banyumanik kota semarang. j kesmadaska; 1. 9. fricilia dan agustiansyah. faktor – faktor yang mempengaruhi ibu dalam pemberian asi eksklusif kepada bayi di puskesmas sebangkau kecamatan kecamatan pemengkat kabupaten sambas. pontianak nutr j; 1. 10. neves a.c.m.d. et all. factors associated with exclusive breastfeeding in the legal amazon and northeast regions, brazil, 2010. rev nutr 2014; 1: 81–95. 11. septiani b dan k. faktor – faktor yang berhubungan dengan pemberian asi eksklusif oleh ibu menyusui yang bekerja sebagai tenaga kesehatan. j ilmu kesehat 2017; 2: 159–174. 12. sohimah dan lestari. analisis faktor yang mempengaruhi pemberian asi eksklusif di wilayah kerja puskesmas cilacap tengah i kabupaten cilacap tahun 2017. j ilm kebidanan 2017; 8: 125–137. 13. prasetyono. dwi sunar. buku pintar asi eksklusif (pengalaman, praktik dan kemanfaatan-kemanfaatannya). yogyakarta: diva press, 2012. 14. anggorowati. hubungan antara dukungan keluarga dengan pemberian asi eksklusif pada bayi. j keperawatan matern; 1. 15. yuliarti n. keajaiban asimakanan terbaik untuk kecerdasan dan kelincahan si kecil. yogyakarta, 2010. 16. hilala agnes. faktor – faktor yang berhubungan dengan pemberian asi eksklusif di wilayah kerja puskesmas tuladenggi kecamatan telaga biru. j s1 keperawatan ung. the effectiveness of garlic, black turmeric, and red betel vine solutions to maintain scalp hygiene (pediculicide efficacy test toward head lice) corresponding author: amin samiasih aminsamiasih@unimus.ac.id south east asia nursing research, vol 2 no 4, december 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.4.2020.1-7 original research the effectiveness of garlic, black turmeric, and red betel vine solutions to maintain scalp hygiene (pediculicide efficacy test toward head lice) amin samiasih1, ayu dianingsih1, richa jannet ferdisa1, fitria wati1, tri hartiti1, ernawati1, arief yanto1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: submit nov 19th, 2020 accepted dec 13th, 2020 published dec 30th 2020 keywords: garlic; black turmeric; red betel vine; pediculicide; lice head lice (pediculosis humanus capitis) is a parasite sticking on the scalp and in between the hair. it lives by laying its eggs on some strands of hair and sucking blood from the scalp, which results in itching, inflammation, restless sleep, and concentration degradation. lice could also lower selfesteem. the infection may also lead to anaemia, which affects the learning pattern and cognitive function of children. however, the use of chemical insecticide may have a harmful effect. therefore, this research tested three natural ingredients, namely garlic, black turmeric, and red betel vine, as the pediculicide. this research was aimed to find safe, natural ingredients to eliminate head lice while maintaining personal hygiene. it was an experimental research with randomized posttest only control grup design. this research's subject was 28 lice, which were grouped into seven treatments with four lice in each group. the seven treatments included the treatment by spraying garlic, black turmeric, and red betel vine solution. the concentration of those natural ingredients was determined at 8% and 16%. the control group was sprayed by using water. the finding showed the significance of black turmeric (p-value 0.000), garlic (p-value 0.000), and red betel vine (p-value 0.001) as the effective pediculicide. the effective concentration as pediculicide was a 16% solution. introduction scalp infection is usually caused by head lice or pediculosis humanus capitis. head lice (pediculus) is a parasite sticking on the scalp and in between the hair. it lives by laying its eggs on some strands of hair and sucking blood from the scalp, which results in itching, inflammation, restless sleep, and concentration degradation. lice could also lower self-esteem. the infection may also lead to anaemia, which affects children’s learning patterns and cognitive function. 1 the elimination of pediculosis humanus capitis by using chemical insecticide may result in negative effects. the pediculicide sold in the market contains a high chemical element, which may result in allergy and poisoning. one of the natural ingredients potent to be antioxidant and antiinflammation is banana skin extract.2 it is effective and could be planted in our yard. this research was aimed to find out the effectiveness of three natural ingredients to eliminate head lice. they were black https://doi.org/10.26714/seanr.2.4.2020.1-7 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.4.2020.1-7&domain=pdf&date_stamp=2020-12-30 south east asia nursing research, vol 2 no 4, december 2020/ page 132-138 133 amin samiasih / the effectiveness of garlic, black turmeric, and red betel vine solutions to maintain scalp hygiene (pediculicide efficacy test toward head lice) turmeric (curcuma aeruginosa roxb), garlic dan red betel vine (piper crocatum). black turmeric (curcuma aeruginosa roxb) is known to be useful for skin health. it contains beneficial essential oil, curcuminoid, alkaloid, and saponin.3 the essential oil is effective in killing head lice. it is because essential oil has its antibacterial effect, which keeps the scalp from damage. the antibacterial property in black turmeric is mainly contributed by terpene compounds, which are monoterpene and sesquiterpene.4 garlic is effective in killing head lice as it contains ethanol with an 8% concentration. it was proven to e effective in killing head lice within 0.030 hours 5. besides, garlic is often used for its antifungal and antibacterial properties. garlic contains essential oil, allicin, scordinin, and saponin.6 red betel vine extract could also kill head lice as it contains 0.8 – 1.8% essential oil (consists of chavicol, chavibetol (betel phenol), allylprocatechol (hydroxychavikol), allypyrocatechol-mono dan diacetate), vitamin c, sugar, cineole, caryophyllene, cadinene, estragole, riboflavin, starch, sesquiterpene, terpene, phenylpropane, tannin, diastase, carotene, p.cymene, thiamine, carvacrol, eugenol and amino acid.7 methods this study consisted of three kinds of research with the same research technique, design, and the number of groups. it was mainly experimental research with randomized posttest only control grup design. the subject of this research was head lice obtained from five female children who lived at sendangguwo district of semarang with pediculosis humanus capitis infection. the sample used was a group of adult head lice, with 12 head lice for each research sample. the research group was divided into three groups of treatment, with four head lice for each treatment group. treatment 1 used herbal spray with a concentration of 8%, treatment 2 used a concentration of 16%, and treatment group 3 used only water. the natural ingredients used were garlic, black turmeric, and red betel vine. in preparing the solution, garlic, black turmeric, and red betel vine were weighed based on its planned concentration size as presented by figure b. the ingredients were grounded, strained, and mixed with waterbased on the demanded concentration, which was 8% and 16% as presented by figure c. the solution was strained by using a strainer (figure d), put into a spray bottle (figure e). the cup and for lice media added with 2g of threads to make present, the similar condition with the real head condition was prepared (figure f). the treatment was started by experimental animal adaptation. the adaptation was carried out in two hours. four lice were put into the cup and propped with 2 grams of white threads (figure g). the 10ml sprayer was used to spray the experimental group three times. meanwhile, the control group was given only a water sprayer. the research was divided into seven treatment groups. treatment group 1 (x1) was sprayed using 8% garlic solution, group 2 (x2) was sprayed using 16% garlic solution, group 2 (x3) was sprayed using 8% black turmeric solution, group 4 (x4) using 16% black turmeric solution, group 5 (x5) using 8% red betel vine solution, group 6 (x6) using 16% red betel vine solution, and group 7 (x7) using only water. the killing effect was measured by using a stopwatch, while the dead lice were observed and noted (figure h). south east asia nursing research, vol 2 no 4, december 2020/ page 132-138 134 amin samiasih / the effectiveness of garlic, black turmeric, and red betel vine solutions to maintain scalp hygiene (pediculicide efficacy test toward head lice) figure a the collection of lice sample figure b herb weighing figure c the herbal solution making process figure d straining the solution figure e herbal solution sprayer figure f the media for lice observation figure g the process of lice spraying figure h observing the solutions’ killing effect results the total sample of the research was 28 lice from five children (figure a). each group of treatment consisted of four lice put into a cup with 2 grams of thread (figure f). the duration of research was two hours for lice adaptation and 45 minutes for data collection. the research data was in the form of killing the power duration of the herbal solution. it was measured by using a stopwatch for 45 minutes. it was shown that the most effective was the 16% red betel vine solution with a minimum of 4 minutes, a maximum of 6 minutes, and an average of 5 minutes of pediculicide duration. the slowest pediculicide duration was in 8% garlic solution with a minimum of 19 minutes, a maximum of 25 minutes, and an average of 22 minutes, as presented by table 1. the difference of garlic, black turmeric, and red betel vine concentration toward the mean of pediculicide duration showed that the 16% concentration was more effective than the 8% solution. the most effective pediculicide was 16% red betel vine solution (x6 group), with the mean of pediculicide was 5 minutes. on the other hand, the least effective pediculicide was 8% black turmeric (x3 group), with the mean of pediculicide was 24 minutes, as presented by graphic 1. the statistical data analysis was implemented for each herbal solution and the control group. the statistical test used was from the mann-whitney test or kruskal-wallis test. the correlation between the implementation of garlic solution with the shown pediculicidal effect was p-value = 0.000. it means that the garlic solution spraying was significant to the pediculicide period. the correlation between the implementation of black turmeric solution with the shown pediculicidal effect was p-value = 0.000. it means that the black turmeric solution spraying was significant to the pediculicide period. the correlation between the red betel vine solution's implementation with the shown pediculicidal effect was p-value = 0.001. it means that the red betel vine solution spraying was significant to the pediculicide period. the three mentioned natural ingredients were significant to kill lice. in other words, the three natural ingredients were potential natural insecticide to eliminate head lice. south east asia nursing research, vol 2 no 4, december 2020/ page 132-138 135 amin samiasih / the effectiveness of garlic, black turmeric, and red betel vine solutions to maintain scalp hygiene (pediculicide efficacy test toward head lice) table 1 the pediculicide duration based on the garlic, black turmeric, and red betel vine solutions’ concentration. pediculicide duration (minute) groups minimum maximum mean treatment group 1 (x1) garlic 8% 19 25 22 treatment group 2 (x2) garlic 16% 13 15 13.75 treatment group 3 (x3) black turmeric 8% 23 25 24 treatment group 4 (x4) black turmeric 16% 19 20 19.25 treatment group 5 (x5) red betel vine 8% 10 15 12.75 treatment group 6 (x6) red betel vine 16% 4 6 5 treatment group 7 (x7) control group only water 30 30 30 graphic 1 the difference of the natural ingredients (garlic, black turmeric, and red betel vine) concentration toward the mean of pediculicide duration discussion spraying 16% black turmeric solution (x4 group) resulted in an average of 19.25 minutes of pediculicide effect. the black turmeric solution is significant toward the pediculicide effect with a p-value 0.000. based on the analysis, the low concentration of black turmeric resulted in a bacteriostatic effect and bactericidal effect in high concentrations. this research proved that 16% black turmeric solution (x4 group) was more effective than the 8% black turmeric (x3 group). it was supported by another research that stated that the higher the black turmeric concentration, the higher the active antimicrobial element in it, the higher ability to prevent microbial development. the low concentration black turmeric could perform as bacteriostatic, and the high concentration black turmeric could perform as bactericidal. the antibacterial property is contributed by terpenoid compounds in the form of monoterpene and sesquiterpene, which are the main components of black turmeric. the terpene compounds in black turmeric are the result of the secondary metabolism of 1 7 ,8 8 7 ,8 2 4 1 9 ,2 5 1 2 ,7 5 5 3 0 t r e a t m e n t g r o u p 1 ( x 1 ) g a r l i c 8 % t r e a t m e n t g r o u p 2 ( x 2 ) g a r l i c 1 6 % t r e a t m e n t g r o u p 3 ( x 3 ) b l a c k t u r m e r i c 8 % t r e a t m e n t g r o u p 4 ( x 4 ) b l a c k t u r m e r i c 1 6 % t r e a t m e n t g r o u p 5 ( x 5 ) r e d b e t e l v i n e 8 % t r e a t m e n t g r o u p 6 ( x 6 ) r e d b e t e l v i n e 1 6 % t r e a t m e n t g r o u p 7 ( x 7 ) c o n t r o l g r o u p o n l y w a t e r p e d ic u l ic id e p e r io d ( m in u t e ) t h e d i f f e r e n c e o f t h e n a t u r a l i n g r e d i e n t s c o n c e n t r a t i o n ( g a r l i c , b l a c k t u r m e r i c d a n r e d b e t e l v i n e ) t o w a r d t h e m e a n o f p e d i c u l i c i d e e f f e c t south east asia nursing research, vol 2 no 4, december 2020/ page 132-138 136 amin samiasih / the effectiveness of garlic, black turmeric, and red betel vine solutions to maintain scalp hygiene (pediculicide efficacy test toward head lice) the plant, which is useful to avoid microbe (bobarala, 2012). black turmeric also contains essential oil, which helps prevent the growth of s. aureus and b. subtitis in certain concentrations. 8,9 the mean of the group's pediculicide effect, with a 16% garlic solution (x2 group), was 13.75 minutes. the garlic spray was significant, with a p-value of 0.000. it was in line with research mentioned that 4% garlic solution could kill lice in 0.4450 hours, 6% garlic solution could kill lice in 0.1380 hours, and 8% garlic solution could be an effective insecticide for head lice as mentioned that the higher solution of garlic was the better able to kill head lice or pediculosis capitis.5 another researcher also stated that garlic extract is mortal for plant lice (m. persicae). in that research, the 0% garlic solution (control group) could kill 34.67% plant lice, 45% garlic solution killed 54.00% lice, and 60% garlic solution killed 72.33% 10,11. the chemical compounds in garlic such as allicin, saponin, and flavonoid are believed to perform as an insecticide for head lice, safe for health and the environment.5 in this research, the treatment group 7 (x7) as the control group was only receiving water spray. the mean of the pediculicide effect was 30 minutes. this research was supported by other researches that if the control group didn't receive any treatment, the pediculicide effect was performed in 8.974 hours. it was because head lice could live for ten days at 5°c without any blood intake and died at 40°c8. head lice could not live without blood intake in 15-20 hours.12 head lice need a warm and humid climate for their incubation period. meanwhile, for reproduction, they need an optimum temperature of 28°c 32°c. another research stated that pediculosis capitis could stay alive for 1-2 days out of the human head. the eggs could stay for a week outside the human head8. the long lifespan of pediculosis capitis, either with or without blood intake, could boost lice growth. the rapid growth and the effect of lice bite result in the itching, which stimulates scratching to eliminate the itching. the itching as the effect of lice's saliva and excretion which is absorbed by the scalp. 9,13,14 the treatment by using garlic is not only killing the lice but also reducing the itching and inflammation in the head. it was supported by research that garlic contains a chemical compound in its essential oil has antibacterial and antiseptic property.6 the essential oil in garlic could also perform antifungal property to prevent candida albicans growth.15 the other chemical compounds in garlic, which are allicin, have a strong aroma, which is powerful to damage disease germ protein. the active element in allicin is assumed to have a powerful antibiotic function.6,16,17 the treatment using red betel vine in this research proved that the 8% red betel vine solution (x5 group) killed the lice in 12.75 minutes, and 16% red betel vine solution (x6 group) could kill in five minutes. the red betel vine solution was significant to kill head lice with a p-value 0.001. this research was in line with the previous research using different concentrations of red betel vine solution for sitophilus oryzae’s mortality. the higher concentration of red betel vine extract, the higher sitophilus oryzae’s mortality. the higher concentration of the essential oil resulted in a higher aromatic effect which is avoided by insects.18 the higher concentration also increases the poisoning effect for an insect, which could inhibit the growth and kill the insect.14 the compound in red betel vine, which is lethal for lice, is tannin. tannin acts as contact and stomach poison for the insect. the mechanism is when lice had direct contact with the solution, the tannincontaining poison absorbed by the wall of the lice body and slowly kill the lice. tannin functions as the protection inside or outside the body tissue. besides, tannin could also shrink the tissue and close the protein on the skin and mucosa structure. meanwhile, the tannin in red betel vine could kill lice. south east asia nursing research, vol 2 no 4, december 2020/ page 132-138 137 amin samiasih / the effectiveness of garlic, black turmeric, and red betel vine solutions to maintain scalp hygiene (pediculicide efficacy test toward head lice) besides, tannin could also act as a stomach poison. the nutrition intake in lice's body could not be digested as it is intervened by tannin from the red betel vine directly sprayed on the lice. indigestion in lice leads to death.15,18 besides tannin, red betel vine also contains phenolic compounds which could kill pediculosis humanus capitis. phenol is an active compound that could initiate typical biological activity such as toxicity to inhibit nutrition, act as an ant parasite, and pesticide. therefore, the phenolic compound in red betel vine could kill results in death in pediculosis humanus capitis.15,19 red betel vine also contains alkaloids, which could act as a stomach poison in insects and lead to death. alkaloid decreases and damages the cell's membrane. this way, alkaloids could infiltrate and poison pediculosis humanus capitis. death is mainly caused by indigestion.20 the effectiveness of red betel vine solution to kill pediculosis humanus capitis was represented by the pediculicide effect shown by the certain herbal concentration. the 16% herbal concentration showed a quicker pediculicide effect compared to the 8% herbal concentration. the other proof of effectiveness could also be presented by the difference of pediculosis humanus capitis condition when it was sprayed by using red betel vine solution and that one sprayed by using only water. the success in using red betel vine could be beneficial for the people as they could get natural insecticide to inhibit pediculosis humanus capitis growth and avoid the use of chemical insecticide to eliminate pediculosis humanus capitis. conclusion the three natural ingredient solutions were significant to kill head lice (pediculosis humanus capitis). they were black turmeric (p-value 0.000), garlic (p-value 0.000) and red betel vine (p-value 0.001). the effective concentration as pediculicide was 16%. the use of natural ingredients black turmeric, garlic, and red betel vine to eliminate head lice (pediculosis humanus capitis) was safer. the natural ingredients are easy to get and could result in harmful side effects. the effective solution was the solution with a 16% concentration. acknowledgments the researcher would like to say thank you to all respondents who participated in this research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. rahmi h, rahmadewi r. antioxidant activity of kawista leaves and fruit skin extract (limonia acidissima l) from karawang regency. j midpro. published online 2020. doi:10.30736/md.v12i1.149 2. samiasih a, subagio wh, dharmana, et al. banana peels extract (musa paradisiaca var kepok) decreased mda in new zealand white rabbit with dm hyperlipidemia. in: iop conference series: earth and environmental science. vol 292. institute of physics publishing; 2019. doi:10.1088/1755-1315/292/1/012008 3. lim tk. curcuma aeruginosa. in: edible medicinal and non-medicinal plants. springer; 2016:233-240. 4. baharun k, rukmi i, lunggani at, fachriyah e. daya antibakteri berbagai konsentrasi minyak atsiri rimpang temu hitam (curcuma aeruginosa roxb.) terhadap bacillus subtilis dan staphylooccus aureus secara in vitro. j akad biol. 2013;2(4):16-24. accessed october 10, 2020. https://ejournal3.undip.ac.id/index.php/biolo gi/article/view/18998 5. pritacindy ap, supriyadi s, kurniawan a. uji efektifitas ekstrak bawang putih (allium sativum) sebagai insektisida terhadap kutu rambut (pediculus capitis). prev indones j public heal. 2017;2(1):1. doi:10.17977/um044v2i1p1-9 6. salima j. antibacterial activity of garlic extract (allium sativum l.). majority. 2015;4(2). south east asia nursing research, vol 2 no 4, december 2020/ page 132-138 138 amin samiasih / the effectiveness of garlic, black turmeric, and red betel vine solutions to maintain scalp hygiene (pediculicide efficacy test toward head lice) 7. fadlilah m. benefit of red betel (piper crocatum ruiz & pav.) as antibiotics. med j lampung univ. 2015;4(3):71. 8. baharun k, rukmi i, lunggani at, fachriyah e. daya antibakteri berbagai konsentrasi minyak atsiri rimpang temu hitam (curcuma aeruginosa roxb.) terhadap bacillus subtilis dan staphylooccus aureus secara in vitro. vol 2. departemen biologi, fakultas sains dan matematika undip; 2013. 9. adham d, moradi-asl e, abazari m, saghafipour a, alizadeh p. forecasting head lice (pediculidae: pediculus humanus capitis) infestation incidence hotspots based on spatial correlation analysis in northwest iran. vet world. 2020;13(1):40-46. doi:10.14202/vetworld.2020.40-46 10. tigauw smi, salaki cl, manueke j. efektivitas ekstrak bawang putih dan tembakau terhadap kutu daun (myzus persicae sulz.) pada tanaman cabai (capsicum sp.). eugenia. 2015;21(3). doi:10.35791/eug.21.3.2015.9703 11. al-zanbagi na, al-hashdi df, head k. in vitro investigation of allium sativum as anti-head lice in jeddah , saudi arabia. 2016;(2277):632635. 12. vonny rumampuk m, keperawatan universitas katolik de la salle manado kampus kombos f, sulawesi utara kode pos m. peranan kebersihan kulit kepala dan rambut dalam penanggulangan epidemiologi pediculus humanus capitis (the importance of hair and scalp hygiene for pediculus humanus capitis epidemic prevention). 13. dehghanzadeh r, asghari-jafarabadi m, salimian s, asl hashemi a, khayatzadeh s. impact of family ownerships, individual hygiene, and residential environments on the prevalence of pediculosis capitis among schoolchildren in urban and rural areas of northwest of iran. parasitol res. 2015;114(11):4295-4303. doi:10.1007/s00436-015-4670-1 14. smith ch, goldman rd. an incurable itch. can fam physician. 2012;58(8):839 lp 841. 15. neng ema zahrotul f. uji toksisitas minyak atsiri serai wangi (cymbopogon nardus l) terhadap mortalitas kutu kepala (pediculus humanus capitis). published online august 2014. 16. verma p, namdeo c. treatment of pediculosis capitis. indian j dermatol. 2015;60(3):238-247. doi:10.4103/0019-5154.156339 17. obaid hm. home remedies for pediculus humanus capitis infection among schoolchildren. our dermatology online. 2018;9(2):131-136. doi:10.7241/ourd.20182.6 18. mon i, siska d, staf e, jurusan p. pengaruh ekstrak daun sirih merah (piper crocatum ruiz &pav) terhadap pertumbuhan bakteri pseudomonas solanacearum. eksakta. 2011;1(1). 19. kurt ö, balcıoğlu ic, limoncu me, et al. treatment of head lice (pediculus humanus capitis) infestation: is regular combing alone with a special detection comb effective at all levels? parasitol res. 2015;114(4):1347-1353. doi:10.1007/s00436-015-4311-8 20. gonzalez-audino p, vassena c, zerba e, picollo m. effectiveness of lotions based on essential oils from aromatic plants against permethrinresistant pediculus humanus capitis. arch dermatol res. 2007;299:389-392. doi:10.1007/s00403-007-0772-7 chickenpox prevention behaviour in the ras laffan industrial city qatar corresponding author: djuhari djuharie@yahoo.com south east asia nursing research, vol 2 no 1, march 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.1.2020.33-38 original research chickenpox prevention behaviour in the ras laffan industrial city qatar djuhari djuhari1 1 medical departement qatar petroleum article info abstract article history: accepted march 4th, 2020 keywords: knowledge; behaviour; chickenpox chickenpox is a highly contagious infectious disease caused by the varicella zoster virus, characterized by a characteristic eruption on the skin and can affect people of all ages. increasing knowledge and behaviour to prevent chickenpox transmission is very important for mining workers, especially in their accommodation environment. the purpose of this study was to determine the relationship between knowledge of mining workers and prevention behaviour of chickenpox transmission. the type of research used is associative descriptive. the respondents of this study were 67 mining workers who lived in the ras laffan industrial city qatar accommodation, which were obtained through total sampling. the results showed that there was a relationship between knowledge and the behaviour to prevent chickenpox transmission with a significant value of p = 0.023, p <α (0.05). suggestions for workers in the ras laffan industrial city qatar accommodation environment, especially those related to preventing the transmission of chickenpox, should be more aware of the very fast transmission of chickenpox. introduction chickenpox is derived from the language of latin, varicella. 1 this disease s known by the term chickenpox chickenpox.2 varicella is a disease infections are very contagious that is caused by a virus varicella zoster, is characterized by the eruption of the typical on the skin. disease chickenpoxcan attack all layers of age, but generally the disease is attacking the children.3,4 the incidence of chickenpox in the world is still high.5–7 he number of cases of chickenpox were registered in qatar has always increased in three years last, began the year 2012 to 2014. the high number of events that require measures of prevention and treatment is good.7 symptoms of chickenpox water usually begin to appear in time 10 to 21 days after the body infected with the virus varicella. symptoms are usually in the form of fever, no appetite eat, myalgia, sore head. but in the case of chickenpox adults complaint, a major form of the sense of pain that is experienced will be very beyond ordinary. the pain will sometimes go away for a long time, even though the other main complaints have reduced or disappeared.4,8 qatar is one of the destinations for migrant workers. a large number of workers migrant the cause needs service health https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.1.2020.33-38&domain=pdf&date_stamp=2020-03-31 south east asia nursing research, vol 2 no 1, march 2020/ page 33-38 34 djuhari / chickenpox prevention behaviour in the ras laffan industrial city qatar increased.9 the labor migrants are generally working in the sectors of industry and construction, as well as maid house stairs. in general, the worker or workers migrants are not aware or less aware of things that relate to the importance of maintaining the health of the body as well as a history of immunization were obtained in the past. in addition to the condition of a place to stay they were overbooked can accelerate the process of transmission of chickenpox. displacement of the population of workers migrant can improve the transmission of disease from one place to place another.10 based on a survey conducted in the environment accommodation of workers mining ras laffan industrial city qatar found the number of visits patients were infected with chickenpox water to al madinah medical center in ras laffan industrial city the period of january through to december 2011 google translation vary each month. the average number of visits patients pox water ranging from 5 of total visits as many as 67 people each month.11 from the results of the survey in the field against the worker's mine who came for treatment to the clinic al madinah health center ras laffan, is found among workers mine who suffered from chickenpox and workers are not suffering from chickenpox mingle and interact with one each other without using a tool of protection themselves. they seem less understanding about what the disease chickenpox, means of transmission and how to prevent it. the objective of this research is to know the relationship between knowledge about how the prevention of transmission of chickenpox with behavioural prevention of transmission of chickenpox. methods this study has used an associative descriptive research design. this study has used a cross-sectional approach. this study measures respondents' knowledge about the transmission and prevention of chickenpox and their prevention behaviour. respondents research it is working mine who worked and lived in the neighbourhood for accommodation ras laffan industrial city qatar both were infected with chickenpox and were not infected with chickenpox. the number of research respondents was 67 people. technics taking samples which have been used in research this is a total sampling. the instrument of research that has been used in research this is a questionnaire. the research instrument consisted of 24 statement items. the questionnaire has been declared valid and reliable. the questionnaire has been carried out by expert tests to assess content validity. then a questionnaire carried out a test try instrument to assess the construct validity. the results of the instrument validity test showed that the research instrument had a value of r = 0.367–0.853 with a cronbach alpha value = 0.957. researchers have explained to prospective respondents before the retrieval of data. it consists of: the purpose of research, benefits of research, and the consequences that should be done during becoming respondents. respondents who had been willing to be the subject of study are required to sign pieces of informed consent. researchers keep the identity of respondents in the research data a secret. the process of making the data has been carried out for one month. data result of research has been carried out the analysis using a test correlation spearman rho. the test is performed to determine the relationship between knowledge workers about transmission and prevention of disease chickenpox with behaviours to prevent disease chickenpox. south east asia nursing research, vol 2 no 1, march 2020/ page 33-38 35 djuhari / chickenpox prevention behaviour in the ras laffan industrial city qatar results this research is carried out in the area of accommodation mine qatar ras laffan city, where the entire respondents were taken researchers are workers mine who works at ras laffan industrial city. research carried out in the period of february through to december 2017 with the number of respondents as many as 67 people. data were taken from 67 respondents were divided into three characteristics respectively: by status of citizens state of respondents who made the object of research the majority are citizens of the state of india as many as 30 people, followed philipines and nepal, each of which amounted to 15 people, citizens of the state of sri lanka as many as 3 people and finally 2 citizens of pakistan and bangladesh each. , the level of education is based on the level of education the majority of educated high school many as 33 people, smp many as 11 people, diploma as many as 10 people, bachelor of as many as nine people and the last elementary school as much as 4 people and group work. based on the type of work the majority of the respondents work in class employee staff (labor) for 53 people and remaining there in the group of senior staff of as many as 14 people. results of the study showed that the level of knowledge workers mine on how the prevention of transmission of chickenpox are divided into two groups, namely high and low. from the results of data processing, it is known that 60 people (89.6%) have low knowledge and 7 people (10.4%) have high knowledge. the values mean knowledge about how the prevention of transmission of chickenpox workers mine for 1.10 then the value median of 1.00. a minimum value of knowledge workers mines on how the prevention of transmission of chickenpox by 1 and the value of a maximum of 2, while the standard deviation ranging from 0308. results of the study show the behaviour of the prevention of the transmission of chickenpox be categorized into two groups, namely low and high. from the results of the processing of the data is known behaviour of prevention of transmission of chickenpox workers mine low as 57 people (85.1%) and 10 men (14.9%) with behavioural prevention high. then the obtained value mean of 1.15, and the value of median of 1.00. minimum value 1 and the value of maximum 2, while the standard deviation of 0.359. figure 1 the relationship between knowledge about prevention of chickenpox transmission with chickenpox prevention behaviour discussion the results of the analysis test using spearman's rho showed a significance value of 0.023 is following the theory that the pvalue is less than 0.05, which means that ho refused to conclude there is a relationship between knowledge workers mine about ways of transmission and prevention of transmission of disease chickenpox with behavioural prevention of chickenpox in the environment of accommodation ras laffan industrial city qatar. the result shows knowledge of the workers mine on how the prevention of transmission of the disease chickenpox known to generally low 89.6%, regard this possibility which becomes the cause of the disease chickenpox is still spreading in the south east asia nursing research, vol 2 no 1, march 2020/ page 33-38 36 djuhari / chickenpox prevention behaviour in the ras laffan industrial city qatar environment accommodation of workers mining ras laffan industrial city of qatar. while the data supporting such as status of citizens state, level of education, group works by answers to a questionnaire on knowledge about how the prevention of transmission of chickenpox was distributed to those obtained frequency level of knowledge of the majority of the low of 60 (89.6%) of the total frequency is 67 (100 %), the value of mean of 1.10, the value median 1.00 and standard deviation of 0.308, it can be described that the level of education, nationality and type of work does not affect the level of knowledge workers mine on how the prevention of transmission of chickenpox. knowledge is an effort that underlies a person's thinking is scientific, while its level depends on scientific knowledge or basic education people are.12 heigh and the low level of knowledge of the workers mine against disease chickenpox depends on the information that is received and does not depend on the level of education of each individual. this means that not all workers mine who has a level of education is high know about how the prevention of transmission of chickenpox much better than the worker's mine who has a level of education low.13 knowledge is not obtained from education formal course, will however be obtained through education non-formal. knowledge someone about an object contains two aspects, namely the aspect of positive and aspects negative. the second aspect of this which will determine the attitude of a person, the more many aspects of positive and object are known, then it will lead to an attitude more positive towards the object specified. one form of the object's health can be described by the knowledge that is gained from the experience itself.14 prevention behaviour of chickenpox disease among mining workers such a the research results is generally low 85.1%. behaviour in here to explain about the role they are to perform the prevention of transmission of chickenpox on worker mine in the environment of accommodation ras laffan industrial city. while the data supporting such as status of citizens state, education level, class works by answers to a questionnaire on knowledge about how the prevention of transmission of chickenpox was distributed to those obtained frequency level of knowledge of the majority of the low of 57 (85.1 %) of the total frequency 67 (100% ), the value of mean of 1.10, the value median 1.00 and standard deviation of 0.308, it can be described that the level of education, nationality and type of education does not affect the level of behaviour workers mine to attempt the prevention of transmission of chickenpox in the environment accommodation of workers qatar industrial city's ras laffan mine. the more low-behavioural prevention of chickenpox water in the environment accommodation of workers mining, the process of transmission and spread of the disease chickenpox becomes very easy. starting from individual to individual other than spread from the environment one into the environment more.3,15 so it can be concluded lack of behavioural prevention of transmission of chickenpox on worker mine very closely related with the level of knowledge of them against the disease chickenpox, as stated in the above that level knowledge workers mine on how the prevention of transmission of chickenpox against the disease was itself generally low. it is following studies of other states that the act of a person constituted by what is known and what is considered to be good to him.16,17 a person's actions are often interpreted in the same way as one's behaviour. good health knowledge is directly proportional to health behaviour.18 this means that the better a person's knowledge is, the better his health behaviour will be. based on the results of the analysis above, the role of health workers, especially nurses south east asia nursing research, vol 2 no 1, march 2020/ page 33-38 37 djuhari / chickenpox prevention behaviour in the ras laffan industrial city qatar who work at ras laffan industrial city, is very much needed, especially in terms of providing intensive counselling and socialization on efforts to prevent the transmission of chickenpox in the accommodation environment of mining workers in ras laffan industrial city qatar. starting from providing information about chickenpox covering the causes, symptoms and signs of someone having chickenpox, the mode of transmission, the complications caused to how to prevent the transmission of chickenpox to all mining workers in the ras laffan industrial city qatar accommodation environment. emphasizing the importance of implementing a clean and healthy lifestyle to mining workers both in times of health and illness. especially for mining workers infected with chickenpox, they should comply with all instructions given by health workers such as washing hands before and after carrying out activities, always being in an isolation room during the treatment period, always using personal protective equipment such as masks when meeting visiting guests., changing clothes every day, cutting fingernails and so on related to personal hygiene. through the above activities, it is hoped that the knowledge of mining workers about how to prevent the transmission of chickenpox will increase, it is hoped that it will lead to positive behaviour among mineworkers regarding efforts to prevent chickenpox transmission in their accommodation environment. the final result expected from all of the above actions is of course to minimize the incidence of chickenpox transmission in the ras laffan industrial city qatar accommodation, which will also greatly affect the work productivity of mining workers at ras laffan industrial city. conclusion the results showed that knowledge has a unidirectional relationship with the prevention behaviour of chickenpox in the accommodation environment of las laffan industrial city qatar. the level of knowledge of respondents about how to prevent chickenpox transmission in the ras laffan industrial city qatar accommodation environment is generally still low, while the level of behaviour to prevent chickenpox transmission is generally also low. considering that the results of this study are very meaningful towards efforts to reduce the number of people with chickenpox in the ras laffan industrial city qatar accommodation environment, the participation of health workers, especially nurses who work at ras laffan industrial city, is very much needed, especially in terms of providing intensive counselling and socialization of efforts. prevention of transmission of chickenpox in the accommodation of mining workers in the ras laffan industrial city qatar. always emphasize the importance of implementing a clean and healthy lifestyle for mining workers both in times of health and illness. acknowledgments i would like to express our appreciation to all respondents who participated in this research and to all units that have supported the implementation of this research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. kennedy pge, gershon aa. clinical features of varicella-zoster virus infection. viruses. 2018;10(11):609. 2. presterl e, diab-el schahawi m, lusignani ls, paula h, reilly js. general definitions. basic microbiol infect control midwives. published online 2018:1. 3. yang j, liu j, xing f, et al. nosocomial transmission of chickenpox and varicella zoster south east asia nursing research, vol 2 no 1, march 2020/ page 33-38 38 djuhari / chickenpox prevention behaviour in the ras laffan industrial city qatar virus seroprevalence rate amongst healthcare workers in a teaching hospital in china. bmc infect dis. 2019;19(1):1-7. 4. duncan dl. chickenpox: presentation, transmission, complications and prevention. br j sch nurs. 2019;14(10):482-485. 5. królasik a, paradowska-stankiewicz i. chickenpox in poland in 2016. przegl epidemiol. 2018;72(3). doi:10.32394/pe.72.3.5 6. bogusz j, paradowska-stankiewicz i. chickenpox in poland in 2017. przegl epidemiol. 2019;73(4). doi:10.32394/pe.73.38 7. sallam m, nadeem s, kumar n. epidemiological situation of chickenpox in qatar (2012-2014). j emerg med trauma acute care. 2016;2016(2):5. doi:10.5339/jemtac.2016.icepq.5 8. ballestas hc, caico c. pathophysiology of nursing.; 2014. 9. ali fmh, nikoloski z, reka h. satisfaction and responsiveness with health-care services in qatar—evidence from a survey. health policy (new york). 2015;119(11):1499-1505. 10. goodman a. the development of the qatar healthcare system: a review of the literature. int j clin med. 2015;6(03):177. 11. rlmc c. rlmc-rashid latif medical college. 12. hyde l. chapter 2 information as a commodity. in: phelps s, hyde l, wolf jpbt-ti, eds. chandos publishing; 2018:19-30. doi:https://doi.org/10.1016/b978-0-08101282-6.00002-5 13. shin j, dronjic v, park b. the interplay between working memory and background knowledge in l2 reading comprehension. tesol q. 2019;53(2):320-347. 14. boyd g, heaton pa, wilkinson r, paul sp. nursing management of childhood chickenpox infection. emerg nurse j rcn accid emerg nurs assoc. 2017;25(8):32-41. 15. stryczyńska-kazubska j, małecka i, biskupska m, bilski b, pietrzycka d, wysocki j. can a healthcare worker be a source of an infection of a patient–a risk of transmitting the chickenpox and shingles virus vzv by the staff of hospital wards–preliminary research findings. j med sci. 2017;86(1):30-35. 16. jahan y, rahman a. management of dengue hemorrhagic fever in a secondary level hospital in bangladesh: a case report. idcases. 2020;21:e00880. doi:10.1016/j.idcr.2020.e00880 17. randolph pk, hinton je, hagler d, et al. measuring competence: collaboration for safety. j contin educ nurs. 2012;43(12):541547, quiz 548-549. doi:10.3928/0022012420121120-79 18. glanz k, rimer bk, viswanath k. health behavior: theory, research, and practice. john wiley & sons; 2015. incidence of neonatal asphyxia events in mothers maternity with early ruptured amniotic fluid corresponding author: muhamad ulil albab ulila6546@gmail.com south east asia nursing research, vol 2 no 3, september 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.3.2020.99-104 original research incidence of neonatal asphyxia events in mothers maternity with early ruptured amniotic fluid muhamad ulil albab1, heriyanti widyaningsih1, sri hartini1, ambarwati ambarwati2 1 stikes cendekia utama kudus, indonesia 2 akper krida husada kudus, indonesia article info abstract article history: submit july 15th, 2020 accepted sept 14th, 2020 published sept 30th 2020 keywords: neonatal asphyxia; maternity mother; premature rupture of membranes asphyxia and intrauterine fetal dead (iufd) are a threat if a premature rupture of membranes is not immediately treated quickly and appropriately. neonatal asphyxia can occur due to complications from premature rupture of membranes. imr in indonesia is the fifth country for asean countries, 35/1000 birth. based on data from ra kartini hospital in jepara, asphyxia cases from approximately (12,6%) and incidence of premature rupture of membranes 816 cases or around (85,8%). while the incidence of neonatal asphyxia born from prom totalled 15 cases or about (1,6%). this research using quantitative descriptive methods with cross-sectional design. this research was conducted on april 21-23, 2020 using a total sampling method of 148 respondents. the data used are secondary data with a single variable, namely the incidence of neonatal asphyxia in mothers with maternity premature rupture of membranes. data analysis uses a descriptive statical test. aims to know the description of the incidence of neonatal asphyxia in mothers with maternity premature rupture of membranes in general hospital of raden ajeng kartini jepara 2019 and describe the incidence of neonatal asphyxia in mothers with maternity premature rupture of membranes in general hospital raden ajeng kartini jepara 2019. the result showed that of 148 respondents on average had no risk age (20-35 years) as many as 120 respondents (81,1%) and the average parity prom mothers as many as 148 respondents had multiparous parity of 85 respondents (57,4%). then from 148 prom mothers, 6 respondents (4,1%) gave birth to babies who had asphyxia. the highest incidence of neonatal asphyxia in mothers with maternity premature rupture of membranes was mild asphyxia of 3 respondents (2,0%), moderate to severe asphyxia of 2 respondents (1,4) and moderate asphyxia of 1 respondent (0,7%). the average degree of asphyxia in women with premature rupture of membranes is mild asphyxia. introduction neonatal asphyxia is a condition in which the baby is unable to breathe spontaneously and regularly after birth. this is caused by fetal hypoxia in the uterus. one of the causes of asphyxia in newborns is complications of early rupture of amniotic fluid due to the occurrence of funicular prolapse, namely the umbilical cord is depressed between the baby's head and pelvis, resulting in compression that causes the cessation of https://doi.org/10.26714/seanr.2.3.2020.99-104 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.3.2020.99-104&domain=pdf&date_stamp=2020-09-30 south east asia nursing research, vol 2 no 3, september 2020/ page 99-104 100 muhamad ulil albab / incidence of neonatal asphyxia events in mothers maternity with early ruptured amniotic fluid fetoplacental perfusion resulting in reduced blood flow from the mother to the fetus so that the baby has hypoxia or o2 exchange disorders to fetal distress and continues to become asphyxia of the newborn. 1 based on the survey demographic and indonesian health on 2017 show mortality of neonates 1.000, 15 per live births the infant mortality rate per live births, 1.000 24 and the child mortality life 1.000. 32 per live births child mortality rate has reached the target sustainable development (tpb / sgds) 2030 which is 25 / 1.000. live births neonatal death rate continued to decline from years of 1.000 1991-2017 32-15 live births.2 the causes of maternal mortality rate in indonesia are bleeding 25%, unsafe abortion 13%, eclampsia 12%, and 20% others. infection is the third cause of high aki. the cause of infection is due to the processes that are passed during pregnancy and childbirth such as premature rupture of membranes (prom) 65%, febrile 17%, amnionitis 0.5-1.5%, urinary tract infections 15%. premature rupture of membranes is the first sequence of causes of infection that can cause maternal mortality rate.3 the incidence of premature rupture of membranes ranges from 10% of all pregnancies. in term pregnancy the incidence varies between 6-9%. whereas in pre-term pregnancy the incidence is 2% of all pregnancies. nearly all preterm premature rupture of membranes will be born before term or labor will occur within one week after rupture of the membranes.4 based on data obtained from ra kartini hospital jepara, cases of asphyxia from december 2018 to december 2019 totaled 120 cases or approximately (12.6%), from december 2018 to december 2019 the incidence of premature rupture of membranes was 816 cases or around (85.8%). meanwhile, the incidence of neonatal asphyxia that was born from labor of ruptured membranes was 15 cases or approximately (1.6%). the incidence of premature rupture of membranes has increased from year to year, according to medical records of cases of premature rupture of membranes, including the top 10 diseases that often occur in the hospital.5 because of this background and the absence of this study, the authors are interested in researching the "preview event on mother maternity neonatal asphyxia membranes rupture with early ra kartini hospital in jepara district. methods this type of research is a descriptive study, which is research conducted to see a description and description of a situation.6 this type of research is a descriptive study of the incidence of neonatal asphyxia in women who give birth with premature rupture of membranes. this research design uses a cross sectional approach, which is a study that studies the relationship between risk factors (independent) and effect factors (dependent), which makes observations or measurements of variables once and at the same time.6 the design of this study by looking at medical records where the respondents studied were mothers who experienced premature rupture of membranes who gave birth to babies with asphyxia. the location in this study was carried out at the ra kartini jepara hospital and was held on 21-23 april 2020. population is all subjects who meet certain characteristics to be used in a study.6 the population in this study were all medical records of women who gave birth with premature rupture of membranes, as many as 148 cases recorded in the medical records of ra kartini hospital jepara from october to december 2019. in this study, the sampling technique in this study used the total sampling method, where in taking the sample of population members were used as samples.7 in this study, the sample used was 148 cases of maternal medical south east asia nursing research, vol 2 no 3, september 2020/ page 99-104 101 muhamad ulil albab / incidence of neonatal asphyxia events in mothers maternity with early ruptured amniotic fluid records with prom. the research instrument is a tool used to obtain data.8 medical records containing data on mothers who gave birth with prom and apgarscore assessments of infants with asphyxia were used in this study to obtain data on mothers who gave birth to premature rupture of membranes and asphyxic babies. this study used secondary data from maternal medical record records with premature rupture of membranes and medical record records for asphyxia babies from october-december 2019, the questionnaire was filled in by researchers including: respondent identity including age, maternal parity, and incidence of neonatal asphyxia in mothers giving birth with premature rupture of membranes. the data in this study were analyzed using univariate analysis. univariate analysis was performed on the variable incidence of neonatal asphyxia in women who gave birth with premature rupture of membranes. results based on table 1 shows that the frequency distribution of the age of mothers giving birth with premature rupture of membranes is mostly at the non-risk age (20 35 years) as many as 120 respondents (81.1%), young at risk age is 8 respondents (5.4%) and age 20 respondents (13.5%) at risk of being old. the mean age of women with premature rupture of membranes was 30.37 years. the frequency distribution of mothers with premature rupture of membranes is mostly multiparous as many as 85 respondents (57.4%), primiparous as many as 62 respondents (41.9%), then grande multipara as many as 1 respondent (0.7%). the mean parity of women with premature rupture of membranes was multiparous. the result shows that the frequency distribution of neonatal asphyxia in women with premature rupture of membranes is mild asphyxia by 3 respondents (2.1%), moderate severe asphyxia by 2 respondents (1.4%), and moderate asphyxia as many as 1 respondent (0.7%). the average status of asphyxia in women with premature rupture of membranes is mild asphyxia. table 1 distribution of the age, parity, and neonatal asphyxia of mothers giving birth with premature rupture of membranes (n = 148) indicators f % age young risk <20 years 8 5.4 no risk 20-35 years 120 81.1 at risk old> 35 years 20 13.5 parity primipara 62 41.9 multiparous 85 57.4 grande multipara 1 0.7 neonatal asphyxia with premature rupture mild asphyxia babies 3 2.1 moderate asphyxia babies 1 0.7 severe asphyxia babies 2 1.4 not asphyxiated 142 95.8 discussion the results of this study indicate that the frequency distribution of the age of mothers who give birth with premature rupture of membranes is mostly at non-risk age (20 35 years) as many as 120 respondents (81.1%), young at-risk age is 8 respondents (5.4%) and age at risk of old as many as 20 respondents (13.5%). the mean age of women with premature rupture of membranes was 30.37 years. the incidence of premature rupture of membranes at the age of the mother who is not at risk is due to an incompetent cervix at the age of the mother who is not at risk (20-35). cervical incompetence is more common in mothers who are> 20 to 35 years old. this condition is a condition in which the flexibility of the cervix to withstand the pregnancy begins to disappear. this occurs due to repeated labor and a history of curettage. an incompetent cervix can also cause premature rupture of the membranes, this can occur because of a history of curettage and age 20-35 years which is caused by a lack of strength in the cervix to hold the conception, making it prone to complications of premature rupture of membranes.9 the age for optimal reproduction for a mother is 20-35 years. south east asia nursing research, vol 2 no 3, september 2020/ page 99-104 102 muhamad ulil albab / incidence of neonatal asphyxia events in mothers maternity with early ruptured amniotic fluid ages <20 and> 35 are classified as at risk in the process of preparing for pregnancy and childbirth. the age of a mother so much will affect her reproductive system. because the reproductive organs are underripe and too old, their ability and plasticity to accept pregnancy have started to decrease. maternal age at risk can lead to complications in mothers such as premature rupture of membranes and complications in infants. research conducted by aprilla (2018) at bangkinang regional hospital found that 32 respondents (58.18%) aged <20 and> 35 years old, the results research are by the theory that women who give birth are under 20 years of age or more than 35. years is a risk factor for premature rupture of membranes that can lead to maternal death. 3 affandi's research (2012) shows that most mothers who experience premature rupture of membranes are mostly at risk ages <20 and> 35 years (71.4%). this shows that most of the respondents aged 20-35 are of the healthy reproductive age with the lowest risk that occurs to mothers and their babies. the results of this study indicate that the frequency distribution of mothers giving birth with premature rupture of membranes is mostly multiparous as many as 85 respondents (57.4%), primiparous as many as 62 respondents (41.9%), then grand multipara as many as 1 respondent (0.7%). the mean parity of women with premature rupture of membranes is multiparous. multiparous parity has a very high risk, this is because multiparous parity has experienced labor more than once so that it can affect the reduced strength of the uterine muscles which are very susceptible to complications of premature rupture of membranes. based on the theory of primiparous parity and grand multipara, it is one of the factors of premature rupture of membranes. women with primiparous parity will be more at risk of experiencing complications of premature rupture of membranes than women with multiparous status because the uterus is still elastic and the reproductive organs are not ready to accept a pregnancy. so that any adjustment is needed to the uterus. whereas in the multiparous grande the incidence of premature rupture of membranes occurs more often because the resistance of the reproductive organs of the mother has begun to weaken and too often the mother gives birth so that pregnant women will again stretch the uterus and the strength of the connective tissue and vascularity decreases, causing fragility which can affect complications premature rupture of membranes.10 the results of aisyah's (2012) study at lamongan regional hospital stated that multiparity parity (80%) can affect the complications of premature rupture of membranes compared to primiparous parity (65%). the results of pujiningsih's (2012) research at sidoarjo regional hospital stated that the incidence of premature rupture of membranes occurred in mothers with primiparas parity of 55 respondents (77.46%), multiparity parity of 101 respondents (59.20%), and grande multipara parity of 4 respondents. (36.36%). it is concluded that the parity of mothers who experience premature rupture of membranes in mothers with multiparous parity.11 the results of this study indicate that the frequency distribution of neonatal asphyxia among women with premature rupture of membranes is mild asphyxia by 3 respondents (2.0%), moderate-severe asphyxia by 2 respondents (1.4%), and moderate asphyxia. as much as 1 respondent (0.7%). the average status of asphyxia in women with premature rupture of membranes is mild asphyxia.11 wiknjosastro (2014) premature rupture of membranes is one of the causes of complications in the fetus in the form of newborn asphyxia and infection. hypoxia that occurs in the fetus can cause the baby to experience asphyxia after birth due to interference with the exchange of o2 gas transport from mother to fetus, there is a disturbance in the supply of o2 and in eliminating co2. complications caused by south east asia nursing research, vol 2 no 3, september 2020/ page 99-104 103 muhamad ulil albab / incidence of neonatal asphyxia events in mothers maternity with early ruptured amniotic fluid premature rupture of membranes, such as infection in the mother and fetus, resulting in prematurity and respiratory dystrome (rds), can increase perinatal mortality and morbidity. 12 the results of utami's (2013) research at dr soedarso hospital, there was a relationship between prom and the incidence of neonatal asphyxia but there was no significant relationship (adjusted or = 0.96; 95% ci = 0.254-1.389; p = 0.811). for respondents, mothers with prom 90 were (52.63%) and mothers without prom were 81 (47.37%) and 27 asphyxic babies from prom mothers were 27 (47.37%) and asphyxic babies born to mothers who were not prom as much as 30 (52.63%). in this study, the researchers concluded that there was an association between prom incidence and asphyxia but there was no significant relationship, but the factor that greatly influenced the incidence of asphyxia was obstructed labor, labor duration> 12 hours had a 20.04 greater chance of occurrence of neonatal asphyxia compared to delivery <12 hours. 13 komsiyati (2014) research results at ambarawa regional hospital found that mothers who experienced prom experienced asphyxia incidence (69.4%), while mothers who did not experience prom incidence of asphyxia (15.7%). where babies born to mothers who experience premature rupture of membranes are at risk of 2,809 times greater risk of neonatal asphyxia than babies born to mothers who do not experience premature rupture of membranes. 14 the assumption of the researchers in this study concluded that the preparedness of medical personnel and medical personnel in dealing with the incidence of prom in mothers who gave birth at ra kartini jepara hospital was to prevent complications that would occur to the mother and the fetus. judging from the medical record data of ra kartini jepara hospital 2019, it can be concluded that the condition of prom in mothers giving birth <24 hours and> 24 hours will be carried out quickly such as: providing stimulation to accelerate the opening of the cervical mouth, vacuum action due to too slow progress in labor and delivery through sectio caesarea. measures to prevent neonatal and maternal emergencies endeavored at reducing the risk of complications such as neonatal emergency in the form of newborn asphyxia. conclusion the most incidence of neonatal asphyxia in women with premature rupture of membranes was mild asphyxia as many as 3 respondents (2.0%), moderate asphyxia by 2 respondents (1.4%), and moderate asphyxia by 1 respondent (0.7%). acknowledgments the researcher would like to say thank you to all respondents who participated in this research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. prawirohardjo s. buku acuan nasional pelayanan kesehatan maternal dan neonatal. 4th ed. jakarta: yayasan pustaka sarwono prawirohardjo, 2010. 2. indonesia kk. profil kesehatan indonesia tahun. jakarta, 2018. 3. aprilla nia. faktor risiko ibu bersalin yang mengalami ketuban pecah dini di rsud bangkinang tahun 2017. j kesehat masy 2018; 2: 48–57. 4. surasmi a. perawatan bayi resiko tinggi. jakarta: egc, 2011. 5. kartini rmrr. data penyakit neonatal. jepara, 2019. 6. riyanto a. aplikasi metodologi penelitian kesehatan. jogjakarta: nuha medika, 2011. 7. ariani ap. aplikasi metodologi penelitian kebidanan dan kesehatan reproduksi. jogjakarta: nuha medika, 2014. south east asia nursing research, vol 2 no 3, september 2020/ page 99-104 104 muhamad ulil albab / incidence of neonatal asphyxia events in mothers maternity with early ruptured amniotic fluid 8. nursalam. konsep dan penerapan metodologi penelitian ilmu keperawatan. jakarta: salemba medika, 2011. 9. prawirohardjo s. ilmu kebidanan. 4th ed. jakarta: pt bina pustaka sarwono prawirohardjo, 2010. 10. puspitasari rn. korelasi karakteristik dengan penyebab ketuban pecah dini pada ibu bersalin di rsu denisa gresik. indones j heal sci 2019; 3: 24. 11. supadrtini, dan mudzolifah s. hubungan antara usia dan paritas dengan letak sungsang pada ibu bersalin supartini. embrio, j kebidanan 2012; i: 30–35. 12. prawirohardjo s& tr. ketuban pecah dini. in: ilmu kebidanan. jakarta: pt bina pustaka sarwono prawirohardjo, 2014. 13. utami rb. risiko terjadinya asfiksia neonatorum pada ibu dengan ketuban pecah dini. j vokasi kesehat 2011; 1: 9–17. 14. komsiyati. hubungan ketuban pecah dini dengan kejadian asfiksia neonatorum di rsud ambarawa. stikes ngudi waluyo, 2014. the anticipation of schools bullying corresponding author: eni hidayati eni.hidayati@unimus.ac.id south east asia nursing research, vol 2 no 4, december 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.4.2020.25-31 original research the anticipation of schools bullying eni hidayati1, christina tri cahyani1, desi ariyana rahayu1, muhammad fatkul mubin1, tri nurhidayati1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: submit dec 2nd, 2020 accepted dec 28th, 2020 published dec 30th 2020 keywords: bullying; teacher; junior high school bullying is an action to harm other people that continuously happen either in groups or individually. bullying could happen in a school environment to the students who are quiet, small and to those unable to defend themselves. this study aims to determine the anticipation of bullying in the school environment. the frequency distribution test results obtained that 250 teachers were in the sufficient category in anticipating bullying prevention and 3 teachers were still in the poor category. the research hopefully can stop bullying in the school environment. bullying is an action to harm other people which is carried out continuously either in groups or individually. bullying could occur in a school environment to students who are quiet, small and those unable to defend themselves. bullying prevented by regulations that could be valid to all school members. the study aims to determine the anticipation of bullying in the school environment. the frequency distribution test results obtained that 250 teachers were in the sufficient category in anticipation of bullying prevention and 3 teachers were still in the poor category. the research hopefully can stop bullying in the school environment. introduction schooling period is a time in which children begin to pay attention to their environment and playmates, at this time children spend more free time with their friends rather than staying at home or hanging out with family. we would never know whether bullying frequently happens in the school environment; there will be many victims if we do not realize the situation.1 someone do repeated treatment who can harm others, both in the group and individually.2 bullying usually only to hurt others and create an aggressive attitude, the perpetrator could be in groups or individuals and only targeting victims whom they think are vulnerable to attack.3 bullying is one of the violence that appears among adolescents and can occur anywhere, especially in the school environment; bullying could be a threatening stressor. bullying is a form of violence that hurts peers to find satisfaction in itself.3 bullying in the school environment is verbal bullying such as taunting, calling parents 'names or changing friends' names as nicknames.4 bullying in our country mostly occurs in the school environment; around 61-73% of https://doi.org/10.26714/seanr.2.4.2020.25-31 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.4.2020.25-31&domain=pdf&date_stamp=2020-12-30 south east asia nursing research, vol 2 no 4, december 2020/ page 156-162 157 eni hidayati / the anticipation of schools bullying bullying cases are in the form of violence, extortion, threatening and taking things, and other forms of cyberbullying.5 bullying behaviour is considered a common thing among school peers, so we never know that it can lead to violence. bullying cases are already familiar in indonesia according to the indonesian child protection commission (kpai), there are 369 reports related to bullying that occurred in schools from 2011 to 2014, and data from the icrw (international center for research on women) in 2015 was 84% the occurrence of violence in schools, this case is the higher number compared to the trend in asia.1 discussion techniques on group guidance, to improve understanding of bullying behaviour, there are 75% cases of bullying in schools including verbal bullying such as mocking, insulting, cheering, calling by other names and insinuating 35%, relational bullying such as spreading gossip, looks cynical and ostracizes 20%, physical bullying is taking people's things without permission and coercing, stepping on their feet, pushing and hitting by 10%, cyberbullying such as teasing friends through social media, giving negative comments on friend status by 10 %.6 if these bullying cases not handled immediately, there will be more victims, it will cause other consequences such as fear, stress, anxiety, insecurity and suicide. according to the counselling teacher, students do not want to go to class because they often receive bullying from their peers. there were many cases and forms of bullying found. the perpetrator will feel satisfied when the victim feels oppressed; the perpetrators' laughter moments when playing with the victim reinforce the behaviour.7 the teacher also plays a role in developing student characteristics in school. they did not only a role model but also a motivator and inspirator. a teacher becomes a figure to be trusted and imitated by students, at the same time they can help students' development and potency; the teacher can also play a role in overcoming violence against school staff. students play an important role in preventing bullying in the school environment.8 bullying can occur and cause by several factors of bullying that happen in the school environment, the lack of teachers' attention to students both in economy and achievement or student behaviour outside the classroom and inside the classrooms, teachers who are rude to students including the tv shows about violence in film scenes.9 bullying is defined as a group of teenagers or individuals who misuse their power so that causing casualties.10 the impact of bullying for victims, they prefer to stay away from the neighbourhood or friends and become coward, while others remained silent and did not reply to the perpetrators.11 bullying is behaviour intended to harm either directly or indirectly by a strong side to a weak side continuously.9 bullying is also an action that carried out continuously in which involves an imbalance side such as a strong group against a weak group.8 meanwhile, according to research3, bullying is an aggressive attack whether psychologically, verbally, socially, or physically which is carried out only for personal satisfaction. bullying also defined as a group of adolescents and individuals who abuse the power that causes victims.10 according to study12, the forms of bullying are physical bullying, verbal bullying, nonverbal-bullying directly, nonverbalbullying indirectly, sexual abuse. this study aims to determine the anticipation of bullying in the school environment. methods descriptive research aims to get more accurate results from the problems under study, therefore the data collected is obtained from the results of interviews, questionnaires or observations.13 this research uses quantitative because of the data generated in the form of analysis and south east asia nursing research, vol 2 no 4, december 2020/ page 156-162 158 eni hidayati / the anticipation of schools bullying numbers using descriptive methods. data collection using a questionnaire to find out how deep the teacher's knowledge of bullying in the school environment, then the results of the questionnaire are used as an evaluation at school. the population is research conducted on all research objects. the population in this study consisted of 35 junior high schools in semarang, with 35 bk teachers as respondents. the sample is a type of research that is only taken part of the research object and is considered representative of the population.14 this research uses the quantitative descriptive method. the design is quantitative descriptive. quantitative research is systemic and usually uses an empirical, destructive, logical, and measurable approach. the quantitative research goal is to use systemic models and develop theories related to natural phenomena.13 sampling technique using a sample of 253 respondents, the sample taken from junior high school teachers. the instrument used in this study using a questionnaire. the questionnaire consists of questions that contain anticipation of the occurrence of bullying at school. results based on table 1 above, the results obtained from 253 respondents, the anticipation of teachers of school bullying include in the category quite are 250 respondents (98.8%), while the anticipation of teachers against the occurrence of bullying in schools includes in category less are three respondents (1.2%). based on table 1 above, the results show that of the 253 respondents who got information sources from television as many as 224 respondents (88.5%), there were 169 respondents (66.8%) who got information sources from the print media peers were 126 respondents (49.8%), 34 respondents (13.4%) received information sources (13.4%), 17 respondents (8.0%) received information sources information from others there are 20 respondents (8.0%). based on table 2 above, the results show that of the 253 respondents, the respondents' answers were based on the research objectives of punishment at school which was included in the correct category in item 18 in how to prevent bullying at school there were 241 respondents (96.4%) while those who were included in in the wrong category there were 12 respondents (3.6%), in the twentieth item the antibullying program in schools that was included in the correct category was 156 respondents (62.4%) while those who were in the wrong category were 97 (37.6%), the second item, one way we respond to bullying actors, there are 245 respondents (98%) who answered incorrectly and 8 respondents (2%) answered incorrectly, the third item, one way so that bullying does not occur at school, there are 245 respondents (98%) who answered correctly and 8 respondents (2%) who answered incorrectly. table 1 distribution of the frequency of teachers' anticipation and information sources (n = 253) indicators f % anticipate teachers enough 250 98.8 less 3 1,2 resources television 224 88,5 print media 169 66,8 peers 126 49,8 health workers 34 13,4 social media 17 8,0 other 20 8,0 south east asia nursing research, vol 2 no 4, december 2020/ page 156-162 159 eni hidayati / the anticipation of schools bullying table 2 distribution of the frequency of respondents' answers based on research purposes on punishment question item answer the questions correct wrong f % f % how to prevent school bullying 241 96,4 12 3,6 stop bullying program at school 156 62,4 97 37,5 what are the ways we deal with bullying 245 98 8 2 what are the ways to prevent bullying from happening at school 145 98 8 2 discussion bullying considered as a common thing and bullying also used as an encouragement for its victims to make themselves better person, some bullying victims' show that they do not deserve to bullied and they choose to fight the perpetrator by bullied them back.15 the impact of bullying for the perpetrator is that they will regret the action he has done when the victim prefers to remain silent and does not reply to the perpetrator. meanwhile, to prevent bullying, families can teach good behaviour to their children at the early childhood stage, so that they can behave well when they are outside the home.10 based on the research that done, there were 4 items of the punishment given by the teacher when a student makes a mistake, and those that include in the most significant number and most correct answers are in items 21 and 31 with the total of 245 respondents, and the most numbers of the wrong answer were in item 20 with a total of 97 respondents. finding out the role of teachers and counsellors in guiding or solving problems, from the research conducted on 253 teachers were consisting of 3 items included in the correct answer category, most of which were in item 33 as many as 248 respondents and teachers whose answer was wrong mostly found in item 34 with the total of 45 respondents. bullying is an incident that often found in adolescents, which can have an impact on victims in mental, physical and other psychosocial health disorders.16 bullying is also defined as vicious behaviour done intentionally and continuously to injure someone physically and mentally. it carried out by one person or group resulted in an imbalance of power or strength.17 bullying itself is also defined as behaviour carried out repeatedly by behaving in aggression and targeting weak children according to the perpetrator, by threatening or disturbing the victim so that the affected victim suffer psychological disorders.18 on the question item about finding out the discipline rules given by the school, from the research that have done on 253 teachers, there are 5 question items and the correct answers are in item 23 as many as 244 respondents, and the most incorrect answers are in item 22 as many as 153 teachers. finding out the regulations from the minister of education and culture that applied in schools, from the research have done on 253 teachers, there are 2 items and the teachers who are correctly answering the questions in item 37 as many as 212 respondents, and those who answer incorrectly in item 40 were 68 respondents. from the research that i have done, there are 253 teachers, there are 2 items and teachers who are in the category of the most number of correct answers are in item 37 as many as 212 teacher respondents, and the most incorrect answers in item 40 are 68 respondents who answered incorrectly. at school, some teachers become places to learn and achieve development according to targets, as for counselling teachers or counsellors who have a role to help students prevent or deal with problems that are happening to them and overcome the south east asia nursing research, vol 2 no 4, december 2020/ page 156-162 160 eni hidayati / the anticipation of schools bullying violence and sexual harassment they are experiencing.9 find out the role of teachers and counsellors in guiding or solving problems. from the research i did, 253 teachers were consisting of 3 items that were included in the correct answer category, most of which were in item 33 as many as 248 respondents and teachers whose wrong answers were mostly found in item 34 with a total of 45 respondents. regulations in the discipline given by schools such as implementing socialization for children about bullying and its consequences of bullying in student life at a later date.19 teachers always assist students in the school environment both in the learning process and in behaviour outside of learning in school. provide various kinds of learning models so that children can interact and work together and respect each other with other friends. provide strict rules to prevent bullying and give sanctions to students who commit bullying.20 bullying in adolescents still exists in the school environment without any warning and sanctions given to the perpetrators, which causes much more bullying victims to come out. teachers' role is very important to prevent bullying in the school environment; the explanations of bullying are needed to create a comfortable and safe environment and avoid bullying. there are many reasons for students to do bullying in school, first is that they do not care for each other between friends that makes the higher number of bullying; second, the perpetrators are also victims of bullying; the third is that the perpetrators do bullying so that they would be considered great and feared by many people, fourth is the need to do revenge.21 another reason students do bullying because they do not know the impact of bullying behaviour; for students who know and understand the impact of bullying, they will not do it.22 if the bullying case is not handled immediately, there will be more victims and it will cause impacts such as fear, stress, anxiety, insecurity and suicide. according to the counselling teacher, students do not want to go to class because they often receive bullying from their peers. so many cases and forms of bullying.23 the perpetrator will feel satisfied when the victim feels oppressed, the laughter of a group of perpetrators when playing with the victim reinforces the behavior.7 the teacher plays a role in shaping the characteristics of students in school, apart from being a role model, the teacher also acts as a motivator and inspirator, a teacher becomes an example of a figure to be digested and imitated by students when being an inspiration the teacher can help students develop and have potential, the teacher can also play a role in overcoming violence against school staff students also plays an important role in preventing bullying in the school environment.8 conclusion teachers in junior high schools apply sanctions (guidance) for victims or perpetrators of bullying. each school teacher also provides lessons about bullying and teaches good relationships between teachers, students, and other friends. the school applies discipline regulations such as educating the students about bullying and its consequences in the future. teachers always assist students in school, both in the learning process and students' behaviour outside of the school area's learning process. school provides various learning models for students to interact and work together and respect each other between friends. school provides strict rules to prevent bullying and give sanctions to students who commit bullying. several schools have implemented regulations given by the minister of education and culture (mendikbud) to prevent bullying in schools. south east asia nursing research, vol 2 no 4, december 2020/ page 156-162 161 eni hidayati / the anticipation of schools bullying acknowledgments we would like to thank the teachers and friends who provided additional information for the school to prevent bullying. the school can do it well and correctly so that there will be no victims and violence in the school environment and a comfortable and safe environment is created. conflicts of interest every school is obliged to implement strict rules for preventing bullying if teachers do not pay attention to students or apply strict bullying regulations, it is feared that many students will become victims of bullying without the knowledge of teachers and other school members. references 1. aini d. voor en na de oorlog. vol 6. s.n.]; 2018. 2. darwin, mubin mf, hidayati e. pengalaman siswa yang mendapatkan bullying di sman 15 semarang. j keperawatan komunitas. 2018;2(1):1-6. 3. yuliani n. fenomena kasus bullying di sekolah. published online 2019. 4. sutanti r. hubungan pola asuh orang tua dengan kejadian bullying pada remaja di smpn 06 yogyakarta tahun 2018. published online march 2019. 5. nurbaiti ae, affarah l, sulistya w, kadriyan h. skrining dan edukasi pencegahan bullying pada siswa sma negeri di kota mataram. j pengabdi magister pendidik ipa. 2019;1(2). doi:10.29303/jpmpi.v1i2.245 6. van der ploeg r, steglich c, veenstra r. the way bullying works: how new ties facilitate the mutual reinforcement of status and bullying in elementary schools. soc networks. 2020;60(january):71-82. doi:10.1016/j.socnet.2018.12.006 7. goleman d, boyatzis r, mckee a. bimbingan kelompok dengan teknik sosiodrama sebagai upaya mengatasi perilaku bullying di sekolah. j chem inf model. 2019;53(9):1689-1699. doi:10.1017/cbo9781107415324.004 8. putri fellinda arini. strategi_guru_dalam_meningkatkan_minat_b. published online 2016:62-76. 9. kartianti s. peran konselor dalam mengurangi perilaku bullying siswa di sekolah. hibualamo seri ilmu-ilmu sos dan kependidikan. 2017;1(1):34-37. 10. citrawathi dm. pengembangan model pendidikan kesehatan integratif dan kolaboratif di sekolah. vol 0.; 2014. 11. kharis a, ain n. dampak bullying terhadap perilaku remaja ( studi pada smkn 5 mataram ). 2019;7(1):44-55. 12. wibow ap. penerapan hukum pidana dalam penanganan bullying di sekolah antonius p.s. wibowo google buku.; 2019. 13. putra sr. panduan riset keperawatan dan penulisan ilmiah. (rusdianto, ed.). d-medika; 2012. 14. prof. dr. soekidjo notoatmodjo. ilmu perilaku kesehatan. rineka cipta. published online 2018:75. 15. rambaran ja, van duijn maj, dijkstra jk, veenstra r. stability and change in student classroom composition and its impact on peer victimization. j educ psychol. 2020;112(8):1677-1691. doi:10.1037/edu0000438 16. moffat ak, redmond g, raghavendra p. the impact of social network characteristics and gender on covert bullying in australian students with disability in the middle years. j sch violence. 2019;18(4):613-629. doi:10.1080/15388220.2019.1644180 17. strindberg j, horton p, thornberg r. coolness and social vulnerability: swedish pupils’ reflections on participant roles in school bullying. res pap educ. 2020;35(5):603-622. doi:10.1080/02671522.2019.1615114 18. stephen k, aine m. ucc library and ucc researchers have made this item openly available. please let us know how this has helped you. thanks! published online 2019. doi:10.1080/15401383.2019.1623147 19. bork-hüffer t, mahlknecht b, kaufmann k. (cyber)bullying in schools–when bullying stretches across con/fflating spaces. child geogr. 2020;0(0):1-13. doi:10.1080/14733285.2020.1784850 20. dardiri a, hanum f, raharja s. the bullying behavior in vocational schools and its correlation with school stakeholders. int j instr. 2020;13(2):691-706. doi:10.29333/iji.2020.13247a 21. hellström l, beckman l. adolescents’ perception of gender differences in bullying. scand j psychol. 2020;61(1):90-96. doi:10.1111/sjop.12523 south east asia nursing research, vol 2 no 4, december 2020/ page 156-162 162 eni hidayati / the anticipation of schools bullying 22. thornberg r, delby h. how do secondary school students explain bullying? educ res. 2019;61(2):142-160. doi:10.1080/00131881.2019.1600376 23. kurniasih n, wanabuliandari s, ristiyani r. bibliometrics analysis in articles of verbal bullying in schools digitalcommons @ university of nebraska lincoln library philosophy and practice ( e-journal ) bibliometrics analysis in articles of verbal bullying in schools nuning kurniasih. libr philos pract. 2020;4087(january):1-10. application of predialytic exercise to reduce fatigue in-patient undergoing hemodialysis corresponding author: nugroho lazuardi nugroho.lazuardi@unimus.ac.id south east asia nursing research, vol 3 no 1, march 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.1.2021.28-32 case study application of predialytic exercise to reduce fatigue in-patient undergoing hemodialysis nugroho lazuardi1,2 1 universitas muhammadiyah semarang, indonesia 2 tugurejo hospital of central java province, indonesia article info abstract article history: submit feb 5th, 2021 accepted march 1st, 2021 published march 28th 2021 keywords: predialytic exercise; fatigue; hemodialysis chronic kidney disease is an irreversible and slow-progressing disorder of kidney function so that the kidneys are unable to maintain the body's metabolism, fluid and electrolyte balance and cause uremia which requires dialysis or kidney transplantation. hemodialysis is management to treat chronic kidney disease that is carried out for life so that the complications that often arise are fatigue, cramps, anxiety, pain. the phenomenon found in the hemodialysis room of the tugurejo hospital semarang, there were 34% of the 84 patients who experienced fatigue which was characterized by lethargy, weakness, drowsiness, dizziness. this research is a quantitative study with a quasi-experimental design. the sample size is 4 respondents in the intervention group without a control group. measurement of the level of fatigue (pre and post-test) using the pfs (piper fatigue scale) which contains 22 subjective statements. predialytic exercise intervention is given for 5 sessions with a duration of 10-15 minutes. the results of this study indicate that the fatigue level of hemodialysis patients has decreased after the intervention of predialytic exercise for 5 sessions. the fatigue score of respondents 1 has decreased from a score of 4.8 (moderate fatigue) to 3.2 (mild fatigue), respondent 2 from a score of 6.3 (moderate fatigue) to 4.3 (moderate fatigue), respondent 3 from score 9 (severe fatigue) to 7 (severe fatigue), and respondent 1 from a score of 4.9 (moderate fatigue) to 2.4 (mild fatigue). the results of this study indicate that there is a decrease in each dimension of fatigue levels so that predialytic exercise intervention is effective to reduce fatigue in patients undergoing hemodialysis. introduction chronic kidney disease (ckd) is an irreversible and slow disruption of kidney function therefore unable to maintain the body's metabolism, fluid, and electrolyte balance cause uremia which requires dialysis or kidney transplantation. there are 70,000 sufferers of ckd in indonesia, and it will be increased every year by up to 10%. data from the indonesian ministry of health (2017), 30,554 active patients were undergoing dialysis, 1,243 patients died with 1-317 months of hd time. indonesian renal registry data (2016), states that as many as 98% of ckd sufferers undergo hemodialysis therapy and 2% of peritoneal dialysis (pd) therapy with the most common causes of ckd are diabetic nephropathy (52%), hypertension (24%).1,2 https://doi.org/10.26714/seanr.3.1.2021.28-32 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.1.2021.28-32&domain=pdf&date_stamp=2021-03-28 south east asia nursing research, vol 3 no 1, march 2021/ page 28-32 29 nugroho lazuardi / application of predialytic exercise to reduce fatigue in-patient undergoing hemodialysis the majority of people with ckd need therapy in the form of hemodialysis. hemodialysis is a process of cleansing the blood using an artificial kidney, namely a dialyzer with the goal is to maintain good nephron function, reduce morbidity, reduce uremia pericarditis, uremia encephalopathy, fluid overload, nutritional disorders, and infections, therefore, the quality of health and the quality of life among patients is improved. the hemodialysis process takes 4-5 hours generally will cause side effects such as physical stress, fatigue, headaches, cramps, and cold sweat due to decreased blood pressure and sugar levels. 3,4 fatigue is a feeling of excruciating characterized by a constant decrease in strength or physical and mental labor. fatigue is a problem that is most often felt as a side effect of ckd sufferers undergoing hemodialysis which can cause physical, social, and psychological problems that interfere with daily activities and the patient's quality of life. fatigue is caused by changes in health conditions, sleep disorders, psychological disorders and poor nutritional status. 4–6 non-pharmacological interventions that can be given to ckd patients with hemodialysis with fatigue are progressive muscle relaxation, range of motion, and breathing exercises or predialysis exercise. predialytic exercise can be increasing blood flow, and the number of capillary areas in the muscles, so it can reduce the occurrence of complications such as fatigue, muscle cramps, and anxiety.6 based on the explanation before, therefore, this study aims to determine the effect of predialytic exercise on the level of fatigue in patients undergoing hemodialysis at tugurejo hospital, central java, indonesia. methods a quasi-experimental design on one group (intervention group) with pre and post-test was used in this study. the population was patients with chronic kidney disease in the hemodialysis installation of tugurejo hospital, central java, indonesia. based on initial data, there were 86 patients who underwent hemodialysis as routinely. the sampling technique is convenience sampling, where the researcher selects the sample at the study site according to the research criteria until the number of research samples is obtained. patients who meet the criteria will be recruited as respondents. this study uses the piper fatigue scale (pfs) to measure the fatigue level of hemodialysis patients. pfs instrument can represent the subjective feelings of the respondents in expressing their fatigue. data collection was carried out before and after being given for 5 meetings with a duration of 10-15 minutes. this study was conducted by emphasizing the principles of research ethics including the consent form, anonymity, and confidentiality. respondents who were willing and agreed become respondents were asked to fill out a questionnaire. before treatment, respondents were explained. the univariate analysis aims to describe the characteristics and level of fatigue among respondents. results the implementation of the predialysis exercise in patients with chronic kidney disease in the hemodialysis unit of tugurejo regional hospital was carried out from may 9, 2019, to may 23, 2019, with 4 patients as respondents who met the inclusion and exclusion criteria. the results of the research analysis are as follows: south east asia nursing research, vol 3 no 1, march 2021/ page 28-32 30 nugroho lazuardi / application of predialytic exercise to reduce fatigue in-patient undergoing hemodialysis table 1 frequency distribution characteristics of respondents with chronic kidney disease who underwent hemodialysis semarang (n=4) indicators f % age <30 years old 31 – 40 years old 1 25 41 – 50 years old >50 years old 3 75 gender male female 4 100 education level primary high school junior high school senior high school perguruan tinggi 4 100 marital status unmarried married widow/widower 3 1 75 25 length of hemodialysis < 12 month 12 – 24 month > 24 month 2 2 50 50 based on data on the characteristics of respondents (table 1), it shows that most (75%) aged> 50 years and all respondents are male and had a high school education level. as many as 3 respondents (75%) are married and 1 respondent (25%) are widowers, while for the duration of hd, 2 respondents (50%) underwent 12-24 months of hd and 2 respondents (50%) underwent hd> 24 months. respondents were given intervention in the form of predialysis exercise with a combination of progressive muscle relaxation movements, range of motion, and breathing exercise. the movements in this physical exercise are combined with the same principle of stretching and relaxing the muscles in the face, neck, shoulders, hands/arms, and legs. exercises were given before the hemodialysis process started for 5 meetings on monday and thursday according to the respondent's schedule for hemodialysis. the duration of the intervention was 10-15 minutes with each movement of 8 beats and accompanied by music. for the first time doing this physical exercise, the respondents did not optimal in following the movements because they were afraid that they would cramp or make their muscles hurt and interfere with the hemodialysis process. the benefits of this physical exercise began to be felt after 3 times after undergoing routine interventions. figure 1 frequency distribution score of fatigue level before and after predialytic exercise figure 1 shows a decrease in the level of fatigue in the four respondents, where respondent 1 from a score of 4.8 (moderate fatigue) to 3.2 (mild fatigue). respondent 2 from a score of 6.3 (moderate fatigue) to 4.3 (moderate fatigue). respondent 3 from score 9 (severe fatigue) to 7 (severe fatigue). respondent 4 from a score of 4.9 (moderate fatigue) to 2.4 (mild fatigue). the average fatigue score was 6.25 (moderate fatigue) in the pre-test and the average fatigue score was 4.25 (mild fatigue) in the post-test. the results showed that there was a decrease in the level of fatigue after being given the intervention of predialysis exercise (post-test) for 5 meetings, namely 2 respondents (50%) had mild fatigue, 1 respondent (25%) moderate fatigue, and 1 respondent (25%) weight fatigue. the value of the fatigue level before the intervention was carried out with a minimum fatigue level of 4.8 and a maximum of 9. before being given the 4,8 6,3 9 4,9 3,2 4,3 7 2,4 0 1 2 3 4 5 6 7 8 9 10 responden 1 (tn. s1) responden 2 (tn. a1) responden 3 (tn. a2) responden 4 (tn. s2) pre test post test south east asia nursing research, vol 3 no 1, march 2021/ page 28-32 31 nugroho lazuardi / application of predialytic exercise to reduce fatigue in-patient undergoing hemodialysis intervention, the respondents were in a fairly varied range of fatigue scores. there is one respondent with a score of fatigue 9, this is due to the age factor (> 50 years). the subjective results obtained from the four respondents said that their body condition was better after hd was done and would have a maximum health status 1 day after hd, however, respondents would feel significantly tired after 2-3 days after hd. during hd, the four respondents said they prefer to use their time to sleep or close their eyes. two respondents can sleep soundly during hd (1-2 hours) and two respondents can only close their eyes without sleeping soundly. according to a statement from the respondent, the cause of the excessive fatigue because he was always feeling unhappy. he said he was not on good terms with his wife so when he was homemade he wants to be angry. he said that he was irritable and emotional. another respondent said that the fatigue was due to not having much activity and that his feet were often swollen which interfered with his activities. the four respondents had poor sleep quality, indicated by sleep time that was only 3-4 hours a day, often waking up at night and having difficulty starting to sleep again, waking up sluggish is a factor that adds to fatigue. discussion the data showed that respondents' fatigue level was varied according to age. age is a factor that can affect individual health. ckd sufferers who undergo hd age over 40 years are at risk of various complications that can interfere with the quality of life, including fatigue. solomon's explained that the older a person is, the physical condition will weak and lead to fatigue condition. 7 decreased physical condition at old age results in higher levels of fatigue. fatigue appears as a result of various factors, including physiological factors (anaemia, malnutrition, uremia, hyperparathyroidism, inflammation) which arise from chronic kidney disease. 8 complaints of fatigue in patients undergoing hemodialysis due to many factors, including poor nutritional status, psychological disorders, changes in health conditions, and poor sleep disorders.4,9 this study showed that there was a decrease in the level of fatigue after being given the intervention of predialysis exercise (post-test) 5 times having mild fatigue levels. these results support a study that physical exercise is effective in reducing fatigue levels in chronic kidney disease patients undergoing hemodialysis. 8 the benefits of physical exercise began to be felt by the respondents, especially from the fourth week onwards. at the beginning of the exercise, the average respondent said they were afraid to do physical exercise, for fear of interfering with the hemodialysis process. regular physical exercise can increase blood flow to the muscles, increase the number of capillaries and increase the area and surface of the capillaries, thereby increasing the movement of urea and toxins from the tissues to the vasculature which are then flowed to a dialyzer or hemodialysis machine. physical exercise can also show improvements in body fitness, physiological function, agility, reducing levels of fatigue, agility and increasing muscle strength. 8 this physical exercise is also able to relax respondents, improve overall circulation, and lower blood pressure. 6 apart from physical exercise, internal and social motivation is also needed to support the survival of hd patients. patients who do physical exercise are likely to experience fewer complications. 10 many of the patients whose hemodialysis process is delivered and awaited by the family make the patient comfortable. lifestyle must also be maintained, especially fluid restrictions to reduce oedema of the extremities or south east asia nursing research, vol 3 no 1, march 2021/ page 28-32 32 nugroho lazuardi / application of predialytic exercise to reduce fatigue in-patient undergoing hemodialysis pulmonary oedema so that heart and lung function is easier and reduce fatigue or shortness of breath. 11 conclusion predialysis exercise has a positive effect to decrease fatigue level for dialysis patients. predialysis exercise can be applied in the hemodialysis unit to reduce the level of fatigue and may improve the quality of life. the initial measurement carried out on the first day before the intervention was moderate fatigue and the second measurement after 5 times given the intervention was decreased to mild fatigue. hemodialysis nurses are expected to apply predialysis exercise as nursing care for decreasing the fatigue level of hemodialysis patients. acknowledgments we gratitude to all parties, responders and nurses at the hemodialysis installation at tugurejo hospital for helping the research process. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. kemenkes ri. info datin ginjal. situasi penyakit ginjal kron. 2017;1–10. 2. indonesian p, registry r, renal i, indonesia pn, kesehatan d, kesehatan d, et al. indonesian renal registry 2016. 2016;1–46. 3. lazuardi n. pengaruh intervensi support group terhadap kualitas hidup pasien penyakit ginjal kronis yang menjalani hemodialisa. 2016;1–80. 4. fari ai, sofiani y, warongan aw, kesehatan fi, katolik u, charitas m, et al. efektifitas progressive muscle relaxation (pmr) dan relaxation breathing exercise (rbe) terhadap tingkat fatigue dan selfcare pasien ggk. j kesehat saelmakers perdana. 2019;2(1):99– 110. 5. amini e, goudarzi i, masoudi r, ahmadi a, momeni a. effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis. int j pharm clin res. 2016;8(12):1634–9. 6. sakitri g. pengaruh intradialitic exercise terhadap fatique pasien hemodialisis di rsup dr. soeradji tirtonegoro klaten. profesi (profesional islam media publ penelit. 2017;15(1):64. 7. sulaiman. hubungan lamanya hemodialisis dengan fatigue pada pasien gagal ginjal di rs pku muhammadiyah yogyakarta. skripsi. 2015;1–11. 8. nur aini dwi. pengaruh latihan fisik terhadap fatique pada pasien iintrahemodialisis di rsud tugurejo semarang. 2015;2015. 9. sakitri g. pengaruh intradialytic exercise terhadap fatigue pasien hemodialisis di rsup dr. soeradji tirtonegoro klaten. profesi (profesional islam media publ penelit. 2017;15(1):64. 10. retno sd. efektivitas latihan fisik selama hemodialisis terhadap peningkatan kekuatan otot pasien penyakit ginjal kronik di rumah sakit umum daerah kota semarang. 2014;98– 107. 11. novitasari acdd. kepatuhan pembatasan asupan cairan terhadap lama menjalani. j prodi keperawatan univ aisyiyah yogyakarta. 2014;8(1):104–12. kangaroo method treatment increases baby's body temperature with low birth weight corresponding author: fenny dwi kurniasih fennydwikurniasih98@gmail.com south east asia nursing research, vol 2 no 4, december 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.4.2020.48-53 case study kangaroo method treatment increases baby's body temperature with low birth weight fenny dwi kurniasih¹, heryanto adi nugroho1, chanif chanif1 1 nursing internship program, universitas muhammadiyah semarang, indonesia article info abstract article history: submit dec 5th, 2020 accepted dec 30th, 2020 published dec 30th 2020 keywords: low birth weight; kangaroo method; increased body temperature birth weight is less than 2500 grams which contribute to infant mortality especially during the perinatal period, one of the interventions that can be done with kangaroo method, this method can make the baby's body temperature stable because the baby who is in the care of the kangaroo method will feel like it exists in the uterus of the mother, in addition to the treatment of kangaroo methods aimed at helping to accelerate the process of increasing the baby's body temperature as well as being able to stabilize the body temperature in babies who experience low birth weight. the design of the study used is a descriptive method with a case study approach of nursing care using a pre and post-test design conducted on 2 respondents. before being given the kangaroo method 1 respondent and respondent 2 experienced low weight measured using observation sheet for 3 days while after being given kangaroo method respondent 1 and respondent 2 experienced weight gain measured using observation sheet for 3 days characterized by normal weight. kangaroo treatment therapy method can increase body temperature in babies with low birth weight in the perinatology room of k.r.m.t wongsonegoro hospital semarang. introduction low birth weight (lbw) is a baby born with a bodyweight of fewer than 2500 grams, where babies with less weight are prone to illness or infection if this is not treated immediately will be at risk of experiencing delays in motor development and learning ability.1 in terms of the relationship between the time of birth and gestational age, the baby's birth is grouped into three, including preterm (preterm) babies, namely babies born with a gestation period of fewer than 37 weeks (259 days), term babies, namely babies born with a gestation period of fewer than 37 weeks (259 days). gestation between 37 to 42 weeks (259-293 days), and babies over months, namely babies born with a gestation period of> 42 weeks or more than 294 days.2 based on riskesdas (2018) basic health research results, the prevalence of the indonesian population having low birth weight problems is 3.27 %. the prevalence of the population in central java with problems according to the proportion of birth weight <2500 was 2.93 % and according to the diagnosis or symptoms experienced by the patient was 3.72 %, https://doi.org/10.26714/seanr.2.4.2020.48-53 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.4.2020.48-53&domain=pdf&date_stamp=2020-12-30 south east asia nursing research, vol 2 no 4, december 2020/ page 178-183 179 fenny dwi kurniasih / kangaroo method treatment increases baby's body temperature with low birth weight while the prevalence of semarang city according to the diagnosis by health personnel was 4.47 %. the prevalence of low birth weight at the age of 0-59 months according to the city of semarang is 5.39%.3 low birth weight their adipose tissue and subcutaneous fat over a little and epidermis is thinner than in adults. the elasticity of the baby's body decreases over the surface area, thereby accelerating heat loss. this is influenced by the length of the baby, the ratio of body surface to body weight for the age of the baby, all of which can affect normal temperature limits.4 this is what causes lbw to need tools and methods, including by inserting the baby into an incubator, performing treatment with natural methods, namely by treating the kangaroo method to stabilize his body temperature to prolong life opportunities. the kangaroo method can meet the basic needs of lbw by providing situations and conditions similar to that of the uterus, thus giving lbw a chance to adapt well to the outside world. given the various advantages, it can help to stabilize the baby's body temperature.4,5 the kangaroo method has a big effect on the baby's body temperature to stabilize because babies who are in the kangaroo method care will feel like they are in the mother's womb.6 the kangaroo method is more effective at increasing body temperature, the heat transfer mechanism occurs in two mechanisms, namely conduction and radiation.4,5 the behaviour regulates the balance between heat loss and production or more commonly referred to as thermoregulation. the hypothalamus detects small changes in body temperature. the anterior hypothalamus regulates heat loss, whereas the posterior hypothalamus regulates heat production.7 the formulation of the problem in this nurse final scientific paper is that this case study aims to determine the kangaroo method treatment for increasing body temperature of infants with low birth weight in the perinatology room of the krmt wongsonegoro hospital semarang. methods methods of this case study use descriptive method nursing process performed on two patients in january 2020 in the hospital krmt wongsonegoro semarang. the application of the kangaroo care method was carried out for 3 days. this case study inclusion criteria that baby weight between 1200 2499 grams, no complications were serious such acute respiratory distress syndrome (ards), not undergoing phototherapy, while the exclusion criteria for this case study is temperature> 37°c, parents or family members who will perform fever kangaroo care method. before caregiving kangaroo method of patients in the first measuring body temperature, after the patient has been measured body temperature then intervention care award kangaroo method to patients performed for 20 minutes, do the treatment for the condition asks the patient how to level s body temperature after being given kangaroo method treatment with intervals of 15 minutes. the equipment used in the application of this case study is swaddling cloth, baby hats, baby socks, digital thermometer. before the application first, measure the temperature of the baby's body and then record the results. use of the kangaroo method care can be given every day and after that, the baby is measured again in temperature. results the subjects of this case study were 2 people consisting of male and female patients. patient characteristics of both cases can be seen in table 1 and the results of the assessment in both cases are shown in table 2. on january 11, 2020, the results of the assessment of data case of patient 1 gender woman, age 22 days premises n medical diagnosis lbw. the patient's mother said south east asia nursing research, vol 2 no 4, december 2020/ page 178-183 180 fenny dwi kurniasih / kangaroo method treatment increases baby's body temperature with low birth weight that her child was still not fluent in drinking the mother's milk because she was not used to it. based on objective data, bodyweight is 1600 grams, height/length 43 cm, head circumference 29 cm, chest circumference 24 cm, upper arm circumference 7c m, and physical examination results show pulse: 141x / minute, breath frequency 30 x/ minute, the temperature of 36.3°celcius. on january 12, 2020, the results of a case review of a patient with 2 sexes were female, 19 days old with a medical diagnosis low birth weight. the patient's mother said that her child was still not fluent in drinking the mother's milk because she was not used to it. based on objective data weight 1550 grams, high/body length 41 cm, round head 27 cm, bust 23 cm, arm circumference above 8 cm, and examination of physical showed the pulse of 138 x/min, the frequency of the hub axle 33 x / minute, temperature 36.5 ° c. nursing diagnoses in patient 1 and patient 2 show that hypothermia is associated with low birth weight. this is confirmed by the analysis of data obtained from the history and physical examination which is influenced by hypothermia on lbw because the baby is still difficult to adjust outside the mother's womb and organs. baby's body that has not been functioning optimally. for babies weighing ≥ 1500 grams or less than 2500 grams, babies will lose up to 10% of body weight during the first 7-10 days. if lbw is given quality care, it can reduce the neonatal mortality rate. kangaroo method care (pmk) is an easy, simple and effective way to treat lbw because kangaroo treatment is a practical, economical and very effective treatment to meet the most basic needs of babies, namely warmth, breast milk, protection from infection, stimulation, safety and compassion.8 interventions were given to the patient 1 and patient 2 is monitor vital signs, especially temperature, provide warmth through the incubator, monitor the provision of methods kangaroo, teach techniques of kangaroo appropriate method. implementation performed on the patient 1 and patient 2, namely the provision of kangaroo method to increase body temperature with a time of 20 minutes, to monitor the provision of kangaroo method, teaches techniques kangaroo method is how to position the baby's stomach and abdomen mother touching each other, monitors vital signs, especially body temperature. during the implementation stage, the nurse carries out the nursing care plan to help clients independently and in collaboration with other medical teams. evaluation in patient 1 and patient 2, namely body temperature in normal conditions, providing warmth through the incubator, collaboration with mother for breastfeeding. based on the results of the evaluation, it can be analyzed that the nursing problem is partially resolved, it can be seen from the two patients experiencing an increase in body temperature, giving the kangaroo method is carried out for the child with low birth weight. table 2 the data obtained from the case study shows that before being given the kangaroo nursing intervention method, respondent 1 and respondent 2 did not experience a decrease in body temperature. body temperature on the first day of respondent 1 and respondent 2 obtained a body temperature of 36.3 °c and 36.5 °c after the nursing intervention was given to respondent 1, it was found that body temperature was 36.4 °c and respondent 2 obtained body temperature of 36.5 °c. on the second day before the nursing intervention was given to respondent 1, the body temperature was 36.4 °c and respondent 2 was 36.5 °c. after the nursing intervention was given to respondent 1 and respondent 2 the body temperature was 36.6 °c and 36.7 °c. on the third day before the nursing intervention was given to respondent 1 and respondent 2, the result was a body temperature of 36.7 south east asia nursing research, vol 2 no 4, december 2020/ page 178-183 181 fenny dwi kurniasih / kangaroo method treatment increases baby's body temperature with low birth weight °c, after being given nursing intervention the results of respondents 1 and 2 were obtained 36.9 °c and 36.8 °c. the results of the case study showed that the body temperature of children with low birth weight in the perinatology room of the krmt wongsonegoro hospital in semarang city experienced an increase in body temperature by the number of 2 patients, in patients 1 and 2 experienced an increase in body temperature from 36.3 °c and 36.5 °c to 36, 9°c and 36.8°c. the success of the process can be seen by comparing the process with the guidelines or process plan, while the success of the action can be seen by comparing the level of independence of the patient's mother. table 1 case characteristics case i case ii patient identity name: baby mrs s age: 22 days birthdate: december 19, 2019 female gender name of parents: mrs s islam tribe: javanese occupation: housewife address: demak, central java medical diagnosis: lbw assessment date: 11 january 2020 patient identity name: baby mrs d age: 20 days birthday: december 21st, 2019 female gender name of parents: mrs d islam javanese ethnic occupation: self-employed address: semarang medical diagnosis: lbw assessment date: january 12, 2020 table 2 body temperature before and after kangaroo method treatment patient day 1 day 2 day 3 before after before after before after patient 1 36.3°c 36.4°c 36.4°c 36.6°c 36.7°c 36.9°c patient 2 36.5°c 36.5°c 36.5°c 36.7°c 36.7°c 36.8°c discussion the results of these case studies show there is an increase in body temperature in children with low birth weight which experienced less weight than normal after a given method of storytelling for 20 minutes. the results of this study are following the results of other studies which explain that the kangaroo method is more effective at increasing body temperature. the heat transfer mechanism occurs in two mechanisms, namely conduction and radiation.8,9 similar results are also explained in other studies which explain that there is an increase in body temperature and body weight after skin-to-skin contact using the kangaroo method.9 similar results were also explained in another study which explained that the kangaroo method affected body temperature in infants with low birth weight as evidenced by an increase in body temperature for infants.10,11 birth weight is an important indicator of the health of the baby, a major factor for survival and a factor for the development and mental development of the baby in the south east asia nursing research, vol 2 no 4, december 2020/ page 178-183 182 fenny dwi kurniasih / kangaroo method treatment increases baby's body temperature with low birth weight future. in terms of maternal factors, several factors affect lbw, including pregnancy and fetal factors. maternal factors include malnutrition during pregnancy, maternal age (<20 years and> 35 years), a gestational distance too close, and illness from the mother herself. pregnancy factors such as hydramnios and multiple pregnancies. fetal factors that affect lbw, such as congenital defects and infections in birth. other risk factors include parity, economic status, education and maternal occupation. invalid sources specified.12,13 birth weight is an important indicator of the health of the baby, a major factor for survival and a factor for the development and mental development of the baby in the future. in terms of maternal factors, several factors affect lbw, including pregnancy and fetal factors.13 maternal factors include malnutrition during pregnancy, maternal age (<20 years and> 35 years), a gestational distance too close, and illness from the mother herself. pregnancy factors such as hydramnios and multiple pregnancies. fetal factors that affect lbw, such as congenital defects and infections in birth.1,14 other risk factors include parity, economic status, education and maternal occupation.15 for good for the mother's pregnancy is 20-35 years. pregnancy under 20 years of age or more than 30 years is a pregnancy with high risk. pregnancy at a young age is a risk factor because at the age <20 years the mother's condition is still growing so that food intake is mostly used to meet the needs of the mother. pregnancies of more than 35 years are less fertile reproductive organs as well as increase the risk of birth with congenital disorders and birth are at risk for low birth weight infants.16 conclusion kangaroo treatment method can increase body temperature, this is evident in patient 1 and patient 2 do not experience body temperature below normal. the kangaroo method is a simple way to care for a newborn where the mother uses her body temperature to warm the baby. kangaroo care is an effective way to meet the most basic needs of babies, namely warmth for the baby, exclusive breastfeeding, protection from infection, safety and compassion. acknowledgments gratitude to allah swt, director of roemani muhammadiyah semarang hospital, patient and family, ns. heryanto an, m.kep, sp.kom as the head of the nurse study program and as the supervisor of the nurse's final scientific work. conflicts of interest the author disclosures no potential conflicts of interest, financial or otherwise. references 1. lowdermilk dl, perry se, cashion k. maternity nursing. 8th editio. mosby/elsevier; 2014. 2. maryunani a. ilmu kesehatan anak dalam kebidanan. jakarta trans info media. published online 2010. 3. kementerian kesehatan ri badan penelitian dan pengembangan. hasil utama riset kesehatan dasar 2018.; 2018. doi:1 desember 2013 4. okinarum gy, mawarti r. pengaruh perawatan metode kanguru terhadap perubahan suhu tubuh pada bblr di rsu pku muhammadiyah yogyakarta tahun 2010. published online 2011. 5. de castro silva mg, de moraes barros mc, pessoa úml, guinsburg r. kangaroo–mother care method and neurobehavior of preterm infants. early hum dev. 2016;95:55-59. 6. feitosa mr, gubert f do a, tomé mabg, et al. primary health care follow-up visits: investigation of care continuity of preterm newborns from a kangaroo-mother care unit. published online 2017. 7. corwin e. handbook of pathophysiology.; 2008. 8. sari bm, arismawati df. the effect of kangaroo care method on the change of body temperature in low birth weight infants (lbwi). int j nurs midwifery sci. 2018;2(02):131-136. 9. ramani m, choe ea, major m, et al. kangaroo mother care for the prevention of neonatal south east asia nursing research, vol 2 no 4, december 2020/ page 178-183 183 fenny dwi kurniasih / kangaroo method treatment increases baby's body temperature with low birth weight hypothermia: a randomised controlled trial in term neonates. arch dis child. 2018;103(5):492-497. 10. yusuf n, hadisaputro s, runjati r, suwondo a, mashoedi id, supriyana s. the effectiveness of combination of kangaroo mother care method and lullaby music therapy on vital sign change in infants with low birth weight. belitung nurs j. 2017;3(4):352-359. 11. parsa p, karimi s, basiri b, roshanaei g. the effect of kangaroo mother care on physiological parameters of premature infants in hamadan city, iran. pan afr med j. 2018;30. 12. wong spw, twynstra j, gilliland ja, cook jl, seabrook ja. risk factors and birth outcomes associated with teenage pregnancy: a canadian sample. j pediatr adolesc gynecol. 2020;33(2):153-159. 13. amri i, nur r, harun h, aulia u. number pregnancy and low birth weight (lbw) babies in anutapura hospital in palu city in 2016. enferm clin. 2020;30:219-222. 14. ricci ss, kyle t. maternity and pediatric nursing. wolters kluwer health/lippincott williams & wilkins; 2009. https://books.google.co.id/books?id=gaytfun d7vic 15. wang h, xiao y, zhang l, gao q. maternal early pregnancy vitamin d status in relation to low birth weight and small-for-gestational-age offspring. j steroid biochem mol biol. 2018;175:146-150. 16. rogne t, tielemans mj, chong mf-f, et al. associations of maternal vitamin b12 concentration in pregnancy with the risks of preterm birth and low birth weight: a systematic review and meta-analysis of individual participant data. am j epidemiol. 2017;185(3):212-223. differences in the measurement of the right and left form of blood pressure in hypertension patients corresponding author: eny pujiati eny.pujiati@yahoo.co.id south east asia nursing research, vol 2 no 3, september 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.3.2020.105-110 original research differences in the measurement of the right and left form of blood pressure in hypertension patients anang nurmoko1, ana fadilah1, eny pujiati2 1 stikes cendekia utama kudus, indonesia 2 akper krida husada kudus, indonesia article info abstract article history: submit july 15th, 2020 accepted sept 17th, 2020 published sept 30th 2020 keywords: blood pressure; hypertension hypertension is one of the number one causes of death, globally. hypertension is the most common cause of cardiovascular events and is a major problem in both developed and developing countries. cardiovascular is also the number one cause of death in the world every year. respondents in this study were patients with a diagnosis of hypertension in hospitalized patients at mardi rahayu kudus hospital, totalling 41 people. the characteristics of hypertension patient respondents seen from the age of the most patients are in the late adult age category (36-45 years), namely 31 people (75.6%), while for early adulthood (26-45 years). 35 years) as many as 10 people (24.4%). the characteristics of hypertension patient respondents seen from the sex of the most patients were male, namely 25 people (61.0%), while the female gender was 16 people (39.0%). results the highest systolic blood pressure was 170 mmhg and the lowest was 145 mmhg. the average systolic blood pressure was 152.90 mmhg. in hypertensive patients on the left arm, the highest systolic blood pressure was 170 mmhg and the lowest was 145 mmhg. the average systolic blood pressure was 152.90 mmhg. based on the dependent t-test, the t value is 12.491 with a p-value of 0.000. it can be seen that the p-value is 0.000 < (0.05), this indicates that there is a significant difference in the results of blood pressure measurements between the right arm and the left arm in hypertensive patients in the inpatient room of mardi rahayu kudus hospital. the difference in blood pressure variations obtained in this study is still considered normal because the difference in map between the right and left arms is 6.11 mmhg (normal 10-20 mmhg). introduction hypertension is defined as an increase in blood pressure that remains above an agreed normal limit, ie diastolic 90 mmhg or systolic 140 mmhg. hypertension is one of the number one causes of death, globally. hypertension is the most common cause of cardiovascular events and is a major problem in both developed and developing countries. cardiovascular is also the number one cause of death in the world every year.1 the results of measuring blood pressure are influenced by several factors, namely the activities carried out before the measurement, the pressure or stress to be https://doi.org/10.26714/seanr.2.3.2020.105-110 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.3.2020.105-110&domain=pdf&date_stamp=2020-09-30 south east asia nursing research, vol 2 no 3, september 2020/ page 105-110 106 eny pujiati / differences in the measurement of the right and left form of blood pressure in hypertension patients experienced, the measurement time, and the position when the measurement is standing or sitting2. lifestyle changes such as smoking, obesity, physical inactivity and psychosocial stress can cause various diseases, one of which can attack the cardiovascular system, especially hypertension. who, data shows that around 1.13 billion people in the world suffer from hypertension. this means that 1 in 3 people in the world are diagnosed with hypertension, only 36.8% of them are taking medication. the number of hypertension sufferers in the world continues to increase every year, it is estimated that by 2025 there will be 1.5 billion people affected by hypertension. it is also estimated that every year 9.4 million people die from hypertension and complications.3 in indonesia, based on kemenkes ri, 2019 data, the prevalence of hypertension in indonesia is 25.8%, the highest prevalence is in bangka belitung (30%) and the lowest is in papua (16.8%). meanwhile, data from the 2016 national health indicator survey shows an increase in the prevalence of hypertension among people aged 18 years and over by 32.4%.4 in addition, according to bpjs health data, the cost of hypertension services has increased every year, namely rp. 2.8 trillion in 2014, rp. 3.8 trillion in 2015, and rp. 4.2 trillion in 2016. based on the basic health research (riskesdas) the prevalence of hypertension in central java increased from 7.6 per million in 2007 to 9.5 peril in 2013.5 this means that out of a thousand inhabitants it is estimated that there are more than 9 people suffering from this disease. meanwhile, based on data from the central java provincial health office 2017, of the eleven types of non-communicable diseases, hypertension is the most common disease suffered by the people of central java with a proportion of 55%, while the data available at mardi rahayu kudus hospital between january to october 2018 were obtained. hypertension cases were 1340 cases.6 hypertension which continues to increase should be controlled. the way is to measure blood pressure correctly. according to several existing theories that the way blood pressure measurements should be done on both arms (right and left). variations in blood pressure can be found in different arteries. normal variation is common in both arms, but should not exceed 5 10 mmhg. a difference of more than 10 mmhg is an indication of vascular disorders, and if the difference is greater than 20-30 mmhg in both arms indicates a suspicion of organic disturbances in blood flow in areas with low blood pressure.2 in fact, where there is measurement of blood pressure on only one arm, especially at mardi rahayu kudus hospital. likewise, when facing snars accreditation in 2018, blood pressure measurement tools are required to use a digital tensimeter related to mercury tensimeter which is not recommended again.7 from these phenomena, this study aims to determine the differences in measurements on the right and left arms of the results of blood pressure in hypertensive patients in the inpatient room of mardi rahayu kudus hospital. methods the design of this study is to use a comparative analytical research design with a cross sectional approach, where the research object is only observed once and measurements are made of the status of the character or object variable at the time of examination by approaching and collecting data at once. the measuring instrument uses a digital tensimeter. the test test used is the dependent t test. the sample in this study was 41 respondents at the mardi rahayu kudus hospital in april 2019 with a purporsive sampling technique. in this study, researchers took blood pressure measurements taken on the respondents' right and left arms, then analyzed the extent to which the measurement results differed in the respondent's two arms. south east asia nursing research, vol 2 no 3, september 2020/ page 105-110 107 eny pujiati / differences in the measurement of the right and left form of blood pressure in hypertension patients results respondents in this study were patients with a diagnosis of hypertension in hospitalized patients at mardi rahayu kudus hospital, totaling 41 people. based on table 1 above, it shows that the characteristics of hypertension patient respondents seen from the age of the most patients are in the late adult age category (36-45 years), namely 31 people (75.6%), while for early adulthood (26-45 years). 35 years) as many as 10 people (24.4%). it shows that the characteristics of hypertension patient respondents seen from the sex of the most patients were male, namely 25 people (61.0%), while the female gender was 16 people (39.0%). table 1 frequency distribution based on age and gender of hypertension patients in the inpatient room indicators f % age early adult 10 24,4 late adult 31 75,6 sex man 25 61,0 female 16 39,0 the result shows that the results of measuring the blood pressure of hypertensive patients on the right arm, the highest systolic blood pressure is 175 mmhg and the lowest is 150 mmhg. the mean systolic blood pressure was 159.68 mmhg with a standard deviation of 6.28 mmhg. then for diastolic blood pressure has a highest value of 120 mmhg and a low value of 95 mmhg. the average diastolic pressure was 105.56 mmhg with a standard deviation of 5.78 mmhg. furthermore, from the results of systolic and diastolic blood pressure in the right arm, the highest map value was 138.3 mmhg and the lowest was 114.0 mmhg with an average result of 122.94 mmhg with a standard deviation of 5.44 mmhg. based on table 2, it shows that the results of measuring blood pressure in hypertensive patients on the left arm, the highest systolic blood pressure is 170 mmhg and the lowest is 145 mmhg. the mean systolic blood pressure was 152.90 mmhg with a standard deviation of 5.93 mmhg. then for diastolic blood pressure, the highest blood pressure is 110 mmhg and the lowest is 85 mmhg. diastolic blood pressure averaged 98.80 mmhg with a standard deviation of 5.8 mmhg. furthermore, from the systolic and diastolic blood pressure results in the left arm, the highest map value was 130.0 mmhg and the lowest map value was 106.0 mmhg, with an average result of 116.83 mmhg with a standard deviation of 5.59 mmhg. this bivariate analysis was used to determine differences in measurements on the right and left arms of the results of blood pressure in hypertensive patients in the inpatient room of mardi rahayu kudus hospital. to find out this difference, a difference test in the results of the map of the right and left arms was used in hypertensive patients using the dependent t test. based on table 2, it shows that the average map result for the right arm is 122.94 mmhg, while on the left arm shows the map result is lower, which is 116.83 mmhg, with an average map difference of 6.11 mmhg. furthermore, after the normality test was carried out, it was found that the two data were normally distributed, namely map kiri sig. 0.821 and map right sig. 0.346 (p> 0.05). based on the results of the normality test, then continued with the dependent t test, the t value is -12.491 with a p-value of 0.000. it can be seen that the p-value is 0.000 < (0.05), this indicates that there is a significant difference in the results of blood pressure measurements between the right arm and the left arm in hypertensive patients in the inpatient room of mardi rahayu kudus hospital. south east asia nursing research, vol 2 no 3, september 2020/ page 105-110 108 eny pujiati / differences in the measurement of the right and left form of blood pressure in hypertension patients table 2 mean differences of blood pressure in the right and left arm in patients hypertension in the inpatient room (n=82) indicators group p right arm left arm systolic 159,68 (±6,28) 152,90 (±5,93) 0.000 diastolic 104,56 (±5,78) 98,80 (±5,88) map 122,94 (±5,44) 116,83 (±5,59) discussion based on the research conducted, it shows that the results of blood pressure measurements of hypertensive patients on the right arm, the highest systolic blood pressure is 175 mmhg and the lowest is 150 mmhg. the mean systolic blood pressure was 159.68 mmhg with a standard deviation of 6.28 mmhg. then for diastolic blood pressure has a highest value of 120 mmhg and a low value of 95 mmhg. the average diastolic pressure was 105.56 mmhg with a standard deviation of 5.78 mmhg. furthermore, from the results of systolic and diastolic blood pressure in the right arm, the highest map value was 138.3 mmhg and the lowest was 114.0 mmhg with an average result of 122.94 mmhg with a standard deviation of 5.44 mmhg. the results of this study were obtained after measuring the right arm of 41 respondents who suffered from hypertension by measuring the patient in a lying position on the bed. the highest systolic blood pressure value was 170 mmhg and the lowest was 150 mmhg and the highest diastolic pressure was 120 mmhg and the lowest was 95 mmhg. this is in accordance with the theory which says that a person is said to have hypertension, which means that the average arterial pressure is higher than the limit considered normal. in a resting state when the mean arterial pressure is higher than 110 mmhg (normal around 90 mmhg) then this is considered hypertension; this value occurs when the diastolic blood pressure is greater than 90 mmhg and the systolic pressure is greater than approximately 135 to 140 mmhg.8 many factors play a role in the occurrence of hypertension, apart from cardiac output factors, peripheral vessel resistance, blood volume, viscosity and elasticity of the walls of blood vessels in a person's body which causes blood pressure not to be constant. artiyaningrum, b., azam, m 2016 identified several conditions that can affect blood pressure, including age, weight, emotions, activity, race, gender, and drugs. in the study, the most age group suffering from hypertension was late adulthood (aged 3645 years), namely 31 people (75.6%) from a total of 41 respondents. this is in accordance with the theory that a person's age affects blood pressure in humans, the older a person, generally his blood pressure will increase.9 in children there is no significant difference in blood pressure between boys and girls. however, after puberty, men tend to have higher blood pressure. conversely, after menopause women have higher blood pressure than men their age. this is in line with the results of the research obtained, that some of the respondents were male, namely 25 people (61.0%), while the female gender was 16 people (39.0%). based on the results of the study showed that the results of measuring blood pressure in hypertensive patients on the left arm, obtained the highest systolic blood pressure of 170 mmhg and the lowest of 145 mmhg. the mean systolic blood pressure was 152.90 mmhg with a standard deviation of 5.93 mmhg. then for diastolic blood pressure, the highest blood pressure is 110 mmhg and the lowest is 85 mmhg. diastolic blood pressure averaged 98.80 mmhg with a standard deviation of 5.8 mmhg. furthermore, from the systolic and diastolic blood pressure results in the left arm, the highest map value was 130.0 mmhg and the lowest map value was 106.0 mmhg, with an average result of 116.83 mmhg with a standard deviation of 5.59 mmhg. south east asia nursing research, vol 2 no 3, september 2020/ page 105-110 109 eny pujiati / differences in the measurement of the right and left form of blood pressure in hypertension patients the results of this study were also obtained after measuring the left arm of 41 respondents who suffered from hypertension by measuring the patient in a lying position on the bed. the age group suffering from hypertension ranged from 36-45 years and there were more men. hypertension or high blood pressure is an increase in systolic blood pressure of more than 140 mmhg and diastolic blood pressure of more than 90 mmhg on two measurements with an interval of five minutes in a state of rest / calm.5 based on the results of research related to differences in measurements on the right and left arms on the results of blood pressure in hypertensive patients in the inpatient room of mardi rahayu kudus hospital, it was found that there was a significant difference in measurements between the right arm and the left arm. this is indicated by the map average result for the right arm of 122.94 mmhg, while the left arm shows the lower map result of 116.83 mmhg, with an average map difference of 6.11 mmhg. after doing the test with the dependent t test, the t value is -12.491 with a p-value of 0.000. it can be seen that the pvalue is 0.000 <  (0.05), this indicates that there is a significant difference in the results of blood pressure measurements between the right arm and the left arm in hypertensive patients in the inpatient room of mardi rahayu kudus hospital. the difference in blood pressure variations obtained in this study is still considered normal because the difference in map between the right and left arms is 6.11 mmhg, this is supported by the theory that blood pressure variations can be found in different arteries. normal variation is common in both arms, but should not exceed 5 10 mmhg. a difference of more than 10 mmhg is an indication of a vascular disorder, and if the difference is greater than 20-30 mmhg in both arms, it indicates a suspicion of an organic disturbance of blood flow in areas with low blood pressure.2 high blood pressure (hypertension) is an increase in blood pressure in the arteries. in general, hypertension is an asymptomatic condition, in which abnormally high pressure in the arteries leads to an increased risk of stroke, aneurysm, heart failure, heart attack and kidney damage. meanwhile, according to iqbal and jamal, hypertension is a condition in which a person experiences an increase in blood pressure above normal which results in an increase in morbidity and mortality.10 blood pressure in adults is classified into 6, namely normal blood pressure, high normal, stage 1 (mild hypertension), stage 2 (moderate hypertension), stage 3 (severe hypertension), and stage 4 (malignant hypertension). normal blood pressure is blood pressure where the systolic pressure is below 130 mmhg and the diastolic pressure is below 85 mmhg, while normal high blood pressure is blood pressure where the systolic pressure is 130-139 mmhg and the diastolic pressure is 85-89 mmhg. stage i blood pressure (mild hypertension) is blood pressure where the systolic pressure is 140-159 mmhg and the diastolic pressure is 90-99 mmhg. stage 2 blood pressure (moderate hypertension) is blood pressure where the systolic pressure is 160-179 mmhg and the diastolic pressure is 100-109 mmhg. stage 3 blood pressure (severe hypertension) is blood pressure where the systolic pressure is 180-209 mmhg and the diastolic pressure is 110-119 mmhg. stage 4 blood pressure (malignant hypertension) is blood pressure where the systolic pressure is 210 mmhg or more and the diastolic pressure is 120 mmhg or more.10 the results of the above study are also in line with the previous study entitled "analysis of differences in the results of blood pressure measurements between the right arm and the left arm in hypertensive patients at rsud. dr.h. abdul moeloek, lampung province" by arwani and sunarno. the results of statistical analysis show that there is a significant difference south east asia nursing research, vol 2 no 3, september 2020/ page 105-110 110 eny pujiati / differences in the measurement of the right and left form of blood pressure in hypertension patients between the results of blood pressure measurements taken on the right arm and the results of blood pressure measurements taken on the left arm in hypertensive patients at rsud dr. h. abdul moeloek lampung (p = 0.012). conclusion based on the dependent t test, the t value is -12.491 with a p-value of 0.000. it can be seen that the p-value is 0.000 < 0.05, this indicates that there is a significant difference in the results of blood pressure measurements between the right arm and the left arm in hypertensive patients in the inpatient room of mardi rahayu kudus hospital. the difference in blood pressure variations obtained in this study is still considered normal because the difference in map between the right and left arms is 6.11 mmhg (normal 10-20 mmhg). acknowledgments the researcher would like to say thank you to all respondents who participated in this research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. carey rm, whelton pk, aronow ws, et al. prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 american college of cardiology/american heart association hypertension guideline. ann intern med 2018; 168: 351–358. 2. ratulangi usam, danes vr, skripsi k, et al. analisa hasil pengukuran tekanan darah antara posisi duduk dan posisi berdiri pada mahasiswa semester vii (tujuh) ta. 2014/2015 fakultas kedokteran universitas sam ratulangi. ebiomedik 2015; 3: 125–129. 3. organization wh. world health statistics overview 2019: monitoring health for the sdgs, sustainable development goals. geneva, 2019. 4. badan penelitian dan pengembangan kesehatan. riset kesehatan dasar (riskesdas) 2013. lap nas 2013 2013; 1–384. 5. kementerian kesehatan. hasil utama riset kesehata dasar (riskesdas). 2018. epub ahead of print 2018. doi: 10.1088/17518113/44/8/085201. 6. dinas kesehatan provinsi jawa tengah. profil kesehatan provinsi jateng tahun 2019. 2019. 7. komisi akreditasi rumah sakit. standar nasional akreditasi rumah sakit edisi 1. 2017; 421. 8. tanto c, liwang f, hanifati s pe. kapita selekta kedokteran. 2017. 9. muhadi. jnc 8 : evidence-based guideline penanganan pasien hipertensi dewasa. cermin dunia kedokt 2016; 43: 54–59. 10. iqbal am js. essential hypertension. [updated 2020 jul 10]. treasure island (fl): statpearls publishing 2020; https://www.ncbi.nlm.nih.gov/books/nbk539 859/. does senior high school strand matter in nursing students’ academic self-regulated learning and academic performance? corresponding author: ryan michael f. oducado rmoducado@wvsu.edu.ph south east asia nursing research, vol 3 no 1, march 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.1.2021.1-7 original research does senior high school strand matter in nursing students’ academic selfregulated learning and academic performance? xerxes g. malaga1, ryan michael f. oducado2 1 negros occidental comprehensive health program, philippines 2 west visayas state university, philippines article info abstract article history: submit jan 25th, 2021 accepted march 6th, 2021 published march 28th 2021 keywords: academic performance; high school strand; nursing; selfregulated learning; students the philippines recently adopted the k to 12 program in basic education. under this program, students can choose their track and strand relative to their interests or career choices when they reach senior high school. however, issues surfaced when the k to 12 graduates were admitted to the college courses not aligned with the strand they have completed. this crosssectional study was conducted to determine the difference in the academic self-regulated learning and performance of the stem (science and technology, engineering, and mathematics) and non-stem graduates in senior high school among freshmen nursing students in a city-subsidized college in the philippines. the academic self-regulation learning scale and grades of students in the first semester were used and analyzed in this study. results showed that there was a significant difference in the academic selfregulated learning (p=0.045) and academic performance (p=0.000) of freshmen nursing students when grouped according to their senior high school strand. the stem graduates had significantly higher academic selfregulated learning and academic performance than the non-stem completers. unfortunately, no significant relationship was established between academic self-regulated learning and academic performance (p=0.559). students who are graduates of the stem strand from senior high school appear to be better prepared to take up the nursing course. colleges of nursing may consider the academic strand of students in senior high school when admitting students in the nursing program. introduction education expands our vision and outlook of the world. hence, it is no wonder that many countries including the philippines are in the molding process of making education the primary asset the country could have. not so long ago, the philippine basic education implemented k-12 curriculum that has been legalized by the republic act 10533.1 the republic act no. 10533 (2013) otherwise known as the enhanced basic education act of 2013 adds two years of senior high school education. high school now has two divisions: the junior and senior high school, and students in the country must pass through the two divisions to earn a high school diploma and qualify to enter college or university. under this program, students are to choose their own track or strand according to their preference, or field of interest, or decide to https://doi.org/10.26714/seanr.3.1.2021.1-7 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.1.2021.1-7&domain=pdf&date_stamp=2021-03-28 south east asia nursing research, vol 3 no 1, march 2021/ page 1-7 2 ryan michael f. oducado / does senior high school strand matter in nursing students’ academic self-regulated learning and academic performance? venture out employment for the next two years of senior high school education. the senior high school students undertake a standard core curriculum and can choose from four tracks of specialization: academic, technical-vocational and livelihood (tvl), sports, and arts and design.3 these tracks are specific areas of study similar to college courses.4 the academic track is further divided into four strands: science, technology, engineering, and mathematics (stem); accountancy, business, and management (abm); humanities and social sciences (humss); and general academic.3 having an ideal strand offer learners a sense of self-assurance and can help students to be passionate about their chosen career.5 alignment to the chosen college course was the main reason of students enrolling in the stem strand.6 besides, a study found that stem status significantly predicted retention and graduation outcomes.7 poor adjustment and academic performance to the health science courses also contribute to dropout rates of students.8 however, the commission on higher education (2017) in the philippines released a memorandum order indicating that all grade 12 senior high school graduates are eligible to enter college irrespective of the strand or track they have taken in senior high school.9 the problem arises when the k to12 graduates are to pursue a college degree that is not related to the strand they finished during their senior high school years. difficulties arise in a sense that that the subjects taken in senior high school are not aligned to the desired academic program, or the skills and knowledge learned by the students in senior high school might not be enough to compensate to the demands of the chosen college degree.10 thus, this study was conducted to determine if there were significant differences in academic performance of k to 12 graduates specifically from the stem and non-stem strand as they unveil their college journey into nursing as their chosen college academic program. it is imperative for nursing educators to understand and regularly assess the academic performance of students.11 research on students’ academic performance or academic achievement is important because it is one of the indicators of students’ success in learning.12–14 moreover, academic and career guidance are among the expressed guidance needs of nursing students.15 helping students understand their likely success in their chosen college degree is thereby necessary. meanwhile, knowing the concept of selfregulated learning is necessary in today’s social and academic world.16 self-regulated learning has been applauded as the key competence to lifelong learning.17 despite being a well-studied topic in the fields of psychology and education, limited research focused on its relationship to the academic performance of nursing students. understanding self-regulation is essential in the development of students’ capabilities and achievement.16 in this study, we also investigated the relationship between selfregulated learning and academic performance among nursing students. methods the research design utilized in the study was cross-sectional research. this study was conducted among 112 freshmen or first-year nursing students in a citysubsidized college in the western visayas region of the philippines. the instrument used was the academic selfregulated learning scale (a-srl-s) developed by magno (2010) to measure self-regulation within the context of students’ learning in higher education. each item is scaled using a four-point likert scale (1-strongly disagree to 4-strongly agree). the a-srl-s contains 54 items with seven (7) subscales. the scale has been reported to have high validity and reliability measures when tested among filipino college students. the internal consistency of south east asia nursing research, vol 3 no 1, march 2021/ page 1-7 3 ryan michael f. oducado / does senior high school strand matter in nursing students’ academic self-regulated learning and academic performance? the seven subscales was between 0.70 and 0.84 18. for this study, the a-srl-s has an overall reliability of cronbach’s alpha 0.95. the survey questionnaires were distributed personally to the students of the said department after their lecture classes. directions were given as to how to answer and fill up the survey instrument. the whole content of the survey instrument was discussed before the participants can answer the questionnaires to avoid confusion. after signing the informed consent forms, the respondents were given ample time (30 minutes) to fill up the said questionnaires. afterwards, the researchers personally retrieved the said questionnaires then checked for completeness of responses. the academic performance of students was measured using their actual grades in the first semester of the academic year 20182019 taken from the office of the registrar with permission from the college dean and after participants consented to partake in the study. a demographic profile sheet was also used to collect pertinent demographic data and identify the academic strand of students. in this study, the students were categorized as either stem or non-stem strand (includes abm, humss, and general academic strands of the academic track and other tracks). data analysis was carried out using spss version 23. mean, standard deviation, frequency, and percentage were used for descriptive analysis. mann-whitney u test was employed to determine significant differences while spearman’s rho was utilized to measure the relationship between academic self-regulation and performance. alpha level of significance was set at 0.05. results table 1 present the profile of the participants. the average age of freshman nursing students was 18.86 (sd=0.73) years. the majority (83.9%) of the students were females. most (81.2%) students belonged to families with an average monthly salary of 15,780 pesos/month or less. a little over half (51.8%) had 4 or more siblings. a little over two-thirds (68.7%) were graduates of the non-stem strand in senior high school. table 2 shows that the composite mean score of nursing students in the a-srl-s was 3.31 (sd=0.53). the mean score of the graduates of the stem strand and nonstem strand were 3.35(sd=0.34), and 3.29 (sd=0.53), respectively. moreover, the mean average grade reflecting the academic performance of first-year nursing students in the first semester was 91.35 (sd=0.67). the mean average grade of the graduates of the stem strand and non-stem strand were 92.39(sd=1.32), and 90.87 (sd=1.60), respectively. table 3 shows that there was a significant difference in academic self-regulated learning and academic performance of freshmen nursing students based on their senior high school strand. graduates of the stem strand were significantly more (p=0.045) self–regulated learners compared to the graduates of the non-stem strand. at the same time, graduates of the stem strand had a significantly higher (p=0.000) academic performance than the graduates of the non-stem strand. table 4 shows that there was no significant relationship (p=0.559) between academic self-regulated learning and academic performance of freshman nursing students. south east asia nursing research, vol 3 no 1, march 2021/ page 1-7 4 ryan michael f. oducado / does senior high school strand matter in nursing students’ academic self-regulated learning and academic performance? table 1 profile and strand in high school m sd f % age (years) 18.86 0.73 sex male 18 16.1 female 94 83.9 monthly family income less than 7,890/month 52 46.4 between 7,890 to 15,780/month 39 34.8 between 15,781 to 31,560/month 17 15.2 above 31,561/month 4 3.6 number of siblings 3 or less 45 40.2 4 or more 58 51.8 no siblings 9 8.0 senior high school (shs) strand stem 35 31.3 non-stem 77 68.7 table 2 academic self-regulation and academic performance variables general stem non-stem m sd m sd m sd academic self-regulated learning 3.31 0.53 3.35 0.34 3.29 0.53 academic performance 91.35 0.67 92.39 1.32 90.87 1.60 table 3 differences in academic self-regulated learning and performance variables academic self-regulated learning academic performance shs strand mean rank u p-value mean rank u p-value stem 65.63 1028.0 0.045 77.41 615.5 0.000 non-stem 53.45 46.99 table 4 academic self-regulation and academic performance variables correlation coefficient p-value academic self-regulation and performance -0.050 0.599 discussion this study investigated the difference in academic self-regulated learning and academic performance among nursing students between graduates of stem and non-stem strand. this study came about after observing students who were nonstem completers were struggling in their science and nursing courses. it has also been observed that their grades were lower in these courses. on the other hand, stem completers have shown remarkable grades in their science and nursing courses. in this study, we found that the academic self-regulated learning and performance of nursing students varied according to their senior high school academic strand. ideally, stem completers are supposed to enroll in nursing. their track and strand are geared towards learning the foundations of academic subjects aligned with the nursing program. our results also indicate that south east asia nursing research, vol 3 no 1, march 2021/ page 1-7 5 ryan michael f. oducado / does senior high school strand matter in nursing students’ academic self-regulated learning and academic performance? graduates of the stem strand had a higher academic self-regulation suggesting that these students are better in terms of planning and organizing, goal-setting, selfevaluation, memory strategy, learning responsibility, seeking assistance, and environmental structuring. similar findings were reported in prior studies. graduates of the stem academic strand had a significantly higher academic performance compared to the non-stem strand graduates. a significant difference in the academic adjustment and performance of freshmen students from different health science disciplines in the philippines was similarly noted in another study.19 a study among engineering students likewise found a significant difference in the calculus 1 performance between students from the stem and non-stem strands.4 students from the stem strand also performed better academically in the applied chemistry course.20 our findings seem to indicate that the stem graduates are likely to succeed in the nursing program with minor difficulties and adjustments as compared to their non-stem counterparts. in addition, our results seem to point out that the k to 12 program of the philippines plays a significant role in preparing senior high school students for their chosen career path if followed appropriately. moreover, our study demonstrated no correlation between academic selfregulation and academic performance among freshmen nursing students. no significant correlation between selfregulation and educational performance among public university students was also reported by sahranavard, miri, & salehiniya (2018).21 no relationship between academic self-regulation and their academic performance was also disclosed in a study among senior high school students in the philippines.22 high self-regulation did not predict school ability in another study.23 it has also been noted that not all selfregulated learning strategies exerted the same influences on academic achievement and a decreasing trend on the effect size between self-regulated learning and academic achievement was observed.17 however, our result is contrary to other studies conducted in other disciplines. a weak positive association between selfregulated learning and academic achievement was found among undergraduate medical students.13 a study among preparatory school students at cag university in mersin, turkey revealed that the more students use self-regulation strategies, the more likely they become academically successful.24 self-regulation of learning and achievement were significantly correlated among the undergraduate program in the faculty of psychology at padjadjaran university.25 four of five domains of self-regulated learning had a positive impact on academic performance of students in another study.26 the variation in findings may be attributed to the different measures used to assess self-regulated learning between studies and also to the relatively limited sample of our study. nonetheless, further research is required to confirm our findings. it is argued that self-regulated learning is a complex phenomenon hence, future scholars need to pay more attention to the different dimensions of self-regulated learning in relation to academic achievement.16 this research has limitations. this study only included first-year nursing students in one nursing school in the philippines who were enrolled in the academic year 20182019. findings cannot be generalized in all schools and students locally and in other countries. also, this study is limited to the academic performance of students in one semester only. future researchers may compare the difference between strands upon completion of the degree. furthermore, our research relied only on self-administered questionnaires for data collection and the cross-sectional research design of our research cannot establish a causal effect of the independent variable to the outcome variable. nonetheless, this south east asia nursing research, vol 3 no 1, march 2021/ page 1-7 6 ryan michael f. oducado / does senior high school strand matter in nursing students’ academic self-regulated learning and academic performance? research has contributed to the limited but growing research on the topic. conclusion the strand or track of students in senior high school influences their academic selfregulated learning and academic performance. students’ stranding in senior high school has prepared them for a better transition in college especially in the nursing program. students who are graduates of the academic stem strand from senior high school appear to be more prepared to take up the nursing course, better able to cope with the demands of the course, and are likely to excel in the nursing school. our study recommends that high school students should be given proper career guidance relative to the course they intend to take in college. likewise, colleges of nursing may consider the academic strand of students in senior high school when admitting students in the nursing program. moreover, our study suggests that added attention and guidance must be provided to non-stem students admitted in the undergraduate nursing program. acknowledgments the authors are grateful to their participants. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. rabacal js, alegato cc. k-12 stem track in one public secondary school: opportunities and challenges. asia pacific j multidiscip res. 2017;5:28–33. 2. republic act no. 10533. an act enhancing the philippine basic education system by strengthening its curriculum and increasing the number of years for basic education, appropriating funds therefor and for other purposes. 2013. 3. development asia. factors affecting senior high school track offerings in the philippines. 2019. 4. molina mg. comparison of the calculus 1 performance of engineering students from stem and non-stem shs strands. pupil int j teaching, educ learn. 2019;3:103–23. 5. magdadaro lrp. passion-based vs. practicalbased preference of strand in senior high school. int j acad res bus soc sci. 2020;10. 6. rafanan rjl, de guzman cy, rogayan d v. pursuing stem careers: perspectives of senior high school students. particip educ res. 2020;7:38–58. 7. whalen d, shelley m. academic success for stem and non-stem majors. j stem educ. 2010;11. 8. mcfarland, stark, cui. trends in high school dropout and completion rates in the united states: 2014. 2016. 9. commission on higher education. ched memorandum order no. 105 series of 2017: policy on the admission of shs graduates to the higher education institutions effective academic year 2018-2019. 2017. 10. magtibay rg, los baños z. the effect of k to 12 strand on first year bit food technology students in pursuing their higher education. int j recent innov acad res. 2019;3:39–46. 11. oducado rmf. are nursing students’ early course and perceived performance related to their final and actual course performance? nurse media j nurs. 2019;9:167–75. 12. oducado rmf, penuela ac. predictors of academic performance in professional nursing courses in a private nursing school in kalibo, aklan, philippines. asia pacific j educ arts sci. 2014;1:21–8. 13. ningrum rk, kumara a, prabandari ys. the relationship between self-regulated learning and academic achievement of undergraduate medical students. in: iop conference series: materials science and engineering. institute of physics publishing; 2018. p. 012155. 14. oducado rmf, sotelo mg, ramirez lmm, habaña mp, belo-delariarte rg. english language proficiency and its relationship with academic performance and the nurse licensure examination. nurse media j nurs. 2020;10:46– 56. 15. oducado rmf, frigillano prs, gunce jjt, jover plb, meliton pn, pangilinan kt. guidance needs of nursing students in iloilo city, philippines. peers inc. 2017;1:35–47. 16. xiao s, yao k, wang t. the relationships of selfregulated learning and academic achievement south east asia nursing research, vol 3 no 1, march 2021/ page 1-7 7 ryan michael f. oducado / does senior high school strand matter in nursing students’ academic self-regulated learning and academic performance? in university students. shs web conf. 2019;60:01003. 17. li j, ye h, tang y, zhou z, hu x. what are the effects of self-regulation phases and strategies for chinese students? a meta-analysis of two decades research of the association between self-regulation and academic performance. vol. 9, frontiers in psychology. frontiers media s.a.; 2018. 18. magno c. assessing academic self-regulated learning among filipino college students: the factor structure and item fit. int j educ psychol assess. 2010;5:61–76. 19. alipio m. academic adjustment and performance among filipino freshmen college students in the health sciences: does senior high school strand matter? 2020; 20. magtibay rg, caballes dg. the k to 12 strands taken by first year bit food technology students and its effect on their academic performance in applied chemistry. . int j recent innov acad res. 2019;3:39–46. 21. sahranavard s, miri mr, salehiniya h. the relationship between self-regulation and educational performance in students. j educ health promot. 2018;7:154. 22. abun d, magallanes t. academic self-regulation of stem of senior high school students of divine word colleges in region i, philippines and their academic performance. texila int j acad res. 2018;5:14–30. 23. johny l, lukose l, magno c. the assessment of academic self-regulation and learning strategies: can they predict school ability? educ meas eval rev. 2012;3:75–86. 24. yeniçıkan s. the relationship between selfregulation strategies and academic achievement at a university context. çağ üniversitesi sosyal bilimler enstitüsü; 2020. 25. agustiani h, cahyad s, musa m. self-efficacy and self-regulated learning as predictors of students academic performance. open psychol j. 2016;9:1–6. 26. ejubović a, puška a. impact of self-regulated learning on academic performance and satisfaction of students in the online environment. knowl manag e-learning an int j knowl manag e-learning. 2019;11:345–63. the relationship between knowledge and medication compliance behavior among patients with tuberculosis corresponding author: jufri hidayat jufrihidayat89@gmail.com south east asia nursing research, vol 2 no 2, june 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.2.2020.1-9 original research the relationship between knowledge and medication compliance behavior among patients with tuberculosis jufri hidayat1, mei-chen lee1, mei-chen lee1, mei-chen lee1 1 national taipei university of nursing and health science, taiwan article info abstract article history: accepted may 24th, 2020 keywords: tuberculosis; tb knowledge; medication adherence; medication compliance behavior tuberculosis (tb) remains the highest priority among infectious diseases in the world today with increasing morbidity and mortality every year. adherence to treatment plays an important role in the success of therapy among tb patients. this study aims to explore the relationship between demographic characteristics, knowledge, and medication compliance behavior among patients with tuberculosis in indonesia. this study was descriptive correlational and cross-sectional design with the total sample was 150 tuberculosis confirmed in medan pulmonary hospital, indonesia. in this study found that there is a significant relationship between ethnicity and medication adherence (continues variable) with p = 0.01. meanwhile when medication compliance behavior was treated as categorical variables, a significant relationship was found between medication compliance behavior and medical history (p = 0.03), smoking (p = 0.005), and alcohol (p = 0.03) among tuberculosis patients in indonesia. in the multivariate analysis, multiple linear regression was performed which surprisingly shows that education was significantly associated with knowledge of tb (p = 0,02), and ethnicity (0.04). introduction the world health organization (who) ranks tuberculosis as the top priority among infectious diseases in the world today. according to who data, in 2018, tuberculosis was among the top 15 death by cause with over one million patients.28 globally, in 2016, the estimated incidence of tuberculosis was 10.4 million cases, equivalent to 120 per 100,000 persons. in recent decades, the countries with the highest incidence of tuberculosis are india, china, indonesia, nigeria, and pakistan, in that order. nationally, in indonesia, the number of new cases of tuberculosis reached 420,994 in 2018, with a prevalence rate of 297/100,000 and an incidence rate of 403/100,000 people. in 2017 there were more than 1,000 reported deaths from tuberculosis in indonesia, which means 189 deaths per 100,000 persons. there were 3 cases among men for every 1 woman newly diagnosed with the disease.6 several studies show that knowledge about the disease is a significant factor in its spread and distribution. in indonesia, one factor that causes the high incidence of tuberculosis is the public’s lack of knowledge about the causes, signs, symptoms, transmission, and treatments of https://doi.org/10.26714/seanr.2.2.2020.1-9 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.2.2020.1-9&domain=pdf&date_stamp=2020-06-30 south east asia nursing research, vol 2 no 2, june 2020/ page 46-54 47 jufri hidayat / the relationship between knowledge and medication compliance behavior among patients with tuberculosis tuberculosis infection.6 a study in tanzania showed that many tb patients there believe tuberculosis is caused by heredity, punishment from god, and spread by white people.19 however, a study in the united state revealed that sufficient knowledge can lead to good attitudes and behaviour for managing the disease and helping to control its spread in the community. furthermore, worldwide, studies have shown that providing patients with adequate knowledge about tuberculosis can significantly improve their treatment adherence, as found by a study done in ethiopia and studies elsewhere.14, 17, 18 similarly, a study in malawi found that tb patients’ treatment-seeking behaviour is influenced by their level of knowledge about the disease.19 likewise, a study in indonesia concluded that knowledge about tuberculosis and risk perception about the disease affects health-care-seeking behavior.20 adherence to treatment plays an important role in the success of therapy. webb and her colleagues state that compliance as personal actions to promote wellness, recovery, and rehabilitation recommended by a health professional.27 compliance behaviour can also be interpreted as the extent to which the patient acts according to advice from a health care provider. compliance behaviour is a major factor in the successful treatment of tuberculosis patients in particular. many studies have shown that patients in various countries stop tb treatment for various reasons. one study in india revealed that most non-compliant behaviours were caused by lack of knowledge and awareness of the disease, as well as low motivation during therapy.23 similarly, a study in nepal also concluded that patients’ treatment adherence is associated with their knowledge and perceptions of tuberculosis and its treatment.15 the number of tuberculosis patients is still high in indonesia and the prevalence rate stands as the third-highest in the world. there are many patients already suffering and dying from the complications of the disease. some important factors are believed to control the spread of infection. for instance, promoting knowledge through health education can increase adherence to tuberculosis treatment. with adequate knowledge, many patients with tuberculosis will become more compliant and complete treatment. previously, some studies in indonesia have investigated knowledge and compliance behaviour in tuberculosis patients. unfortunately, most of the studies only focused on rehabilitation of adult patients and adolescents and prevention training for health workers and medical students. however, studies emphasizing awareness about tuberculosis and adherence to treatment are still needed. this study will contribute significantly to describing the state of knowledge about the disease and compliance behaviour among tuberculosis patients in indonesia. methods this study was a descriptive correlational and cross-sectional design to identify significant variables and to examine the relationship between them, including demographic data, knowledge of tuberculosis, and medication compliance behaviour. this study used a convenient sampling technique to collect data. a total of 150 participants diagnosed with tuberculosis from chest outpatient clinic, medan pulmonary hospital. the data was collected by using a questionnaire from the tuberculosis knowledge questionnaire developed by dr lock (2011) consisting of 14 question items. as for medication adherence, using the medication adherence scale consisting of 8 question items developed by hayati (2011). the inclusion criteria in this study were male or female aged ≥ 18 years old, diagnosed with tuberculosis (acid-fast bacilli or thorax rontgen) by a specialist south east asia nursing research, vol 2 no 2, june 2020/ page 46-54 48 jufri hidayat / the relationship between knowledge and medication compliance behavior among patients with tuberculosis physician, received tb drug therapy at least one month, and agreed to participate by signing an informed consent form. exclusion criteria are patients who have met the inclusion criteria but those who have failed in first tb treatment, and those who were foreigners. the data collection was performed from july to august 2019. after irb was approved and get permission, the data collection began with patients with positive tuberculosis diagnoses who were visiting for routine checkups. if agreed to participate the researcher has to be explaining the procedures, purpose, and give informed consent. after participants went through these steps, the data collection started using the questionnaire by performing face-to-face interviews. the analysis was done descriptively by describing the patient’s characteristics. in the univariate analysis, the researcher used the pearson correlation, one-way anova, ttest, and chi-square to find the relationship between the variables. the medication compliance behaviour variables were performed two times with different model (categorical and continues). in the multivariate analysis, the researcher used multiple linear regression to find which factors were the most associated with medication compliance behaviour and tuberculosis knowledge. data were collected after obtaining approval from irb ntunhs, department of health north sumatera, indonesia, and the university of north sumatera with the approval number was 1826/vii/sp/2019. results descriptive statistic of the population, tuberculosis knowledge and medication compliance behavior the result showed that the age of participants in this study ranged from 18-78 years old with the mean age score was 40.03 (sd = 16.21). the majority of participants were men (n = 87, 58%), married (n = 75, 50%) and lived in the rural area (n = 94, 62.7%). a large number of participants graduated from senior high school (n= 67, 44.7%), and belongs to the batak ethnic (n = 57, 38.0%). over three-quarters of participants stated that they had heard about tuberculosis before (n = 115, 76.7%). almost two-thirds of the participants revealed that they had a family history of tuberculosis (n = 96, 64.0%), and over onethird said they did not (n = 54, 36%). the great majority of participants stated that they received support from family for carrying out self-care (n = 138, 92.0%), with a smaller number saying they received such support from friends (n = 6, 4.0%), and health workers (n = 5, 3.3%). regarding living arrangements, a large majority lived with family (n = 138, 92.0%), and a much smaller number lived alone (n = 9, 6.0%), with the rest residing in geriatric homes (n = 3, 2.0%). as for participants’ occupations, 2.7% were farmers, 2% were fishermen, 24% were entrepreneurs, 5.3% were civil servants, 37.3% were unemployed, 2% of the participants were retired, and 27% had a mix of other occupations. interestingly, well over half of the participants stated that they did not have a medical history of longterm disease such as diabetes or tuberculosis (n = 91, 60.7%), and ironically, 33% of them were still smoking while taking medication, and 16.7% were still drinking alcohol while on medication. the descriptive statistics were shown in table 1 for the tuberculosis knowledge scale and medical compliance behaviour among patients with tuberculosis. on the tuberculosis questionnaire, possible scores ranged from 0 (minimum) to 14 (maximum). the mean score on tuberculosis knowledge was 8.67 (sd = 2.10), ranging from 1 to 13. among participants, the mean score on medication compliance behaviour was 6.91 (sd = 1.09) ranging from 4 to 8. on this questionnaire, a score of eight is considered compliant; whereas a score less than eight is south east asia nursing research, vol 2 no 2, june 2020/ page 46-54 49 jufri hidayat / the relationship between knowledge and medication compliance behavior among patients with tuberculosis considered noncompliant. in this questionnaire score, 8 is considered compliance; whereas scoring <8 is considered incompliance. table 1 descriptive statistic of the scale scale m sd min max tuberculosis knowledge 8.67 2.10 1.00 13.00 the medication adherence 6.91 1.09 4.00 8.00 the relationship between demographic characteristics to medication compliance behaviour (continues variable). the following table revealed how demographic characteristic associated with medication compliance behaviour (continues variables) among tb patients in indonesia. the result showed that ethnicity had a significant relationship with medication adherence (f = 2.54, p = 0.01). a tukey post hoc test found that the javanese (1) and the batak (2) had better adherence than others (9). meanwhile, another variable including age, gender, and education had no significant relationship with medication adherence among tb patients in indonesia. table 2 characteristics of the participants variables n m ± sd t/f/r p age 40.03 ± 16.21 -0.05c .57 gender -1.45b .15 male 87 6.80 ± 1.12 female 63 7.06 ± 1.03 education 0.24a .96 never 1 6.00 ± 0.00 elementary 22 6.82 ± 1.30 junior secondary school 34 6.97 ± 1.11 senior secondary school 67 6.90 ± 1.12 collage 4 7.00 ± 0.82 university 19 6.95 ± 0.85 master 3 7.33 ± 0.58 ethnicity 2.54a .01* (1) java 50 7.06 ± 1.00 1>9d (2) batak 57 6.93 ± 1.10 2>9d (3) chinese 2 8.00 ± 0.00 (4) mandailing 10 6.60 ± 0.97 (5) minangkabau 4 7.50 ± 0.58 (6) melayu 8 6.63 ± 0.92 (7) karo 9 7.00 ± 1.00 (8) aceh 2 8.00 ± 0.00 (9) others 8 5.63 ± 1.41 (10) geriatric home 3 7.00 ± 1.00 the relationship between demographic characteristics to medication compliance behaviour (categorical variable). another variable that showed significant relationship were medical history (x2 = 4.63, p = 0.03). the result showed that patients with the previous medical history of chronic disease that require long term medication had better adherence in treatment compared to new patients. similarly, there was a significant association between south east asia nursing research, vol 2 no 2, june 2020/ page 46-54 50 jufri hidayat / the relationship between knowledge and medication compliance behavior among patients with tuberculosis smoking and treatment adherence among tb patients in indonesia (x2 = 7.72, p = 0.005). likewise, alcohol showed significant relationship with adherence patients in medication (x2 = 4.91, p = 0.03). table 3 the relationship between demographic characteristics to medication compliance behaviour variabl es medication compliance behaviour t/x2 p incomplian ce n (%) complianc e n (%) medica l history 4.6 3b .03* yes 32 (32.99) 27 (50.94) no 65 (67.01) 26 (49.06) smokin g 7.7 2b .005 ** yes 40 (41.24) 10 (18.87) no 57 (58.76) 43 (81.13) alcohol 4.9 1b .03* yes 21 (21.65) 4 (7.55) no 76 (78.35) 49 (92.45) factors predictors of tuberculosis knowledge and medication compliance behaviour multiple linear regression was conducted to determine the most linear combination of sub-variables in demographic characteristics both knowledge of tb and treatment adherence. two predictors variables including education and ethnicity had a significant result with p = 0.02, and p = 0.04. discussion descriptive statistics of the study population, tuberculosis knowledge, and medication compliance behaviour the age of participants ranged from 18 to 78 years old with a mean age of 40.03 (sd = 16.21), which means that the participants, on average, were still young and productive. this is similar to subjects in a study by dotulong et al. (2015) which observed that patients from 15 to 55 years old had high mobility and outdoor activity, so their potential exposure to pulmonary mycobacterium tuberculosis was also high. subjects in another study done in indonesia also had similar characteristics, with the mean age of tb patients 40 years old.2 likewise, a majority of tb patients in a study done in nepal were between 35 and 54 years old.15 the similarity of those study characteristics might be contributed by the socioeconomic factors and study design. the gender breakdown of participants in this study—87 males (58%) and 63 females (42%)—was similar to that of a study conducted by ratnasari and nurtanty (2018) in her research about tb in indonesia which found that men with tuberculosis were more numerous than women, probably due to heavier workloads, insufficient rest, and unhealthy habits, such as smoking and drinking.22 in ethiopia, tb patients were more common among men than women.1 as for the education background of participants in the current study, most participants (44.7%) graduated from senior high school, 22.7% graduated from junior high school, 14.7% only finish in elementary, 12.7% reached until university, 2.7% finish in college, and only 0.7% do not have formal education. this characteristic is similar to participants in a study conducted in another part in nigeria.25 the fact that most tb participants graduated from senior high school among those countries is probably because of the socioeconomic status where not all people can afford to continue to study at the university level. in this study, most participants’ ethnicity was batak (n = 57, 38%). half of the participants in this study were married (n = 75) and 62.7% (n = 94) lived in rural areas. just over three-quarters of participants also stated that they had heard of tuberculosis before being diagnosed (76.7%, n = 115), south east asia nursing research, vol 2 no 2, june 2020/ page 46-54 51 jufri hidayat / the relationship between knowledge and medication compliance behavior among patients with tuberculosis and 64% had no family history of tuberculosis (n = 96). the relationship between demographic characteristics to medication compliance behaviour (continues variable). the study found that ethnicity had a significant relation (p = 0.01 or less than 0.05) with treatment adherence among tuberculosis patients in indonesia. the posthoc test result showed that both the javanese and the batak ethnicity were more compliant compared to the category of others. others here refers to ethnic groups with only one or two members represented in the data collected, such as the ambonese, the buginese (people from the southsulawesi tribe), or the sundanese (people from west java). the different levels of treatment adherence among ethnicities in indonesia might be attributed to unequal access to health information across the country or to differences in cultural beliefs that affect individual points of viewpoint regarding western-style medication. this finding is similar to findings of studies in other countries that found differences in medication adherence between ethnic groups. for example, in the united states, numerous studies have demonstrated differences in medication adherence between ethnic groups as well as identifying a range of reasons for them. some studies conducted in the u.s. that explored race and ethnicity with adherence to prescription medication among seniors revealed that blacks and hispanics were less likely to adhere to treatment compared to whites. this is one of the reasons why blacks are more likely to die from heart disease than any other u.s ethnic group and hispanic americans have twice the mortality from diabetes compared to whites.9, 10 likewise, one literature review which explored medication adherence to oral hypoglycemic agents among diabetes patients in different ethnic groups reported that filipinos had poorer medication adherence, while blacks were less adherent to medication treatment, compared to whites.21 although little research had done on differences between ethnicities in indonesia due to the political sensitivity of the topic, it seems likely that there are economic and educational differences between groups. moreover, access to medical care may be affected by geographic factors as medical professionals tend to be concentrated in urban areas, but some ethnicities live primarily in rural areas. the relationship between demographic characteristics to medication compliance behaviour (categorical variable). this section will show another study finding form different model of medication compliance behaviour. in the previous section, the medication compliance variable was treated as a continuous variable. however, in this part, the variable will be treated as categorical. this study found that the medical history of chronic illness was significantly associated with medication adherence of tuberculosis patients in indonesia. the study result showed that tb patients with a history of long-term disease with long-term treatment tend to be more compliant compared to tb patients without a medical history. the experience of long-term medication train patients to be more discipline in medication timing, dosage, and duration. this result is similar to studies from some countries. a study by urata and colleagues about the impact of diabetes perception on medication adherence among diabetes patients in japan found that patients with long-term medication history were consistently had greater adherence than patients without medication history, had a higher percentage of recovery and had low percentage of failing in treatment.26 similarly, a study by choi found that having experience of tb treatment was associated with good medication adherence among tb patients in korea.4 south east asia nursing research, vol 2 no 2, june 2020/ page 46-54 52 jufri hidayat / the relationship between knowledge and medication compliance behavior among patients with tuberculosis a similar result also showed that smoking was significantly associated with medical compliance behaviour. the study result from the bivariate analysis shows that the pvalue was 0.005 which means that participants who were smoking will be more likely to have poor adherence. this finding is similar to a study from the u.s identifying factor predictors of medication adherence and smoking cessation among smokers found that active smoking was significantly associated with poor adherence among tuberculosis patients.5 this study found that alcohol use had a significant relationship with medication compliance behaviour among tuberculosis patients in indonesia. the finding of the study shows the small number of alcohol use among participants (n = 25, 16.7%). the p-value was 0.03 indicating that patients with no alcohol consumption tend to be more compliant. some studies around the world have similar results. for example, a study in nigeria found that alcoholic use among tb patients had poor treatment adherence such as forget medication timing, hospital appointment, and which lead to interruption and non-adherence behaviour.13 similarly, a study in uzbekistan investigating the factor that makes patients default in tuberculosis treatment and poor adherence found that the high percentage of defaulter was patients with alcohol use.11 factor predictor of medication compliance behavior as illustrated in the result found that education was statistically significant and indicating the most powerful factor in tuberculosis knowledge of patients. the standardized coefficients showed β = 0.22 and the p-value was p = 0.02. the unstandardized coefficient of the variable of education was β = 0.36 indicating that patients who have a high level of education were more likely to have a high of tuberculosis knowledge score. the higher education levels the better tuberculosis knowledge, and the lower education level of the patients the lower knowledge of tuberculosis patients. likewise, the result found that ethnicity had statistically significant results compared to other variables and indicating that ethnicity was recognized as predictive factors, as shown in the table, the standardized coefficient was (β = -0.18, p = 0.04). moreover, the unstandardized coefficient for the ethnicity was (β = -0.08) indicating that people from ethnic java and batak are more likely to compliance compared to other groups ethnic in indonesia. conclusion tuberculosis remains the highest priority among infectious diseases in the world today with increasing morbidity and mortality every year (who). the purpose of this study was to explore the relationship between knowledge and medication adherence among patients with tuberculosis in indonesia. this study found that ethnicity had a significant relationship with medication adherence (as a continuous variable). moreover, a significant was found between medication compliance behaviour and the categorical variables, including the medical history of chronic illness, smoking, and alcohol use. in the univariate analysis, education was significantly associated with tuberculosis knowledge and ethnicity was consistently associated with medication adherence. acknowledgments i would like to thank my advisor for the continues support, patience, and guidance that she offered throughout my time in the master’s program. she helped me with the organization, insight, and suggestions that contributed to the overall construction and completion of this research. i hold dear in my heart for my parents, and friends for their unlimited support and encouragement until i got my degree. south east asia nursing research, vol 2 no 2, june 2020/ page 46-54 53 jufri hidayat / the relationship between knowledge and medication compliance behavior among patients with tuberculosis conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. 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(2010). knowledge, health-seeking behaviour and perceived stigma towards tuberculosis among tuberculosis suspects in a rural community in southwest ethiopia. plos one, 5(10), 1-7. doi:10.1371/journal.pone.0013339 2. aditama, h. p., & aris, a. (2013). hubungan pengetahuan dan motivasi pasien tbc (tuberkulosis) dengan kepatuhan berobat pasien tbc yang berobat di upt puskesmas mantup kabupaten lamongan. surya 2 (15), agust 2013 tuberkulosis (tb). 33-39. [aditama, h. p., & aris, a. (2013). the relationship of tbc (tuberculosis) patients' knowledge and motivation with tb treatment patients who seek treatment at the upt pusup mantup lamongan regency. surya 2 (15), agust 2013 tuberculosis (tb). 33-39.] 3. alikari, v., tsironi, m., matziou, v., tzavella, f., stathoulis, j., babatsikou, f., & zyga, s. (2019). the impact of education on knowledge, adherence and quality of life among patients on haemodialysis. quality of life research, 28(1), 7383. doi:10.1007/s11136-018-1989-y 4. choi, h., chung, h., muntaner, c., lee, m., kim, y., barry, c., & cho, s. (2016). the impact of social conditions on patient adherence to pulmonary tuberculosis treatment. the international journal of tuberculosis and lung disease, 20(7), 948-954. doi:10.5588/ijtld.15.0759 5. cropsey, k. l., clark, c. b., stevens, e. n., schiavon, s., lahti, a. c., & hendricks, p. s. (2017). predictors of medication adherence and smoking cessation among smokers under community corrections supervision. addictive behaviors, 65, 111-117. doi:10.1016/j.addbeh.2016.10.010 6. depkes, (2010). profil kesehatan indonesia. jakarta, indonesia: departemen kesehatan republik indonesia. [ministry of health, (2010). indonesian health profile. jakarta, indonesia: ministry of health of the republic of indonesia] 7. dotulong, j., sapulete, m. r., & kandou, g. d. (2015). hubungan faktor risiko umur, jenis kelamin, dan kepadatan hunian dengan kejadian penyakit tb paru di desa wori kecamatan wori. jurnal kedokteran komunitas dan tropik, 3(2), 57-65. [dotulong, j., sapulete, m. r., & kandou, g. d. (2015). the relationship between risk factors for age, sex, and occupancy density with the incidence of pulmonary tb disease in wori village, wori district. journal of community and tropical medicine, 3 (2), 57-65.] 8. erawatyningsih, e., & purwanta, h. s. (2009). faktor-faktor yang mempengaruhi ketidakpatuhan berobat pada penderita tuberkulosis paru. berita kedokteran masyarakat, 25(3), 117-124. doi:10.22146/bkm.3558. [erawatyningsih, e., & purwanta, h. s. (2009). factors that influence non-compliance with treatment in patients with pulmonary tuberculosis. community medicine news, 25 (3), 117-124. doi:10.22146/bkm.3558] 9. gellad, w. f., haas, j. s., & safran, d. g. (2007). race/ethnicity and nonadherence to prescription medications among seniors: results of a national study. journal of general internal medicine, 22(11), 1572-1578. doi:10.1007/s11606-007-0385-z 10. gerber, b. s., cho, y. i., arozullah, a. m., & lee, s. y. (2010). racial differences in medication adherence: a cross-sectional study of medicare enrollees. the american journal of geriatric pharmacotherapy, 8(2), 136-145. doi:10.1016/j.amjopharm.2010.03.002 11. hasker, e., khodjikhanov, m., usarova, s., asamidinov, u., yuldashova, u., van der werf, m. j., & veen, j. (2008). default from tuberculosis treatment in tashkent, uzbekistan; who are these defaulters and why do they default? biomed central infectious diseases, 8(1), 1-7. doi:10.1186/1471-2334-8-97 12. hayati, a. (2011). evaluasi kepatuhan berobat penderita tuberkulosis paru tahun 2010-2011 di puskesmas kecamatan pancoran mas depok (unpublished bachelor's thesis), universitas indonesia, jakarta, indonesia. [hayati, a. (2011). evaluation of compliance with pulmonary tuberculosis treatment in 2010-2011 at pancoran mas depok sub-district health center (unpublished bachelor's thesis), university of indonesia, jakarta, indonesia.] 13. ibrahim, l. m., hadejia, i. s., nguku, p., dankoli, r., waziri, n. e., akhimien, m. o., & nwanyanwu, o. (2014). factors associated with interruption of treatment among pulmonary tuberculosis patients in plateau state, nigeria. 2011. pan african medical journal, 17(1), 1-8. doi:10.11604/pamj.2014.17.78.3464 14. kaona, f. a., tuba, m., siziya, s., & sikaona, l. (2004). an assessment of factors contributing to treatment adherence and knowledge of tb transmission among patients on tb treatment. biomed central public health, 4(1), 1-8. doi:10.1186/1471-2458-4-68 south east asia nursing research, vol 2 no 2, june 2020/ page 46-54 54 jufri hidayat / the relationship between knowledge and medication compliance behavior among patients with tuberculosis 15. keiwkarnka, b., sermsri, s., shiyalap, k., & nepal, a. k. (2012). compliance with dots among tuberculosis patients under community based dots strategy in palpa district, nepal. international journal of infection and microbiology, 1(1), 14-19. doi:10.3126/ijim.v1i1.6717 16. lock, w. a., ahmad, r. a., ruiter, r. a., van der werf, m. j., bos, a. e., mahendradhata, y., & de vlas, s. j. (2011). patient delay determinants for patients with suspected tuberculosis in yogyakarta province, indonesia. tropical medicine & international health, 16(12), 15011510. doi:10.1111/j.1365-3156.2011.02864.x 17. martin, l. r., williams, s. l., haskard, k. b., & dimatteo, m. r. (2005). the challenge of patient adherence. therapeutics and clinical risk management, 1(3), 189-199. 18. munro, s. a., lewin, s. a., smith, h. j., engel, m. e., fretheim, a., & volmink, j. (2007). patient adherence to tuberculosis treatment: a systematic review of qualitative research. plos medicine, 4(7), e238. 1230-1245. 19. nyasulu, p., sikwese, s., chirwa, t., makanjee, c., mmanga, m., babalola, j. o., & munthali, a. c. (2018). knowledge, beliefs, and perceptions of tuberculosis among community members in ntcheu district, malawi. journal multidiscipline of healthcare, 11, 375-389. doi:10.2147/jmdh.s156949 20. palupi, d. l. m. (2013). pengaruh pendidikan kesehatan terhadap perubahan pengetahuan, sikap dan perilaku penderita tuberculosis yang berobat di wilayah kerja puskesmas surakarta. surakarta, cj, indonesia: sebelas maret university. [palupi, d. l. m. (2013). the effect of health education on changes in knowledge, attitudes and behavior of tuberculosis patients who seek treatment in the work area of the surakarta puskesmas. surakarta, cj, indonesia: eleven march university.] 21. peeters, b., van tongelen, i., boussery, k., mehuys, e., remon, j. p., & willems, s. (2011). factors associated with medication adherence to oral hypoglycaemic agents in different ethnic groups suffering from type 2 diabetes: a systematic literature review and suggestions for further research. diabetic medicine, 28(3), 262275. 22. ratnasari, n. y., & nurtanti, s. (2018). analysis on factors related with treatment behavior of pulmonary tuberculosis patient. kemas: jurnal kesehatan masyarakat, 14(1), 81-89. doi:10.15294/kemas.v14i1.12518 23. sakalle, s., waskel, b., dixit, s., pandey, d., sirohi, s., & saroshe, s. (2014). a study on patient compliance of tuberculosis enrolled under revised national tuberculosis control programme. national journal community medicine, 5, 96-99. 24. uchenna, o. u., chukwu, j., oshi, d., nwafor, c., & meka, a. (2014). assessment of tuberculosisrelated knowledge, attitudes and practices in enugu, south east nigeria. journal of infectious diseases and immunity, 6(1), 1-9. doi:10.5897/jidi2011.0020 25. urata, k., hashimoto, k., horiuchi, r., fukui, k., & arai, k. (2019). impact of diabetes perceptions on medication adherence in japan. pharmacy, 7(4), 1-14. doi:10.3390/pharmacy7040144 26. webb, c. a., derubeis, r. j., & barber, j. p. (2010). therapist adherence/competence and treatment outcome: a meta-analytic review. journal of consulting and clinical psychology, 78(2), 200211. doi.org/10.1037/a0018912 27. who. (2018). global tuberculosis report 2018. geneva, switzerland: the world health organisation. therapy of brain exercise on the quality of sleeping in elderly corresponding author: ita irvana itairvana99@gmail.com south east asia nursing research, vol 2 no 3, september 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.3.2020.1-6 original research therapy of brain exercise on the quality of sleeping in elderly ita irvana1, galia wardha alvita1, icca narayani pramudaningsih2, vera fitriana2 1 stikes cendekia utama kudus, indonesia 2 akper krida husada kudus, indonesia article info abstract article history: submit july 15th, 2020 accepted sept 5th, 2020 published sept 30th 2020 keywords: brain gym; sleep quality; elderly the aging is a natural process that cannot be avoided with age. even though it is a natural thing, the process of aging still causes problems both physically, biologically, mentally and socio-economically due to a decline which is called a degenerative process the process of degeneration that occurs in the elderly, causes time. world health organization (who) confirmed that there were 600 million elderly people in 2012 worldwide. who also noted that there are 142 million elderly people in the southeast asia region. meanwhile, according to the central statistics agency (bps), it was noted that the number of elderly people in indonesia reached 28 million in 2012 from only 19 million in 2006. the results of the data recapitulation of the central java health office recorded 3 million elderly people in central java. the method in this study was experimental research and quasiexperimental design type with quasi-experimental design and village control group. sample determination using the total sampling technique with a sample size of 30 respondents. data analysis was performed using the wilcoxon test. the results obtained before being given an intervention that has a level of good sleep quality amounted to 43.3% and after given an intervention that has a level of quality of sleep that is good, the minimum is 76.7%. statistically obtained a p-value of 0,000 (<0.05) can be interpreted that there is a significant influence on brain gymnastics on the quality of sleep in the elderly. introduction aging is a natural process that cannot be avoided with age. even though it is a natural thing, the process of aging still causes problems both physically, biologically, mentally and socio-economically due to a decline which is called a degenerative process the process of degeneration that occurs in the elderly, causes time. effective sleep will decrease so that adequate quality of sleep is not achieved and will cause various kinds of sleep complaints or sleep disturbances.1 the disturbance of sleep patterns causes suffering for the elderly because it reduces the quality of life so that it needs attention from health workers. the approach in managing sleep disorders must be systematic and comprehensive both physically and mentally, not only medical drugs but complementary therapies need to be developed by training the elderly to relax their thoughts before going to sleep such as taking deep breaths, reading books, using aromatherapy, or using aromatherapy. brain exercise therapy.2 https://doi.org/10.26714/seanr.2.3.2020.1-6 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.3.2020.1-6&domain=pdf&date_stamp=2020-09-30 south east asia nursing research, vol 2 no 3, september 2020/ page 1-6 2 ita irvana / therapy of brain exercise on the quality of sleeping in elderly sleep problems faced by the elderly can be used as a reference for providing appropriate nursing interventions in overcoming problems related to sleep fulfilment. physical exercise is proven to increase the fulfilment of sleep needs in the elderly because it can get relaxation, improve blood circulation, and can reduce stress.3 world health organization (who) confirmed that there were 600 million elderly people in 2012 worldwide. who also noted that there are 142 million elderly people in the southeast asia region. meanwhile, according to the central statistics agency (bps), it was noted that the number of elderly people in indonesia reached 28 million in 2012 from only 19 million in 2006. the results of the data recapitulation of the central java health office recorded 3 million elderly people in central java. this figure shows an increase in the number of elderly people by 22.5% from 2,323,541 in 2010. quantitatively, this parameter is higher than the national size. data from the central statistics agency show that the number of elderly people over 60 years of age in central java province has experienced an increase in life expectancy. the increase in the elderly in the coming year can bring new social problems if the elderly is the responsibility of the population of productive age in the future. in 2014 the number of elderly people reached 3.83 million people or 11.43 per cent of the total population of central java province then increased to 3.96 million people or 11.72% in 2015. meanwhile, based on the results of the projection figures 18 profile of the elderly in central java 2018 population in 2018, the number of elderly people in central java province increased to 4.49 million people or 13.03%.4 changes in sleep patterns in the elderly can result in changes in the neurological system which can decrease the number and size of neurons in the central nervous system. changes in sleep can affect sleep quality related to the aging process such as increased sleep latency, waking early can reduce the stages of deep sleep. to overcome sleep disorders in the elderly it is necessary to carry out non-pharmacological therapies such as brain exercise. brain gym or brain exercise is a simple movement that uses the brain as a whole. brain exercise is educational kinesiology which means "educare " (pulling out) and " kinesis" (the study of body movements). so that with brain exercise, we can draw out the potential that is buried in us through body movements. based on the results of preliminary studies on elderly social care homes potroyudan jepara on the 29th of january 2020, there are 3 0 elderly who live in nursing, a male total of 11 elderly and female amounted to 19 elderly people with an average age above 60 years. based on interviews conducted by researchers with 10 respondents, 4 people said they were often sleepy in the morning because they often wake up at night and have difficulty sleeping again. meanwhile, as many as 6 people complained of going to bed early and waking up again at midnight. based on this reason, the authors are interested in knowing the quality of sleep for the elderly in the potroyudan jepara elderly social centre. methods the type in this research is quasiexperimental or quasi-experimental with one group pretest and posttest. the population in this study were elderly patients who experienced quality sleep in potroyudan social service institutions in jepara. where the population is 30 people. there is also a total sample size of 30 samples and the determination of the sample using the total sampling technique. the inclusion criteria in this study were elderly people aged 5 0 years and above. the elderly with poor sleep quality are taking sleeping pills. the exclusion criteria were the elderly outside the potroyudan social service institutions in jepara. the elderly who do not have problems with sleep disorders are not willing to be south east asia nursing research, vol 2 no 3, september 2020/ page 1-6 3 ita irvana / therapy of brain exercise on the quality of sleeping in elderly respondents. elderly who have chronic diseases. the location of this research was located at the potroyudan social service home in jepara in july 2020. instrument of research is using sop gymnastics brain and observation sheets and questionnaires psqi. the results of this study used the wilcoxon test statistical test. results based on table 1, the results show that the age of most respondents is 66-80 years old, with 18 respondents with a percentage of 60.0 %, followed by 50-65 years of age, whose respondents were 19 people with a percentage of 40.0%. the number of men was 12 people ( 40.0 %) and female were 18 people ( 60.0 %). table 1 frequency distribution based on age of elderly respondents at the potroyudan social institution in jepara in july 2020 (n = 30) indicators f % age 50-65 12 40.0 66-80 18 60.0 sex male 12 40.0 female 18 60.0 based on table 2, before giving the intervention, there were 13 people with a good sleep quality level with a percentage of 43.3% and 17 people who had a bad sleep quality level with a percentage of 56.7%. whereas in the category after giving the intervention, there were 23 people with a good sleep quality level with a percentage of 76.7% and 7 people who had a bad sleep quality level with a percentage of 23.3%. the statistical test results obtained p-value 0.00 0 (<0.05), it can be concluded that ho is rejected so that it can be interpreted statistically there is the effect of brain exercise on the quality of sleep in the elderly. table 2 distribution of frequency of sleep quality in the elderly before and after being given brain exercise therapy at the potroyudan social institution in jepara in july 2020 (n = 3 0 ) indicators f % before being given brain gym good 13 43.3 bad 17 56.7 after being given brain gym good 23 76.7 bad 7 23.3 p 0.000 discussion from the results of research conducted at the potroyudan social institution in jepara, based on the age characteristics of the respondents, it was found that the age of the most respondents was 66-80 years with a percentage of 68.3%. this is in line with research conducted5 most of the respondents aged 60-80 years stated that a person will experience a decrease in organ function when entering old age. this makes the elderly more susceptible to diseases such as joint pain, osteoporosis, parkinson's and others which tend to affect poor sleep quality due to decreased physiological functions.6 the aging process will tend to experience many problems from various changes in the physiology of organs that take place over time. also, the aging process will increase the likelihood of disease and even death. in the end, aging results in a decrease in anatomical and cellular conditions due to the metabolic buildup that occurs in the cell. in the elderly, there is a decrease in the hormone melatonin. the hormone melatonin plays a role in the hours and quality of sleep in the elderly. from the results of the analysis of the characteristics of the gender of the respondents, it was found that the response of female was more ( 53.3 %) compared to male respondents. this is also supported by research conducted by ismahmudi most of the respondents are female (68.7%) who say that it is influenced by the life expectancy of female who are greater than men. more sleep disturbances occur than in men.7 female tend to have poor sleep south east asia nursing research, vol 2 no 3, september 2020/ page 1-6 4 ita irvana / therapy of brain exercise on the quality of sleeping in elderly quality due to a decrease in the hormones estrogen and progesterone which have receptors in the hypothalamus. this has a direct influence on circadian rhythm and sleep patterns. psychological conditions such as increased anxiety, anxiety, and emotions are often out of control in female due to decreased estrogen which causes sleep disturbances. based on the results of the wilcoxon statistical test, it was found that the p-value was 0.000 (<0.05).it can be concluded that ho was rejected so that it could be interpreted statistically that there was an effect of brain exercise on the quality of sleep in the elderly with a frequency value before giving intervention that had a good sleep quality level. 13 people with a percentage of 43.3% and those who have a poor sleep quality level are 17 people with a percentage of 56.7%. whereas in the category after giving the intervention, there were 23 people with a good sleep quality level with a percentage of 76.7% and 7 people who had a bad sleep quality level with a percentage of 23.3%. this is in line with the results of ismahmudi's research, where the results of odds ratio value = 7.875, there is a significant relationship between brain vitalizing exercises and the quality of sleep in the elderly. which states that any exercise done by the elderly is proven to improve sleep disorders in the elderly. because exercise that is done regularly will stimulate the hpa axis activity and increase o2 transport throughout the body, thereby increasing the fulfilment of sleep needs. gymnastics for the elderly also stimulates a decrease in sympathetic nerve activity and an increase in parasympathetic activity which affects the decrease in adrenal hormones, noneprinefrin and catecholamines as well as vasodilation of blood vessels which results in oxygen transport throughout the body, especially the brain smoothly. also, the secretion of melatonin helps fulfil sleep needs, in this condition it will improve the quality of sleep in the elderly. this is also following the research conducted by othe research obtained the quality of sleep in the elderly after having intervened in ergonomic exercise for 8 times in 4 weeks, there was an increase in sleep quality (69.2%) with a statistical value of α <0.05, meaning that ergonomic exercise affected the quality of sleep in the elderly. sleep disorders. which states that there are several non-pharmacological management for the management of sleep disorders, one of which is doing daily exercise/exercise and one of them is gymnastics. exercise can increase oxygen in the brain which will stimulate increased serotonin secretion which can make the body calm and easier to sleep which can also improve the cycle and pattern of rem and nrem sleep. brain therapy aims to increase blood flow to the brain, as well as stimulate the two hemispheres of the brain to work. brain exercise can activate the brain in three dimensions, namely lateralitycommunication, focusing-understanding and centring-regulation. light movements with a play through the hands and feet can provide stimulation or stimulus to the brain. the movement that produces this stimulus can increase cognitive abilities (alertness, concentration, speed, perception, learning, memory, solving, problems and creativity).8 sleep quality is an important constituent of an essential part of a person's quality of life.9 based on this understanding, sleep quality is a condition in which a person's awareness of something decreases, but the brain still works in such a way in regulating digestive function, heart and blood vessel activity and maintaining immunity, in providing energy to the body and in cognitive processes.10 the quality and quantity of sleep are strongly influenced by several factors, one of which is physical exercise, a tired person usually gets restful sleep, fatigue is the south east asia nursing research, vol 2 no 3, september 2020/ page 1-6 5 ita irvana / therapy of brain exercise on the quality of sleeping in elderly result of work or fun exercise. exercising 2 hours or more before bedtime keeps the body cool and maintains fatigue that promotes relaxation.11 the aging process makes it easier for the elderly to experience sleep disorders. elderly people often complain of three main problems in initiating and maintaining sleep. brain gymnastics is aimed at relaxing or centring dimensions, stimulating or lateral dimensions and lightening or focusing dimensions. the concentration dimension can increase blood flow to the brain, increase oxygen reception so that it can eliminate negative thoughts, envy, jealousy, and others that can trigger stress. the lateral dimension will stimulate the coordination of the two hemispheres, namely the left and right, improve breathing, stamina, release tension, reduce fatigue, and so on. the focusing dimension to help remove focus barriers from the brain corrects inattention, lack of concentration, etc. each dimension has a specific task so that the exercise movements that are carried out can vary. with brain gym movements, you can activate the neocortex and parasympathetic nerves to reduce the increase in adrenal hormone in the body which can relieve psychological and physical tension. so that the soul and body become relaxed and balanced.8 it is necessary at the time of the elderly require a factor driving because organs and physiological functions have been decreased. sleep patterns can be improved if you do physical exercise, brain exercise or other things that make the body do activities so that the quality of the body can be better. conclusion the results of the study can be concluded based on the characteristics of the age of the most respondents aged 66-80 years. based on the results of the statistical test, it was found that statistically there is an effect of brain exercise on the quality of sleep of the elderly in potroyudan social institutions in jepara. acknowledgments the author realizes that without the help and encouragement of various parties, the completion of this research will not be realized. therefore, with sincerity and humility, the authors would like to express their gratitude and highest appreciation to all respondents in this study. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. darmojo rb. teori proses menua. dalam: martono hh, pranarka k, pengarang. buku ajar boedhi-darmojo geratri. 4th ed. jakarta: balai penerbit fakultas kedokteran universitas indonesia; 2011. 3-12. p. 2. claproth r. the powerful danger of midbrain activation. jakarta: grasindo; 2010. 3. sharma, s. parashar d. effect of resistance training over aerobic exercice in improving quality of sleep in older adults. indian j phystotherapy occup ther. 2013;7 (4),:197– 202. 4. pbs. profil lansia provinsi jawa tengah 2019. badan pusat statistik. 2019. 5. oktora dwi s et al. the effect of murottal al qur’an therapy on the quality of sleep of the elderly in the dewanata cilacap social rehabilitation unit. soedirmaan j nurs. 2016;11(3):168–73. 6. azizah l. elderly nursing. yogyakarta: graha i lmu; 2011. 7. khasanah et al. kualitas tidur lansia balai rehabilitasi sosial “mandiri” semarang. j keperawatan diponegoro. 2012;1(1):189–96. 8. astuti n. management of insomnia at older age. 2015; 9. luo et al. prevalence and risk factors of poor sleep quality among chinese elderly in an urban community: results from the shanghai aging study. 2013; 10. sari r. the effect of rose aromatherapy on improving sleep quality in the elderly. south east asia nursing research, vol 2 no 3, september 2020/ page 1-6 6 ita irvana / therapy of brain exercise on the quality of sleeping in elderly muhammadiyah universiti of surakarta; 2015. 11. hidayat et al. introduction to human sleep needs. 2015. high ultrafiltration increasing intradialytic blood pressure on hemodialysis patients corresponding author: yunie armiyati yunie@unimus.ac.id south east asia nursing research, vol 3 no 1, march 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.1.2021.8-15 original research high ultrafiltration increasing intradialytic blood pressure on hemodialysis patients yunie armiyati1,2, suharyo hadisaputro3, shofa chasani4,5, untung sujianto6 1 department of nursing, universitas muhammadiyah semarang, indonesia 2 doctoral program, faculty of medicine, universitas diponegoro, indonesia 3 postgraduate program of health polytechnic of semarang 4 hemodialysis center, roemani hospital, indonesia 5 faculty of medicine, universitas muhammadiyah semarang, indonesia 6 department of nursing, faculty of medicine, universitas diponegoro, indonesia article info abstract article history: submit feb 20th, 2021 accepted march 16th, 2021 published march 28th 2021 keywords: hemodialysis; ultrafiltration; intradialytic blood pressure the increase in blood pressure when the patient is undergoing hemodialysis is experienced by patients with intradialytic hypertension. this condition can be very dangerous for the patient, must be prevented and needs to be controlled. prevention can be done by controlling variables that can affect intradialytic blood pressure, including ultrafiltration during hemodialysis. this study aims to analyze the relationship between ultrafiltration (ultrafiltration goal, ultrafiltration rate) and intradialytic blood pressure. this research was a descriptive-analytic study with a cross-sectional design, with 112 samples at two centres of dialysis in semarang. data were analyzed using the spearman rho. the finding obtained showed that ultrafiltration goal (ufg) and ultrafiltration rate (ufr) correlated with intradialytic blood pressure (systolic, diastolic and mean arterial pressure). the magnitude of ufg an associated with increase in intradialytic systolic (p=0,024; r=0,213), increase in intradialytic diastolic (p=0,007; r=0,252) and increase in mean arterial pressure (p=0,016; r=0,227). high ufr is associated with with increase in intradialytic systolic (p=0,037; r=0,211), increase in intradialytic diastolic (p=0,001; r=0,320) and increase in mean arterial pressure (p=0,034; r=0,200). determination of ultrafiltration during hemodialysis must be done carefully and precisely to prevent an increase in intradialytic blood pressure. introduction chronic kidney disease (ckd) is an irreversible decline in renal function so that the kidneys are unable to regulate body homeostasis.1 ckd patients at the end stage kidney disease stage require renal replacement therapy to maintain body functions.2 hemodialysis is a kidney replacement therapy that is widely used by patients with end-stage kidney disease. hemodialysis is effective in removing fluids, electrolytes and metabolic waste and improves the quality of life for ckd patients. the main goal of hemodialysis in patients with end-stage kidney disease is symptom relief, controlling uremia, fluid overload, https://doi.org/10.26714/seanr.3.1.2021.8-15 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.1.2021.8-15&domain=pdf&date_stamp=2021-03-28 south east asia nursing research, vol 3 no 1, march 2021/ page 8-15 9 yunie armiyati / high ultrafiltration increasing intradialytic blood pressure on hemodialysis patients and electrolyte imbalance.3 however, various intradialytic complications can occur in patients undergoing hemodialysis. the complications experienced by many hemodialysis patients are an increase in intradialytic blood pressure or the occurrence of intradialytic hypertension. intradialytic hypertension is a persistent increase in blood pressure during hemodialysis and at the end of hemodialysis is higher than blood pressure at the initiation of hemodialysis. it’s marked by an increase in mean arterial blood pressure (map) > 15 mmhg on dialysis sessions. several studies in indonesia show that the incidence of intradialytic hypertension is a common complication experienced by many patients. a retrospective cohort study of 22,955 hemodialysis treatments showed that the prevalence of intradialytic hypertension was 21.3 per 100 procedures.4 research in denpasar found that the incidence of idh was 32.1%.5 research on hemodialysis patients in yogyakarta also concluded that the frequency of intradialytic hypertension was 54%.6 another study on 198 hemodialysis patients in palembang also showed that 58.6% of the patients had intradialytic hypertension. the increase in blood pressure can be severe even to the point of a hypertensive crisis that endangers the patient.7 high intradialytic blood pressure will affect hemodialysis adequacy, increasing the risk of heart failure and patient death. previous studies in 151 routine hemodialysis patients showed that high interdialytic blood pressure was associated with an increased risk of stroke and death. a total of 13.91% of patients with high interdialytic blood pressure had a stroke and 16.56% of patients died.8 an increase in intradialytic blood pressure must be anticipated with proper control of the risk factors. various factors cause an increase in intradialytic blood pressure including excess fluid (fluid overload). an increase in blood pressure during hemodialysis can occur due to activation of the reninangiotensin-aldosterone system (raas) due to hypovolemia when the fluid withdrawal is carried out through ultrafiltration.7 the process of withdrawal of fluid during hemodialysis through ultrafiltration involves the fluid withdrawal rate or ultrafiltration rate (ufr) and the amount of fluid withdrawn or ultrafiltration goal (ufg). the amount and speed of fluid withdrawal during hemodialysis can be seen from the ultrafiltration which is regulated in the form of ufg and ufr determination. determination of the ufg and ufr should be optimal to achieve normotensive conditions in hemodialysis patients. when hemodialysis is performed, the ufg determination is determined to draw excess fluid in the blood, the ufg size depends on the addition of the interdialytic body weight gain (idwg) and the target patient's dry weight.9 the phenomenon in the field is often the determination of ultrafiltration based on the increase of idwg which indicates the amount of fluid buildup in the body. excess fluid occurs due to poor fluid intake regulation during the interdialytic period, which is characterized by a high idwg value.10 if fluid intake is excessive, during the period between dialysis there will be a large weight gain.11 hypervolemia (fluid overload) is believed to play a role in the pathogenesis of intradialytic hypertension.12 often the ultrafiltration determination during hemodialysis exceeds the requirements. a decrease in relative blood volume and total blood volume due to a large ultrafiltration goal decreases blood flow to the kidneys, stimulates the release of renin and causes hypertension.13 this study aims to analyze the relationship between ultrafiltration during hemodialysis (ultrafiltration goal, ultrafiltration rate) and intradialytic blood pressure. this research is useful to anticipate and prevent south east asia nursing research, vol 3 no 1, march 2021/ page 8-15 10 yunie armiyati / high ultrafiltration increasing intradialytic blood pressure on hemodialysis patients intradialytic hypertension by controlling these factors. methods the study design was a cross-sectional study. the aim of the studies to determine the relationship between ultrafiltration goal (ufg), ultrafiltration rate (ufr) and intradialytic blood pressure. the population were 188 patients who underwent hemodialysis in january 2019 in two hemodialysis units in semarang central java, indonesia. sampling using purposive sampling according to the inclusion criteria. the inclusion criteria of this study were: patients undergoing regular hemodialysis for more than three months, scheduled hemodialysis with a frequency of 2 times a week with a duration of hemodialysis 4 hours, awareness of compos mentis, can communicate well verbally, aged 18-60 years and not using erythropoietin. the sample of this study were 112 patients. the instrument used in this study as a tool for measuring blood pressure (bp) before, during and after the patient underwent hemodialysis using a digital sphygmomanometer. measurement blood pressure using a standard digital sphygmomanometer that has been calibrated. blood pressure measurements were taken before hemodialysis, at 2.5 hours hemodialysis (intradialytic) and after hemodialysis. measurements were made on the arm that was not attached to the vascular access. the predialysis blood pressure was measured 5 minutes before the dialysis needle was inserted and the post-analysis blood pressure was measured 5 minutes after the dialysis needle was removed. ufg is the amount of fluid drawn by the hemodialysis machine during a hemodialysis session in litres, which can be seen from the hemodialysis machine monitor screen. excess ufg is the amount of fluid drawn by the hemodialysis machine during one hd session in excess of 4.8% dry body weight. ufr is the amount of fluid drawn by the hemodialysis machine per kilogram of body weight per hour (ml/kg/hour). this research applies the principles of research ethics include the principles of confidentiality, benefits, the principles of respecting human dignity and the principles of justice. this study was conducted after obtaining approval from the ethics committee. the principles of research ethics in this research. univariate analysis was used to describe the characteristic data of respondents in the form of age, gender, frequency of hemodialysis, length of undergoing hemodialysis, and ultrafiltration (ufg and ufr). research data were analyzed univariately and using a personal computer program. univariate analysis by presenting numeric and categorical data. numerical data such as age, frequency of hemodialysis, length of undergoing hemodialysis, ultrafiltration (ufg and ufr) and blood pressure are described in the central tendency (mean, minimum, maximum and standard deviation). data categorized by gender distributed in a frequency distribution. the data normality test was carried out before carrying out the bivariate test. the results of the normality test with saphiro will showed that ultrafiltration data and intradialytic blood pressure were not normally distributed (p <0.005). bivariate analysis was performed using statistical data processing software on the computer, used spearman's rho test. bivariate statistical test to determine the relationship and direction of the relationship between the ultrafiltration variable and intradialytic blood pressure. results table 1 showed the mean patient age was 47,77 years with the youngest age being 20 years and the oldest being 70 years. the number of male and female respondents is equal, each 50%. the mean length of hemodialysis was 26,20 months. the mean frequency of hemodialysis was 184,95 times. the mean of ultrafiltration goal (ufg) was south east asia nursing research, vol 3 no 1, march 2021/ page 8-15 11 yunie armiyati / high ultrafiltration increasing intradialytic blood pressure on hemodialysis patients 2704,91 times and the mean of ultrafiltration goal (ufr) was 11,366 ml/h/kg. the results in table 2 show that the mean pre-dialysis systolic blood pressure was 158.214 mmhg, the lowest was 107 mmhg and the highest was 195 mmhg. the mean pre-dialysis diastolic blood pressure was 86.652 mmhg, the lowest was 76 mmhg and the highest was 114 mmhg. the mean intra-dialysis systolic blood pressure was 168.839 mmhg, the lowest was 110 mmhg and the highest was 198 mmhg. the average intradialysis diastolic blood pressure was 95.161 mmhg, the lowest was 86 mmhg and the highest was 115 mmhg. the average post-dialysis systolic blood pressure was 169.920 mmhg, the lowest was 100 mmhg and the highest was 211 mmhg. the mean post-dialysis diastolic blood pressure was 94.384 mmhg, the lowest was 74 mmhg and the highest was 121 mmhg. the figure 1 shows an increase in intradialytic and post-dialysis blood pressure. this research showed that the mean systolic, diastolic and mean arterial pressures of intradialytic and postdialysis were higher than before (pre) hemodialysis. the results of statistical analysis with spearman rho test showed that there was a relationship between ultrafiltration (ufg and ufr) with intradialytic systolic blood pressure, intradialytic diastolic blood pressure (p=and mean intradialytic arterial pressure (p-value < 0,005). the greater the ufg and ufr the higher the intradialytic blood pressure (r 0,211-0,320). table 1 characteristic of respondents (n=112) indicators f % mean ± sd (min-max) age 47,77 ± 11,66 (20-70) gender male 56 50 female 56 50 frequency of hemodialysis 184,95 ± 153,79 (24-807) length of hemodialysis (months) 26,20 ± 39,012 (3-374) ultrafiltration goal (ml) 2704,91 ± 1000,359 (500-4000) ultrafiltration rate (ml/h/kg) 11,366 ± 4,020 (2-18) table 2 description of pre, intra dan post hemodialysis blood pressure (n=112) indicators (blood pressure) mean ± sd (min-max) pre dialytic blood pressure sistolic (mmhg) 158,214 ± 17,151 (107-195) diastolic (mmhg) 86,652 ± 18,186 (76-114) mean arterial pressure (mmhg) 134,432 ± 12,736 (92,7-164,3) intra dialytic blood pressure sistolic (mmhg) 168,839 ± 18,009 (110-198) diastolic (mmhg) 95,161 ± 9,28 (86-115) mean arterial pressure (mmhg) 156,779 ± 134,049 (96,7-155) post dialytic blood pressure sistolic (mmhg) 169,920 ± 21,461 (100-211) diastolic (mmhg) 94,384 ± 13,052 (74-121) mean arterial pressure (mmhg) 144,763 ± 17,362 (90-174) south east asia nursing research, vol 3 no 1, march 2021/ page 8-15 12 yunie armiyati / high ultrafiltration increasing intradialytic blood pressure on hemodialysis patients figure 1 pre, intra and post hemodialysis blood pressure (n=112) table 3 statistical analysis of the relationship between ultrafiltration and intradialytic blood pressure in hemodialysis patients (n=112) indicators p r ufg – intradialytic systolic blood pressure 0,024* 0,213 ufg – intradialytic diastolic blood pressure 0,007* 0,252 ufg – intradialytic mean arterial pressure pressure 0,016* 0,227 ufr – intradialytic systolic blood pressure 0,037* 0,211 ufr – intradialytic diastolic blood pressure 0,001* 0,320 ufr – intradialytic mean arterial pressure (map) 0,034* 0,200 *spearman rho discussion blood pressure is one hemodynamic indicator that needs to be considered in patients undergoing hemodialysis. an increase in blood pressure or a decrease in blood pressure during the hemodialysis process can endanger the patient's condition. research on hemodialysis patients in indonesia shows that the increase in blood pressure during hemodialysis is more experienced by patients undergoing hemodialysis. this research showed that the mean systolic, diastolic and mean arterial pressures of intradialytic and post-dialysis were higher than before (pre) hemodialysis. the increase in blood pressure during hemodialysis is also referred to as intradialytic hypertension have an increased mortality risk compared to patients with modest decreases in blood pressure during dialysis. intradialytic hypertension is associated with extracellular volume overload in addition to acute increases in vascular resistance during dialysis. management strategies should include reevaluation of fluid overload and high ultrafiltration during hemodialysis.14 hemodialysis patients have to control fluid overload by controlling interdialytic weight gain (idwg). control of idwg is needed to prevent an increase in the incidence of increasing blood pressure during hemodialysis. a study in china showed that reducing fluid overload in intradialytic hypertension patients with high predialytic blood pressure can effectively improve their blood pressure, but did not affect blood pressure in normal predialytic blood pressure intradialytic hypertension cases.15 an important factor causing an increase in intradialytic blood pressure, among others, is excess fluid. hypervolemia condition will have implications for the many intradialytic fluid withdrawals determined by ultrafiltration. increased blood pressure during hemodialysis can occur due to activation of the renin-angiotensinaldosterone system due to hypovolemia when fluid withdrawal occurs intradialytic through ultrafiltration. the findings of this study showed that increased ultrafiltration during hemodialysis increases the risk of intradialytic hypertension. this research showed there was a relationship between ultrafiltration (ufg and ufr) with intradialytic systolic blood pressure, intradialytic diastolic blood pressure and intradialytic mean arterial pressure. the greater the ufg and ufr the higher the intradialytic blood pressure. the results of this study corroborate the findings of previous studies. the findings of 0 50 100 150 200 pre diaysis intra dialysis post dialysis sistolic diastolic map south east asia nursing research, vol 3 no 1, march 2021/ page 8-15 13 yunie armiyati / high ultrafiltration increasing intradialytic blood pressure on hemodialysis patients this study reinforce the results of research on hemodialysis patients in surakarta, that the amount of ultrafiltration during hemodialysis has a positive correlation with the incidence of increased intradialytic blood pressure with p = 0.003 and r = 0.421.16 previous studies have examined ultrafiltration rates for mortality and cardiovascular disease (cvd). ultrafiltration speed is divided into 3 categories: <10 ml/hour/kg, 10-13 ml/hour/kg, and> 13 ml/hour/kg. faster ultrafiltration in hemodialysis patients is associated with a greater risk of multiple causes of cvd morbidity and mortality.17 a study of 64 hemodialysis patients showed that there was a linear correlation between high ufr and all cardiovascular disease morbidity and mortality where ufr was ≥ 10 ml/hour/kg body weight has the highest risk.18 excessive ultrafiltration during hemodialysis due to high idwg will lead to activation of the sympathetic nervous system, activation of raas, increased cardiac output. the process with intradialytic ultrafiltration risks reducing the relative blood volume (rbv) and total blood volume (tbv). the decrease in rbv and tbv will decrease blood flow to the kidneys and stimulate renin release. renin stimulates angiotensin i to angiotensin ii causing vasoconstriction and aldosterone secretion.2 then vasoconstriction and aldosterone secretion will trigger an increase in intradialytic blood pressure. determination of the amount of ultrafiltration must be optimal to achieve normotensive conditions in hemodialysis patients. when hemodialysis ufg determination is determined to attract excess, the magnitude of the ufg may depend on the addition of the idwg and the target dry weight of the patient9. high ufg can lead to intradialytic vascular resistance. intradialytic vascular resistance surges remain implicated as the driving force for blood pressure increases.19 previous studies on patients who had hypertension during hemodialysis showed dilatation of the heart. the patient had an increase in blood pressure on ultrafiltration. a study by cirit et al concluded that paradoxical blood pressure increases with ultrafiltration usually due to overhydration and heart dilation.20 another study also by chou et al proved that aggressive ultrafiltration can decrease the heart index and mean arterial pressure (map), these results support volume overload as the cause of the initial increase in map during ultrafiltration.21 this study also showed there was a correlation between ultrafiltration (ufg and ufr) with intradialytic mean arterial pressure (p= 0,016 & p=0,034). the greater the ufg and ufr the higher the intradialytic mean arterial pressure (r=0,227 & r=0,200). previous research on seven patient undergoing hemodialysis showed that after the fluid was withdrawn a total of 2520 ± 1698 cc then 4.5 ± 2.3% of the body fluid was withdrawn, the systolic heart function parameters were significantly increased to the maximum, arterial pressure increased from 107 ± 5 to 118 ± 6 mmhg with p <0.027. this increase in blood pressure was accompanied by an increase in the cardiac index (from 3.8 ± 0.6 to 4.8 ± 1.1 l / min / m2, p <0.027). this study also concluded that the increased blood pressure during ultrafiltration is due to an increase in cardiac output, mediated by volume overload.22 fluid excess (overload) can also be associated with adherence to fluid intake. the findings of this study indicate that poor fluid adherence correlated with the incident of increasing intradialytic blood pressure. hemodialysis patients should comply with the restriction of fluid intake. if the patient is not adherent, there is a higher risk of fluid overload and a higher risk of intradialytic hypertension. care must be taken to determine the amount of ultrafiltration during hemodialysis to keep blood pressure stable and the patient's condition safe. south east asia nursing research, vol 3 no 1, march 2021/ page 8-15 14 yunie armiyati / high ultrafiltration increasing intradialytic blood pressure on hemodialysis patients determination of ultrafiltration that is not excessive and within the normal range will reduce the risk of an increase in intradialytic blood pressure. determination of ultrafiltration during hemodialysis must be done carefully and precisely to prevent an increase in intradialytic blood pressure. conclusion there is a relationship between ultrafiltrate and intradialytic blood pressure. the greater the ultrafiltration, the more the intradialytic blood pressure increases. acknowledgments thanks to patients and nurses at two hemodialysis units in rs roemani (roemani hospital) and rsud wongsonegoro (wongsonegoro hospital) semarang. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. steddon s, chesser a, cunningham j, et al. oxford handbook of nephrology and hypertension. oxford university press, 2014. 2. hinkle jl and cheever kh. brunner and suddarth's textbook of medical surgical nursing. in: squazzo k, (ed.). 14th ed. philadelphia: wolters kluwer, 2018, p. 6112. 3. kallenbach jz. review of hemodialysis for nurses and dialysis personnel-e-book. elsevier health sciences, 2015. 4. buren pnv, kim c, toto rd, et al. the prevalence of persistent intradialytic hypertension in a hemodialysis population with extended follow-up. int j artif organs 2012; 35: 1031-1038. 2012/10/16. doi: 10.5301/ijao.5000126. 5. kandarini y. peran ultrafiltrasi terhadap hipertensi intradialitik dan hubungannya perubahan kadar: endothelin-1, asymmetric dimethylarginin dan nitric oxide. disertasi, universitas airlangg, 2012. 6. armiyati y. hipotensi dan hipertensi intradialisis pada pasien chronic kidney disease (ckd) saat menjalani hemodialisis di rs pku muhammadiyah yogyakarta. in: prosiding seminar nasional unimus semarang, 2012, pp.126-135. 7. chazot c and jean g. intradialytic hypertension: it is time to act. nephron clinical practice 2010; 115: c182-c188. 8. cheng y, li y, zhang f, et al. interdialytic blood pressure variability and the risk of stroke in maintenance hemodialysis patients. 2020; 99. 9. nkf. update of the kdoqi clinical practice guideline for hemodialysis adequacy. minessota: national kidney foundation, 2015. 10. agarwal r and light rp. intradialytic hypertension is a marker of volume excess. nephrology dialysis transplantation 2010; 25: 3355-3361. 11. suwitra k. penyakit ginjal kronik. in: sudoyo aw, setiyohadi b, alwi i, et al. (eds) buku ajar ilmu penyakit dalam. 6 ed. jakarta: fk-ui, 2014, pp.570-573. 12. locatelli f, cavalli a and tucci b. the growing problem of intradialytic hypertension. nature reviews nephrology 2010; 6: 41. 13. smeltzer sc, bare bg, hinkle jl, et al. brunner & suddarth's textbook of medical-surgical nursing. 13th ed.: lippincott williams & wilkins, 2013. 14. buren pnv and inrig jk. mechanisms and treatment of intradialytic hypertension. blood purification 2016; 41: 188-193. 15. zhang y, zhang x, li j, et al. dry-weight reduction improves intradialytic hypertension only in patients with high predialytic blood pressure. blood press monit 2019; 24: 185-190. 2019/02/27. doi: 10.1097/mbp.0000000000000373. 16. johan a. hubungan besar ultrafiltrasi saat hemodialisis dengan kejadian peningkatan tekanan darah intradialitik pada pasien gagal ginjal kronik. uns, surakarta, 2016. 17. flythe je, kimmel se and brunelli sm. rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality. kidney international 2011; 79: 250-257. 18. kim tw, chang ti, kim th, et al. association of ultrafiltration rate with mortality in incident hemodialysis patients. 2018; 139: 13-22. 19. buren pnv. pathophysiology and implications of intradialytic hypertension. curr opin nephrol hypertens 2017; 26: 303-310. 2017/04/12. doi: 10.1097/mnh.0000000000000334. south east asia nursing research, vol 3 no 1, march 2021/ page 8-15 15 yunie armiyati / high ultrafiltration increasing intradialytic blood pressure on hemodialysis patients 20. cirit m, akcicek f, terzioğlu e, et al. ‘paradoxical’rise in blood pressure during ultrafiltration in dialysis patients. nephrology dialysis transplantation 1995; 10: 1417-1420. 21. chou k-j, lee p-t, chen c-l, et al. physiological changes during hemodialysis in patients with intradialysis hypertension. kidney international 2006; 69: 1833-1838. 22. gũnal a, karaca i, celiker h, et al. paradoxical rise in blood pressure during ultrafiltration is caused by increased cardiac output. journal of nephrology 2002; 15: 42-47. the effect of starfruit juice to reduce the blood pressure in elderly patients corresponding author: endhar arifathul farida endharfarida@gmail.com south east asia nursing research, vol 2 no 3, september 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.3.2020.111-116 original research the effect of starfruit juice to reduce the blood pressure in elderly patients endhar arifathul farida1, ilham setyo budi1, jamaludin jamaludin2 1 stikes cendekia utama kudus, indonesia 2 akper krida husada kudus, indonesia article info abstract article history: submit july 15th, 2020 accepted sept 20th, 2020 published sept 30th 2020 keywords: hypertension; elderly; star fruit juice hypertension is classified as a disease that is often called the silent killer. hypertension can attack various ages, including the elderly. hypertension in the long term will cause various complications. in treatment of hypertension, many natural plants that can be consumed, one of which is star fruit. sweet starfruit juice is very useful for lowering blood pressure because of its fiber, potassium, phosphorus and vitamin c content. this study was to determine the effect of starfruit juice on lowering blood pressure in elderly people with hypertension at the integrated service center in the working area of rejosari dawe kudus public health center. this study used a quasy experiment method with a pre-test-post-test research design with a control group. a sample of 20 people, divided into two groups, namely 10 people in the experimental group and 10 people in the control group. the results of the independent t-test, the results of the posttest systolic blood pressure p value = 0.004, while the diastolic blood pressure posttest p value = 0.014, so it can be seen that the p value <0.05, then h0 is rejected and ha is accepted. in this study, it can be concluded that there is an effect of giving star fruit juice on reducing blood pressure in elderly people with hypertension at the integrated service center in the working area of the rejosari dawe kudus community health center. introduction the process of aging is a process of disappearing slowly the ability of the network to repair itself replace and maintain its normal function.1 many elderly people today suffer from several degenerative diseases, namely hypertension. hypertension is classified as a disease that is often referred to as a silent killer because it can cause the sufferer to die, hypertension does. not immediately kill the sufferer, but hypertension triggers the emergence of a deadly disease. 2 hypertension in the long term will cause various complications. extremely high blood pressure can damage the inside of a small artery, possibly blood clots, if this happens it can lead to heart attack, blindness, kidney failure, and stroke. 3 the incidence of hypertension has increased in the world. according to who (2013) hypertension kills 9.4 million people in the world every year.3 based on data sourced from riskesdas 2016.4 the prevalence of elderly hypertension in indonesia is 45.9% for 55-64 years, 57.6% https://doi.org/10.26714/seanr.2.3.2020.111-116 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.3.2020.111-116&domain=pdf&date_stamp=2020-09-30 south east asia nursing research, vol 2 no 3, september 2020/ page 111-116 112 endhar arifathul farida / the effect of starfruit juice to reduce the blood pressure in elderly patients for 65-74 years and 63.8% for> 75 years.5 according to the central java provincial health office, the number of people at risk, from the results of blood pressure measurements, as many as 1,153,371 people or 12.98% stated hypertension.6 from the data from the kudus regency health office in 2016, there were 451,224 people aged 18 years and over, of the 188,208 people examined, 75,074 were men, (8.26%) had hypertension and (41.71%) were not hypertensive. of the 105,494 women examined, 10,530 (9.98%) had hypertension and 94,964 (99.8%) did not have hypertension. 7 to reduce the incidence of hypertension, an approach is needed that is done, namely pharmacologically and nonpharmacologically. the pharmacological approach is to use antihypertensive drugs, while the non-pharmacological approach includes limiting salt intake, quitting smoking, and by using fruit and vegetable juice therapy. one of the fruit juice therapies is the provision of sweet starfruit juice for hypertension sufferers.8 this sweet star fruit is very useful for lowering blood pressure because of its fiber, potassium, phosphorus and vitamin c content. based on the dash (dietary approaches to stop hypertension) research, it is said that to lower blood pressure, it is highly recommended to consume foods that are high in potassium and fiber. 9 the results of research by putri aulia (2018) on the effect of giving starfruit juice on changes in blood pressure of hypertension patients in nursing homes with a quasi-experimental method. the research was conducted for 7 days with a sample of 10 people, divided into two groups of control and experiment. the results showed that 5 respondents who were given star fruit juice had a change in blood pressure with an average difference in systolic blood pressure before and after administration with p value = 0.014, meaning that there was a significant difference. the results obtained in research on the effect of giving averrhoa carambola juice on the reduction of blood pressure in the elderly with hypertension. the quasiexperimental method of 10 respondents who had been selected by means of purposive sampling showed the effect of starfruit juice on reducing blood pressure.10 from the results of the preliminary survey, the data obtained by the elderly who suffer hypertension comes to do a health check at the the integrated service center, which is numbered 20 people. after interviewing researchers, most of the elderly have risk factors hypertension, namely the habit of consuming coffee, smoking and consuming salt. elderly control blood pressure using medicine from a doctor, besides that, the community does not yet know about nonpharmacological therapy with herbal therapy, namely using starfruit juice is useful for lowering blood pressure. based on the description of the data above, the researcher is interested in conducting a research entitled the effect of giving star fruit juice on reducing blood pressure in elderly people with hypertension at the integrated service center in the working area of rejosari public health center. methods this type of research is quantitative, the research design is quasy experiment with the design of the pre-test-post-test design with the control group, namely by comparing the results obtained before and after being treated in the experimental group and the control group. this research was conducted on december april 20 to 27 2019 at the village health post in japan, the working area of the rejosari community health center holy dawe. in this study the population was all elderly who came to the elderly integrated service center in japan village who experienced hypertension. the sample is elderly suffering from hypertension who meet the inclusion criteria. the sampling technique was purposive sampling with a sample size of 20 south east asia nursing research, vol 2 no 3, september 2020/ page 111-116 113 endhar arifathul farida / the effect of starfruit juice to reduce the blood pressure in elderly patients people with details of 10 people as the experimental group and 10 people as the control group. to find out the respondent's blood pressure, a calibrated sphygmomanometer was used. the analytical test used in this study used the independent t test. results the results show that the blood pressure before being given the juice star fruit in the experimental group, it was found that the average systolic blood pressure of the respondents was 183.20 mmhg while the average diastolic blood pressure was 100.00 mmhg with a standard deviation of systole 10.560 and diastole 5,270. the results show that the respondent's blood pressure after being given starfruit juice in the experimental group, the average systolic blood pressure of the respondents was 155.60 mmhg, while the average diastolic blood pressure was 90.30 mmhg, with a standard deviation of systole 10.700 and diastole 2.710. the results indicate that the respondent's blood pressure before given starfruit juice in the control group, the average systolic blood pressure of the respondents was 188.80 mmhg while the mean diastolic blood pressure was 105.00 mmhg with a standard deviation of systole 24.027 and diastole 11.671. the results indicate that the blood pressure of the respondents after being given star fruit juice in the control group obtained an average pressure the respondent's systolic blood was 182.30 mmhg while the mean diastolic blood pressure was 99.90 mmhg, with a standard deviation of systole 22,886 and diastole 10,754. the results show that the mean and standard deviation of blood pressure systole and diastole between measurements before and after juicing star fruit in the experimental group. the mean bp of systole before giving star fruit juice was 183.20 mmhg with sd 10,560, while the mean diastole was 100.00 mmhg and sd 5.270. on the measurement of the systole after giving star fruit juice was 155.60 mmhg with sd 10.700 while the average diastole was 90.30 mmhg with sd 2.710. this effect was tested by using the paired t test, namely using the paired test the sample t-test obtained p value = 0.000, so it can be seen that the p value <0.05, it can be concluded that there is an effect of giving starfruit juice on reducing blood pressure in elderly people with hypertension at the village health post in japan village working area of rejosari dawe kudus health center. the results show that the mean and standard deviation of blood pressure systole and diastole between measurements before and after juicing star fruit in the control group. the mean bp of systole before giving star fruit juice was 188.80 mmhg with sd 24.027, while the mean diastole was 105.00 mmhg with sd 11,671. the systole blood pressure after giving star fruit juice was 182.30 mmhg with sd 22,886, while the average diastole was 99.90 mmhg with sd 10,754. this effect was tested by using the paired t test, namely using the paired test the sample ttest obtained p value = 0.000, so it can be seen that the p value <0.05, it can be concluded that there is no effect of starfruit juice on lowering blood pressure in elderly people with hypertension in the village of japan in the working area of rejosari dawe kudus health center. the results indicate that the statistical analysis is in the form of averages and standard deviation of systolic and systolic blood pressure after being given star fruit juice between the experimental group and the control group. systole average the experimental group was 155.60 mmhg with sd 10,700 while the mean diastole was 90.30 mmhg and sd 2.710. in the control group systole measurement was 182.30 mmhg with sd 22,886 while the mean diastole was 99.90 mmhg and sd 10,754. this effect was tested by using the unpaired t test, namely using the test the independent t-test obtained the results south east asia nursing research, vol 2 no 3, september 2020/ page 111-116 114 endhar arifathul farida / the effect of starfruit juice to reduce the blood pressure in elderly patients from the posttest systole in the experimental group p value = 0.004, the results from the diastole pos test in the experimental group p value = 0.014, so it can be seen that the p value <0.05, it can be concluded that there is an effect of giving juice starfruit on lowering blood pressure in elderly people with hypertension at the village health post in japan, the working area of the rejosari dawe kudus health center. table 1 mean difference of blood pressure in elderly people with hypertension indicators group p intervention group control group systole before intervention 183.20 (±10.560) 188.80 (±24.027) 0.004** systole after intervention 155.60 (±10.70) 182.3 (±22.88) p 0.0001* 0.0001* diastole before intervention 100.00 (±5.270) 105.00 (±11.67) 0.014** diastole before intervention 90.3 (±2.71) 99.9 (±10.75) p 0.0001* 0.0001* * paired t-test ** independent t-test discussion hypertension is not known the cause factor. which factor may affect it from genetics or heredity and environment.11 in addition, there are risk factors that can cause an increase in blood pressure, including gender, age, stress, smoking habits, drinking coffee, physical activity, salt intake.12 based on the description above, the researchers concluded that the respondents' high blood pressure was due to various factors of an unhealthy lifestyle. therefore, researchers suggest that respondents who suffer from hypertension are expected to reduce the factors that affect blood pressure increase, by increasing awareness to adopt a healthy lifestyle. after being seen from the results of blood pressure measurements before giving star fruit juice and compared with the results of blood pressure measurements after giving star fruit juice, it was found that there was a decrease in blood pressure both systolic and diastole after giving star fruit juice to the respondents. this shows that star fruit juice has benefits in lowering systolic and diastolic blood pressure in hypertensive sufferers. the use of traditional medicines such as star fruit juice can lowers blood pressure and is very attractive to respondents. this sweet star fruit is very useful for lowering blood pressure because of its fiber, potassium, phosphorus and vitamin c content. based on the dash (dietary approaches to stop hypertension) research it is said that to lower blood pressure, it is highly recommended to consume foods high in potassium and fiber.9 based on the description above, the researchers concluded that star fruit juice is quite effective in reducing blood pressure in people with hypertension. paired t test results obtained p value = 0.000, so it can it is known that the p value <0.05, it can be concluded that there is an effect of giving starfruit juice on reducing blood pressure in elderly people with hypertension at the integrated service center in the working area of rejosari dawe kudus health center. these results indicate that star fruit juice is effective for reducing blood pressure in elderly people with hypertension, star fruit juice given is starfruit juice as much as 200 cc taken once a day after meals and carried out for 7 consecutive days in elderly people with hypertension. there is an effect of star south east asia nursing research, vol 2 no 3, september 2020/ page 111-116 115 endhar arifathul farida / the effect of starfruit juice to reduce the blood pressure in elderly patients fruit juice on blood pressure seen from the decrease in the average blood pressure of both systole and diastole between before and after star fruit juice, the average decrease in systolic blood pressure was 27.6 mmhg, while diastole was 9.02 mmhg,this decrease occurs due to star fruit juice. the results of vetri nathalia's research (2017) show that 5 respondents who were given star fruit juice had a change with the average difference in systolic blood pressure before and after administration with p value = 0.014, meaning that there was a significant difference between blood pressure after and before giving star fruit juice.13 the results of adianto's research (2014) show that from 30 respondents who were given star fruit juice, there was a change using wilcoxon, it was found that the systolic p value = 0,000 and the diastolic p-value = 0,000 then ha was accepted, and ho was rejected, meaning that there was an effect of giving starfruit juice on lowering blood pressure in the elderly with hypertension.14 according to researchers, star fruit juice has an effect in reducing blood pressure in hypertensive patients, where by drinking star fruit juice regularly can reduce the workload of the heart. because star fruit contains potassium which can lower blood pressure in sufferers. the paired t test results obtained p value = 0.000, so it can be seen that the p value <0.05, it can be concluded that there is an effect of giving starfruit juice on reducing blood pressure in elderly people with hypertension at the integrated service center in the working area of rejosari dawe kudus health center. the results showed the measurement of pressure before and after giving star fruit juice in the control group also experienced a decrease, namely the decrease in the mean systolic blood pressure was 6.5 mmhg while the mean decrease in diastolic pressure was 5.1 mmhg. these results indicated that the control group had a decrease in blood pressure between measurements before and after giving star fruit juice because of the effect of taking anti-hypertensive drugs. at the time of the study before being given star fruit juice intervention, the elderly measured blood pressure first from both groups, after that, the experimental group was given intervention and the control group was not given intervention because the control group was using anti-hypertensive drugs, for 30 minutes a re-measurement was carried out in the control group. so that there are elderly people who experience a decrease in blood pressure, both systolic and diastolic. the results of cholifah's research (2018) stated that the value of blood pressure in the intervention group or the group given star fruit juice showed that the p value of systole after the study was 0.03 and diastole was 0.014. this shows a p value <0.05, so ho is rejected, which means that there is an effect of giving sweet starfruit juice on blood pressure.15 the test results with unpaired t test that is using the test independent t-test, the results obtained from systolic blood pressure at p value = 0.004, while diastolic blood pressure p value = 0.014. so it can be seen that the p value <0.05, it can be concluded that there is an effect of starfruit juice on the decline blood pressure in elderly people with hypertension at the village health post in japan, the working area of the rejosari community health center, dawe district, kudus regency. the effect of star fruit juice on reducing blood pressure can be seen from the difference in the average systolic and diastolic blood pressure between the experimental group and the control group, where the average systolic blood pressure in the experimental group is 155.60 mmhg, while the average diastolic blood pressure is 90.30 mmhg. in the control group blood pressure measurement, the mean systolic south east asia nursing research, vol 2 no 3, september 2020/ page 111-116 116 endhar arifathul farida / the effect of starfruit juice to reduce the blood pressure in elderly patients blood pressure was 182.30 mmhg, while the average diastolic pressure was 99.90 mmhg. the results of vetri nathalia's research (2017) show that 5 respondents who were given star fruit juice had a change with the average difference in systolic blood pressure before and after administration with p value = 0.014, meaning that there was a significant difference between blood pressure after and before giving star fruit juice. this is because the experimental group was given star fruit juice and the control group only used anti-hypertensive drugs.13 conclusion the result was found that blood pressure systole posttest p value was 0.004 and diastole p value was 0.014, so it can be seen that the p value <0.05. then h0 is rejected and ha is accepted, there is an effect of giving star fruit juice on reducing blood pressure in elderly people with hypertension at the integrated service center in japan village, the working area of the rejosari dawe health center. acknowledgments the researcher would like to say thank you to all respondents who participated in this research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. lilik ma’rifatul azizah. keperawatan lanjut usia. yogyakarta: graha ilmu, 2011. 2. ratna dewi pudiastuti. penyakit-penyakit mematikan. yogyakarta: nuha medika, 2013. 3. world health organization. ageing and life course. 4. hipertensi di indonesia berdasarkan riskesdas. riskesdas. 5. kemenkes ri. situasi lanjut usia (lansia) di indonesia. infodatin pus data dan inf kementeri kesehat republik indones. 6. dinkes jateng. profil kesehatan provinsi jawa tengah tahun 2017. 2017. 7. dinkes kudus. profil kesehatan kabupaten kudus. 8. muhammadun. hidup bersama hipertensi seringai darah tinggi sang pembunuh sekejap. yogyakarta: in-books, 2010. 9. chaturvedi, m. k. and bassin jk. assessing the water quality index of water treatment plant, and bore wells, in delhi, india. env monit assess 2011; 449–453. 10. arza pa, irawan a. pengaruh pemberian jus averrhoa carambola terhadap penurunan tekanan darah pada lansia penderita hipertensi. j kesehat 2018; 9: 51. 11. nurarif .a.h. dan kusuma. h. aplikasi asuhan keperawatan berdasarkan diagnosa medis & nanda nic-noc. yogyakarta, 2015. 12. robert kowalski. terapi hipertensi: program 8 minggu menurunkan tekanan darah tinggi. alih bahasa rani ikawati. bandung: qanita mizan pustaka, 2010. 13. nathalia v. pengaruh pemberian jus buah belimbing terhadap perubahan tekanan darah penderita hipertensi di panti jompo effect of carambola fruit juice of changes in blood pressure patients with hypertension in nursing homes latar belakang hipertensi saat ini masih me. 2017; 201–216. 14. ardiyanto i, nuraeni a, supriyono m. efektifitas jus belimbing terhadap penurunan tekanan darah pada lansia di kelurahan tawangmas baru kecamatan semarang barat. j ilmi keperawatan dan kebidanan 2014; 1–8. 15. cholifah n, … ss-… ik dan, 2018 u. pengaruh juice belimbing manis (averrhoa carambola linn) terhadap tekanan darah pada lansia dengan hipertensi di desa lemah putih. j ilmu keperawatan dan kebidanan 2018; 9: 118–125. analysis of nursing supervision function in nursing supervision implementation corresponding author: etik kustiati etik.kustiati@yahoo.com south east asia nursing research, vol 2 no 3, september 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.3.2020.123-131 case study analysis of nursing supervision function in nursing supervision implementation etik kustiati1, vivi yosafianti pohan2, tri hartiti3 1,2,3 master of nursing program, universitas muhammadiyah semarang, indonesia article info abstract article history: submit august 30th, 2020 accepted sept 29th, 2020 published sept 30th 2020 keywords: supervisory function; nursing room; nursing supervision preparaing rooms for covid 19 patients must be supported by the availability of superior human resources and good nursing management functions. nursing care given to covid 19 patients must be complete and well documented. the quality of service needs to be monitored on an ongoing basis by optimizing the supervisory function of the head of the room and the orphans by means of nursing supervision. the purpose of this analysis is to determine the usefulness of the nursing room supervision function in this case by implementing nursing supervision. the use of the action method in this analysis aims to develop new skills or new approaches and be applied directly and studied the results. the assessment using eight nursing management functions carried out in sulaiman 4 room roemani muhammadiyah semarang hospital found that the most priority problems were not optimal in the implementation of the supervisory activities of the head of the room and head of the team. the supervision activities in the sulaiman 4 room have actually been carried out but have not been scheduled and well documented. actions taken by refreshing the nursing supervision through small group discus activities, preparation of supervision schedules and making supervision formats. evaluation of the actions taken, sgd was attended by 19 participants consisting of 15 nurses sulaiman 4 and four other inpatient heads, the supervision schedule was made according to the agreement of the head of the room and the head of the team. the direct supervision format was used in sulaiman 4 room according to the predetermined schedule, namely on december 11, 2020. the results achieved from the supervision obtained a significant increase in the number of completeness of nursing documentation from 48.24% to 82.98%. introduction nursing is a form of professional service that is part of the health service system based on knowledge, this service is manifested in a comprehensive form of services including bio, psycho-social and spiritual guidance given to individuals, families and communities both in a healthy state and in a sick condition covering all the process of life from human birth to death. 1 the activity of providing nursing services to individuals, families, groups or communities is the meaning of nursing, quality nursing management will produce quality nurses so that the nursing services provided will also be of quality. because https://doi.org/10.26714/seanr.2.3.2020.123-131 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.3.2020.123-131&domain=pdf&date_stamp=2020-09-30 south east asia nursing research, vol 2 no 3, september 2020/ page 1-9 124 etik kustiati / analysis of nursing supervision function in nursing supervision implementation good service quality is currently a top priority for community demands for health services. good quality services will provide assurance to patients of protection and legal certainty for both patients and nurses themselves. quality service quality will further improve the health status of patients.2 one of the functions of nursing management, namely the supervisory function, plays a very important role in improving the quality of nursing services where through monitoring activities in this case is carried out by monitoring and evaluation through nursing supervision. through supervision activities, it is expected to solve problems as soon as possible against deviations, mistakes and failures from the expected goals. in addition to being a means of problem solving, supervision activities are also an activity to guide and motivate. through nursing supervision activities will increase the productivity of nurses.3,4 nursing management is a form of science and art in managing nursing resources that are dynamic, proactive, efficient, effective and rational in running an organization by implementing a nursing management process to achieve a goal and objectivity in nursing care and nursing services. nursing management in which there are activities in the form of organization, workforce management, direction, supervision, care room management, logistics management, nursing quality assurance programs and programs, patient safety, is an integral part of providing services. through this nursing management process the objectives of nursing services and the objectivity of nursing care in health facilities can be realized.5 the supervisory function is an activity in nursing management that aims to find and correct important deviations in nursing care service activities in a health service. the implementation of supervision by means of supervision is planned in a systematic, measured, planned, and documented manner. the supervisory function in nursing management is indispensable to provide control and limitation for implementing nurses in providing nursing care to patients, so that the goal of achieving excellent and quality service can be achieved. supervision as a form of the process of implementing the supervisory function in nursing management in its implementation remains oriented towards patient-focused services (patient center care).6 the supervisory function in this case is carried out by means of nursing supervision which is a very important managerial activity. through supervision, the implementation of the supervision function can run well to improve service quality and performance. regular and scheduled supervision will support planned activities and expected goals.5 nursing supervision is a continuous process of activities carried out by the leader with the aim of knowing the extent of the level of knowledge, skills, creativity and compliance with the procedures performed by the nurse under him. nursing supervision is also useful for exploring the quality and ability of nurses through support, direction, observation, guidance, and motivation.7 nursing care is a series of activities to provide direct nursing practice to patients in various health facilities by referring to the existing rules of the nursing profession. nursing care standards are one of the references of the quality of nursing care provided to patients. the quality and quality of a hospital is also supported by quality nursing care standards.8 nursing care standards according to the ministry of health of the republic of indonesia in 1998 include the stages of the nursing process, namely assessment, diagnosis, nursing planning, nursing implementation and evaluation.9 south east asia nursing research, vol 2 no 3, september 2020/ page 1-9 125 etik kustiati / analysis of nursing supervision function in nursing supervision implementation nursing care standards can be used as a determinant of the success and quality of nursing care. the provision of quality nursing care must be in accordance with the established standards of the nursing profession. nursing care services are used fairly, efficiently, effectively and safely for patients and nurses as satisfying service providers. social, economic, cultural, religious, ethical and values aspects in society are considered and used to assess the quality of nursing services by using nursing care standards. nursing care standards are also used to maintain and improve service standards in health facilities.10 roemani muhammadiyah semarang hospital is a private hospital in the middle of the city of semarang that provides health services that aim to improve health status and is always oriented to the interests of the community. the health services provided are always balanced with dedication to the surrounding community. rs. roemani muhammadiyah semarang strives to create a solid organization and management oriented towards the quality of service for the community. so that the process of repair and improvement is carried out in various aspects of services and facilities and infrastructure. to realize an increase in the quality of service at the roemani muhammadiyah hospital in semarang, the field of care organizes nursing supervision. nursing supervision carried out in the field of care is the supervision of nursing services in general and the area of supervision of all units under the field of care. meanwhile, supervision of the treatment room has been carried out but the implementation has not been optimal. supervision of the treatment room is only carried out once a month, there is also no implementation schedule and documentation of the implementation of supervision. methods the method used is the action method, which is a method that aims to develop new skills or new approaches and is applied directly and the results are reviewed. where this analysis is prepared based on the assessment of eight nursing management functions, namely the function of organizing, personnel, directing, monitoring, care management, logistics management, quality assurance programs and patient safety. the results of the assessment in the sulaiman 4 room based on the eight nursing management functions found five problems, namely: not optimal in the implementation of supervision activities of the head of the room and the team head, the implementation of nursing care was not in accordance with the spo, lack of manpower needs, the number of completeness of documentation was still low, the drill was still low in the last three months. of the five problems above, the priority order of the problems according to the hanlon theory and the joint agreement of the head of sulaiman room 4 is that the problem of not optimal implementation of the supervisory activities of the head of the room and the team leader is considered very important and needs immediate resolution. from the problem that the implementation of the supervision activities of the head of the room and the head of the team has not been optimal, the action taken is to refresh again about the supervision through the small group discus activity, preparation of the supervision schedule according to the agreement of the ka ru and the ka of the sulaiman 4 room team, making the supervision format. the results of the actions carried out by sgd which were carried out on december 7, 2020, attended by 19 participants consisting of 15 nurses (ka ru, team head and implementing nurses), four other inpatient heads, the schedule for supervision of the team leader and head of the team was made on december 8, 2020, the format of nursing supervision which was immediately applied in sulaiman room 4 on december 11, 2020. south east asia nursing research, vol 2 no 3, september 2020/ page 1-9 126 etik kustiati / analysis of nursing supervision function in nursing supervision implementation results roemani muhammadiyah semarang hospital is one of the health facilities that has a vision to create a global quality hospital by 2030 with the application of the latest technology based on islamic values. based on the results of the assessment carried out in room sulaiman 4, it has provided nursing services as required in the snars 1.0 accreditation, but these efforts have not been running optimally, because it is still in the refinement stage. this can be seen from the results of the analysis of the problems found by students during the application practice, namely: 1. not yet optimal implementation of supervisory activities for the head of room and head of the team 2. implementation of nursing care is not in accordance with the spo 3. lack of personnel needs 4. the number of documentation completeness is still low 5. drill is still low in the last 3 months the problems found have been taken based on an agreement with sulaiman 4 and the supervisor of roemani muhammadiyah semarang hospital, by sticking to the theory of applying the problem, namely the hanlon theory. every intervention that is made and implemented is an effort that is considered the most effective in adjusting the needs of the problem and able to answer existing problems. description of the discussion of the interventions carried out which is taken from the main problem, namely the not optimal implementation of the supervisory activities of the head of the room and the head of the team. supervision is an active process of directing, guiding and influencing the results of individual task performance, in this case the nurse as an individual who is supervised. direct supervision is carried out by the head and team leader to find problems as early as possible so that the resolution can also be faster and more effective. clinical supervision needs to be carried out in a programmed, scheduled manner, and not to look for errors or deviations. supervision is also carried out, especially in providing guidance and direction to improve the understanding of the nurse in carrying out their duties and responsibilities in providing services from the results of observations made by practical application students during the implementation of nursing clinical supervision activities in sulaiman room 4, it was found that the team had carried out supervision in accordance with the existing spo of supervision. however, there are some things that need to be improved, namely when: assessment the head of the room and the head of the team are expected to be able to schedule a scheduled and continuous nursing supervision so that it can be known by all the nurses preparation before carrying out the scheduled supervision, the head of the room / head of the team should first orientate or convey the material about the supervision that will be carried out. implementation the ka ru and the ka of the team in carrying out the direction and guidance are expected to have the ability to express questions that lead to the nurse's awareness of the benefits that are obtained. because whatever is done on the occasion of the team and the center of efforts to gain new awareness, insight and identify goals evaluation when conducting the evaluation, it is expected that the ka ru and the ka of the team will be able to carry out supervisory assessments, provide feedback and clarification as well as reinforcement on the achievement of the progress of the south east asia nursing research, vol 2 no 3, september 2020/ page 1-9 127 etik kustiati / analysis of nursing supervision function in nursing supervision implementation implementing nurse and follow up for improvements. nursing supervision in room 4 roemani muhammadiyah semarang hospital in sulaiman room has been carried out according to spo standards. the ka ru and ka of the team already understood the refresh that was given as evidenced by the implementation of the supervision program in the sulaiman 4 room which was held on december 11, 2020. the results of the discussion with the head of the sulaiman room 4 compiled a supervise format that was easy to use because it was in the form of a check list and clear assessment. the format also helps the ka ru and the ka of the team in identifying missing scores, making it easier for the team and the team to supervise. pdsa implementation of supervision in sulaiman 4 rs roemani muhammadiyah semarang 1. supervision implementation data analysis based on the results of interviews and observations in sulaiman's room4, data on the implementation of supervision is still conditional at least once a month, there is already a supervision sop, but the implementation is not yet appropriate 2. pdsa a) plan problem: supervision of head and team head is not yet structured and scheduled purpose: supervision of ka ru and ka teams is carried out in a programmed, scheduled, continuous and documented manner actions: refresh back about supervision via sgd preparation of supervision schedules making supervision format b) do implementation of sgd supervision socialization of supervision format c) study observation of the implementation of supervision with an average result of supervision of 82.98% the results of the discussion were also found that the supervision format created was feasible and easy to apply d) action sgd supervise to the head, head of the team and the executive nurse in the sulaiman room 4 rs roemani muhammadiyah semarang preparation of supervision schedules develop supervision format perform tiered supervision from the explanation above, there is a correspondence between the theory of nursing management functions, especially the supervisory function, with the priority of the issues raised, namely the not optimal implementation of supervisory activities for the head of the room and the head of the team. indeed, the supervisory function is very necessary because with supervision through supervision carried out by both the head and the team, a solution can be immediately sought for the problems found during supervision, one of which was found in the implementation of supervision in sulaiman 4, namely regarding the completeness of documentation and implementation of handover. problems found during the implementation of the nursing management application in the sulaiman 4 in addition to not optimal south east asia nursing research, vol 2 no 3, september 2020/ page 1-9 128 etik kustiati / analysis of nursing supervision function in nursing supervision implementation implementation of the supervision of the head of room and head of the team, namely 1. the implementation of nursing care is not in accordance with the spo implementation: refresh nursing spo by room leader and ka team, by reading at least 1 spo per hand over evaluation: implementation of spo refresh has been carried out starting december 9, 2020 appropriateness theory: in accordance with nursing management theory and research results, refresh spo is needed so that the care provided is in accordance with the patient's needs. 2. lack of personnel needs implementation: optimizing existing nurses while waiting for the recruitment process to be completed and additional nurses can enter the sulaiman 4 evaluation: the recruitment process has been carried out, registration starts on december 10 and 11, followed by a written test on december 14, 2020, it is hoped that the 3rd week of december can be oriented. suitability theory: quality of nursing care, effective and efficient service according to nursing management theory and in accordance with the results of other research. 3. the number of documentation completeness still low implementation: a. build a strong commitment from the head, team and nurse administrators to carry out complete nursing documentation b. bed teaching site filling out nursing documentation by ka ru and ka team. evaluation: a. joint commitment to improve completeness of documentation, bed site teaching and refresher of spo held on december 8, 2020 b. the results of supervision carried out on december 11, 2020 on the completeness of rm documentation increased significantly by 82.98 conformity theory: completeness of documentation is very important in the nursing care process, therefore joint commitment and continuous evaluation monitoring of nursing documentation needs to be done, this is in accordance with the nursing management function in care management. the implementation of nursing care standards is the core of nursing practice, it needs to be supported by good nursing management functions in order to guarantee the quality of nursing services. 3. drill is still low in the last 3 months implementation: providing the best service in accordance with the spo evaluation: on the 8th it was opened. the isolation room with a capacity of 8 beds, until december 16th, all beds were fully occupied. conformity theory. quality services will certainly improve the quality of nursing care so that patients will feel satisfied with the services provided. in accordance with the nursing management function in nursing quality assurance. discussion preparing rooms for covid 19 patients must be supported by the availability of superior human resources and good nursing management functions. nursing care given to covid 19 patients must be complete and well documented. the quality of service needs to be monitored continuously by optimizing the supervisory function of the south east asia nursing research, vol 2 no 3, september 2020/ page 1-9 129 etik kustiati / analysis of nursing supervision function in nursing supervision implementation head of the room and the orphans by means of nursing supervision. the implementation of nursing supervision of nursing care in the covid 19 isolation service must be well scheduled and documented. the nursing management function is primarily a supervisory function with the priority of the issues raised, namely the not yet optimal implementation of the supervisory activities of the head of the room and the head of the team. in fact, the supervisory function is very much needed because with supervision through supervision carried out by both the head and team leader, solutions can be immediately sought for problems found during supervision. one of the findings in the implementation of supervision in sulaiman room 4 was about the completeness of documentation and the implementation of hand over. after carrying out nursing supervision actions that are scheduled and well documented, significant results are obtained, namely the completeness of documentation of 82, 98% some of the results of research that have been conducted by other researchers related to supervision and its benefits are increasing nursing care and documentation aimed at achieving patient satisfaction levels. the results of other research can be concluded that discharge planning is one of the indicators of sustainable nursing services which, if done properly by nurses, will be able to improve the quality of nursing services and patient satisfaction. one of the influencing factors is the leadership of the head of the room, especially in the function of directing the nurse when carrying out discharge planning. the directive function carried out by the head of the room is in the form of providing motivation, supervision, and conflict management.11 other research shows that more than half (53.3%) of the head of the room carried out the supervision and documentation which was done completely and incompletely, the same amount (50%) was carried out by the executive nurse. the results of bivariate analysis with chi-square were obtained (p = 0.021), it can be concluded that there is a relationship between the supervision of the head of the room and the documentation of nursing care in the inpatient room of rsi ibnu sina bukittinggi.12 other research showed have difference in documenting nursing care before and after being given supervision with a p value of 0,000.13 the other research concluded that the combination of the supervisory function in the nursing field and the training that the supervisor participated in had a significant relationship with the implementation of supervision by the supervisor. supervision periodically and with effective supervision techniques improve the performance of nurses in nursing services.14 nursing supervision that is structured, scheduled and well-documented is very beneficial for improving the quality of hospital services. this is supported by several published research results. in fact, the supervisory function is very necessary because with supervision through supervision carried out by both the head and the team, a solution can be immediately sought for problems found during the implementation of nursing supervision. through nursing supervision, the number of completeness of medical record documentation increased significantly from 24.48% to 82.98% nursing spo refresh needs to be done periodically. its implementation requires monitoring and evaluation so that the nursing care carried out by the implementing nurse can be in accordance with the spo determined by the hospital. joint commitment both room leader, the head of the team and the implementing nurses to achieve an increase in the number south east asia nursing research, vol 2 no 3, september 2020/ page 1-9 130 etik kustiati / analysis of nursing supervision function in nursing supervision implementation of documentation completeness. one of the monitoring and evaluation with supervision is able to increase the value of completeness of medical record documentation. the increase in the number of covid patients is comparable to a full bed in the covid room provided. increasing bor while still paying attention to the quality of nursing services will have an impact on patient satisfaction. providing quality services can be done by means of supervision which can be carried out by the head of the room and the head of the team. conclusion rs. roemani muhammadiyah semarang is one of the hospitals in semarang. based on the results of the assessment carried out in sulaiman room 4, 3 problems in nursing management were formulated and the priority problems were as follows 1. not yet optimal implementation of supervisory activities for the head of room and head of the team 2. implementation of nursing care is not in accordance with the spo 3. lack of personnel needs 4. the number of documentation completeness is still low 5. drill is still low in the last 3 months there are five problems found, but based on the priority of the problem according to hanlon, namely the not optimal implementation of the supervisory activities of the head of the room and the head of the team, the solution is sought by implementing supervision in sulaiman 4 room as many as 9 implementing nurses with a value of completeness of documentation of 82.98%. this result significantly increased from the initial value before implementation by students of 48.24%. the implementation of supervision has used a mutually agreed supervision format and according to the time set in the supervision schedule. the understanding of the head of the room and the head of the team on the implementation of supervision is very understood, they are able to carry out the briefing process and guidance to the nurse under him the recommendes suggestions for the hospital is expected to continuously run programs that can improve the quality of hospital services. it is hoped that the hospital should improve the implementation of the management function of the head of the room, especially in the implementation of nursing supervision and it is hoped that the implementation of supervision can be carried out in stages and continuously. the head of the room and the head of the team are expected to be able to continue to motivate the nurse in charge to always improve the quality and run the program that has been compiled. nurses are expected to realize the importance of the role of nurses in the success of health services by continuing to work on the programs that have been prepared. acknowledgments special thanks to dr. ns vivi yosafianti pohan, m.kep , dr. tri hartiti, skm, m.kep for the constructive criticism and advice for this nursing management application report. i would like to express my deepest gratitude to universitas muhammadiyah semarang and rs roemani muhammadiyah semarang for their assistance and cooperation. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. apelia g. manajemen asuhan keperawatan. published online 2019. doi:10.31227/osf.io/8d2z6 south east asia nursing research, vol 2 no 3, september 2020/ page 1-9 131 etik kustiati / analysis of nursing supervision function in nursing supervision implementation 2. irfantian a, arofiati f. pengaruh supervisi keperawatan terhadap persepsi penerapan patient safety dan pendokumentasian asuhan keperawatan. j admmirasi. 2018;3(2):80-90. 3. listiyono ra. studi deskriptif tentang kuaitas pelayanan di rumah sakit umum dr. wahidin sudiro husodo kota mojokerto pasca menjadi rumah sakit tipe b. j kebijak dan manaj publik. 2015;1(1):2-7. 4. nusrial. supervisi kepala madrasah dalam meningkatkan efektifitas layanan administrasi di madrasah tsanawiyah negeri 3 kota jambi. published online 2019. 5. julianto m. peran dan fungsi manajemen keperawatan dalam manajemen konflik. fatmawati hosp j. published online 2016:1-7. 6. devara alan putri a, ari fakhrur rizal a. hubungan pengawasan kepala ruang dengan kinerja perawat dalam memberikan. 2020;1(3):2181-2187. 7. agustina. hubungan supervisi dengan pendokumentasian asuhan keperawatan di ruang rawat inap rumah sakit tk ii kartika husada kubu raya i . 8. ujung h. standar asuhan keperawatan. published online 2008. 9. dedi b. kepemimpinan dan manajemen pelayanan keperawatan: teori, konsep dan implementasi. 2019;(november 2019):397. 10. nursalam. manajemen keperawatan aplikasi dalam praktik keperawatan profesional edisi 4. 4th ed. salemba medika; 2014. 11. imallah rn, khusnia af. fungsi pengarahan kepala ruang dalam pelaksanaan discharge plannning perawat di rs pku muhammadiyah yogyakarta. heal sci pharm j. 2019;3(1):21. doi:10.32504/hspj.v3i1.94 12. andriani m. hubungan supervisi kepala ruangan dengan pendokumentasian asuhan keperawatan di ruangan rawat inap rsi ibnu sina bukittinggi. ilmu kesehat ’afiyah. 2017;4(1):18-24. 13. ananda yuanita, asmawati a, alkafi a. pengaruh supervisi kepala ruangan terhadap pelaksanaan pendokumentasian asuhan keperawatan di ruang rawat inap rsu aisyiyah padang tahun 2018. jikj ilmu kesehat. 2018;2(2):108-112. doi:10.33757/jik.v2i2.125 14. winarti r. sa, yetti k, besral b. peningkatan pelaksanaan supervisi oleh supervisor melalui pengawasan bidang keperawatan. j keperawatan indones. published online 2008. doi:10.7454/jki.v12i3.216 high flow nasal cannula oxygen therapy in long hauler covid-19 patients corresponding author: sarinti sarinti ns.sarinti@unimus.ac.id south east asia nursing research, vol 3 no 1, march 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.1.2021.33-39 case study high flow nasal cannula oxygen therapy in long hauler covid-19 patients sarinti sarinti1,2, fefi eka wahyuningsih2,3 1 universitas muhammadiyah semarang, indonesia 2 tugurejo hospital of central java province, indonesia 3 department of nursing, alkautsar nursing academy, indonesia article info abstract article history: submit feb 5th, 2021 accepted march 1st, 2021 published march 28th 2021 keywords: long haulier covid-19; ards; high flow nasal canul; critical care long hauler covid-19 is a condition that describes a person who has recovered from covid-19 and is declared with a negative pcr smear 2 times but still feels signs and symptoms for a longer period of time, even severe and critical symptoms. most cases complicate acute respiratory disorder syndrome (ards), which can lead to death. fulfilment of non-invasive high concentration oxygenation requirements as an intervention modality in this case. the purpose of this case study was to determine the effect of giving oxygen therapy through the high flow nasal cannula (hfnc) on the respiratory function of covid-19 long haulier patients. the method of nursing care was a case study on 2 respondents with a descriptive approach method. there were 2 cases of long haulier covid-19 patients with comorbid smokers, diabetes mellitus, experiencing moderate ards complications, desaturation, and tachypnea. patients received oxygen therapy intervention through hfnc while being treated in the critical care room, and after being given hfnc oxygen therapy for 5 days there was a decrease in respiratory frequency, a change in breathing pattern from shortness of breath to shortness of breath, an increase in oxygen saturation, an increase in the rox index, an increase in po2 and blood ph in normal limit. nursing care that focuses on respiratory management in covid-19 long haulier patients improves patient outcomes in particular, namely decreased respiratory rate, changes in the respiratory pattern of shortness of breath, increased oxygen saturation, increased rox index, increased po2 and blood ph within normal limits. introduction long hauler covid-19 is a term that describes the phenomenon of symptoms experienced by patients after being infected with covid-19.1 someone who has recovered from covid-19 and tested negative but still feels signs and symptoms for longer.2 the symptoms felt by sufferers of covid-19 vary. about 80% of people with covid-19 experience mild symptoms and can recover in just two weeks. however, there are also those who experience a severe response that takes three to six weeks. a person is said to have a covid-19 long hauler if he is infected with the corona virus and experiences symptoms for 28 days or more after being infected. a research and survey published in august 2020 showed that 50-80% of sufferers still https://doi.org/10.26714/seanr.3.1.2021.33-39 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.1.2021.33-39&domain=pdf&date_stamp=2021-03-28 south east asia nursing research, vol 3 no 1, march 2021/ page 33-39 34 sarinti sarinti / high flow nasal cannula oxygen therapy in long hauler covid-19 patients experience disturbing symptoms within 3 months of recovering from covid-19.3 health workers and researchers have focused on the acute phase of covid-19, but follow-up monitoring after discharge for long-term effects (long hauler covid-19) is needed. of the patients recovering from covid-19, around 87.4% said that there was at least one persistent symptom, especially fatigue and dyspnea. the most common symptoms are fatigue, shortness of breath, cough, joint pain, and chest pain.4 while long-term symptoms include difficulty thinking and concentration, depression, muscle aches, headaches, chest pain, intermittent fever, tachycardia.3, 5 the phenomenon of covid-19 long hauler patients at tugurejo hospital who have severe symptoms is treated in the covid-19 icu room, but if the results of pcr swabs that have been carried out 2 times in a row are negative and require critical care 19. this patient who has tested negative for covid-19 still feels symptoms of dyspnea, fatigue, joint pain, reduced muscle function, impaired ability to perform daily activities, and mental health problems such as posttraumatic stress disorder, anxiety, and depression. the number of long hauler cases covid-19 in december 2020-february 2021 was 30 patients. there were 15 patients given oxygen therapy through hfnc, 5 patients received oxygen therapy through mechanical ventilation, 7 patients received oxygen through a non-rebreathing mask, 3 patients received oxygen therapy through a nasal cannula and 1 patient experienced worsening conditions from hfnc oxygen therapy to a mechanic ventilator. the duration of using hfnc and the length of stay of these patients varied between 5-14 days. the main life-threatening problem for covid-19 long hauler patients is a problem attacking the respiratory system and some patients in the course of the disease will develop insufficient refractory hypoxemic breathing which requires mechanical ventilation. currently, the non-invasive method of giving high concentration oxygen through hfnc is a modality in long hauler covid-19 patients, especially those who experience moderate and severe ards failure.6, 7 delaying or preventing mechanical ventilation procedures can reduce the need for a ventilator.8 nasal high-flow oxygen therapy (hfnc) allows the delivery of warm and humidified gases at a high flow rate and the appropriate fraction of inspired oxygen (fio2), is currently frequently used in patients with hypoxemic acute respiratory failure (harf).9 a 2020 study showed that 28 patients with severe covid-19 symptoms, 67.8% of patients with hfnc improved, 32.2% of patients failed using hfnc and needed niv, 17.8% required intubation.10 hfnc also plays an important role in correcting hypoxemia in about two-thirds of patients with covid-19. from previous studies, there has been no specific study for covid-19 long hauler patients. this case study aims to determine the effect of oxygen therapy through hfnc on specific patient outcomes, namely improving breathing patterns, lowering respiratory frequency, increasing oxygen saturation and increasing blood oxygen pressure (pao2) of covid-19 long hauler patients in critical care rooms. methods this study is a case study of nursing care using pre and post test conducted on 2 respondents with a descriptive approach method. the variable of this study was hfnc oxygen therapy on the respiratory function of covid-19 long hauler patients. this study was conducted in the critical care room of tugurejo hospital on february 4february 15, 2021. covid-19 patients whose pcr results were 2 times negative and/or patients who had a history of covid-19 in the past were the population of this study. the subjects of this study consisted of 2 patients obtained by south east asia nursing research, vol 3 no 1, march 2021/ page 33-39 35 sarinti sarinti / high flow nasal cannula oxygen therapy in long hauler covid-19 patients purposive sampling. sampling according to the inclusion criteria, namely long hauler covid-19 patients with comorbid diabetes mellitus who had severe breathing problems, the patient was conscious and able to communicate. exclusion criteria of the patient were no longer able to continue the study because of severe breathlessness, worsening of the condition and requiring mechanical ventilation. the instruments in this case study were the hfnc machine, bed side monitor, oximetry, and blood gas analysis results. data collection procedures: a) determine the patient according to the criteria. b) provide informed consent to prospective respondents. c) after the prospective respondent agrees to become a respondent, the researcher contracts the time to do the research. d) record the breath pattern, measure the respiratory frequency, oxygen saturation, and record the measurement results in the respiratory function status column before being given intervention. d) researchers provide intervention to respondents in the form of hfnc oxygen therapy with a flow of 60 l/minute and 90% fio2. e) every day the patient is remeasured the respiratory function status until day 5. f) record the measurement results in the respiratory function status column after the intervention. g) give hfnc oxygen therapy in accordance with the development of the patient's condition every day. results the subjects of this case study were 2 people, consisting of male and female patients. patient characteristics in both cases can be seen in table 1 and the assessment results in both cases are shown in table 2. first case; a 52 years old male was admitted to the critical care room with complaints of severe shortness of breath, cough, swallowing pain, weakness, lack of appetite, desaturation and compos mentis awareness. the patient had a history of diabetes mellitus with his blood sugar currently under control. the patient did not have fever, blood pressure and pulse rate were within normal limits. the results of laboratory tests of blood gas analysis obtained data on oxygen levels in the blood (po2) 45 mmhg, the p/f ratio of the results was 50 (severe ards), the d-dimer test was 2030 ug/l, the blood sugar when the results were 146 g/dl and x-rays. the result typically viral pneumonia. physical examination obtained data on complaints of severe shortness of breath, respiratory rate 31 times per minute, 88% oxygen saturation, blood pressure 126/92 mmhg, pulse 100 times per minute and temperature 36.5 ° c. diet low in sugar and carbohydrates. the patient experienced major nursing problems as ineffective breathing patterns and impaired gas exchange. patients received oxygen therapy through hfnc flow of 60 liters per minute and a concentration of 90%, rox 3.19, heparin syringe pump 10,000 iu per 24 hours, meropenem injection therapy 500 mg per 8 hours, novorapid 0-0-10 iu (sc) and bricasma inhalation therapy combined with heparin 25,000 iu every 6 hours. acetyl cysteine oral therapy 3 times per day. the patient received rl/tutofusin infusion therapy 30 drops per minute. second case; a 58 years old woman was admitted to the critical care room with complaints of severe shortness of breath, cough, swallowing pain, weakness, lack of appetite, desaturation, restlessness and compos mentis awareness. the patient had a history of diabetes mellitus with his blood sugar currently under control. the patient did not have fever, blood pressure and pulse rate were within normal limits. the results of laboratory examination of blood gas analysis obtained data on oxygen levels in the blood (po2) 45 mmhg, the p/f ratio was 50 (severe ards), rox 2.95, the d-dimer examination was 2100 ug/l, blood sugar at 170 gr/dl and chest x-ray results typically viral bilateral pneumonia. physical examination obtained data on complaints of south east asia nursing research, vol 3 no 1, march 2021/ page 33-39 36 sarinti sarinti / high flow nasal cannula oxygen therapy in long hauler covid-19 patients severe shortness of breath, respiratory rate of 35 times per minute, oxygen saturation of 93%, blood pressure of 126/85 mmhg, pulse 80 times per minute and temperature of 36.3 ° c. diet low in sugar and carbohydrates. the patient experienced major nursing problems as ineffective breathing patterns and impaired gas exchange. patients received oxygen therapy through hfnc flow 60 liters per minute and a concentration of 90%, heparin syringe pump 10,000 iu per 24 hours, meropenem injection therapy 1 gram per 8 hours, novorapid 14 iu per 8 hours (sc) and bricasma inhalation therapy combined with heparin 25,000 iu every 6 hours. acetyl cysteine oral therapy 1 tablet per 8 hours. the patient received infusion therapy of rl/tutofusin 20 drops per minute. the nursing diagnoses that occurred in these 2 patients were ineffective breathing patterns and impaired gas exchange. nursing problems that occur in physiological subcategory disorders are gas exchange disorders associated with increased airway resistance and decreased pulmonary complaints, hyperthermia associated with lung virus infections.11, 12 nursing intervention given is to measure the frequency of breathing, increase oxygen saturation and increase oxygen pressure in the blood (pao2). then the patient is given hfnc oxygen therapy according to the patient's needs. implementation of nursing measures: the patient's respiratory status is measured and the results of laboratory tests. then the patient was given hfnc oxygen therapy with initial parameters of flow 60 and fio2 90% for 5 days. evaluations are carried out every day to determine the progress of the patient's condition so that oxygen administration is tailored to the patient's needs. table 2 shows that 2 patients after being given hfnc oxygen therapy for 5 days experienced an improvement in the respiratory frequency of patient 1, namely from 26 times/ minute to 22 times/minute and patient 2 the frequency of breathing on the first day 35 times/ minute after day 5 to 19 times/minute. the breathing patterns of patients 1 and 2 on days 1 and 5 also experienced a change from shortness of breath to not shortness of breath. the oxygen saturation in patient 1 on the first day was 94% after day 5 to 97% and patient 2 on the first day 92% after day 5 to 99%. laboratory results po2 of patient 1 first day 45 after day 5 to 99 and patient 2 on day 45 after day 5 to 164. blood ph was within normal limits. the rox index on day 5 in patient 1 became 8.82 and 10.42 in patient 2. the hfnc oxygen parameter decreased according to the development of the patient's condition each day. hfnc oxygen flow and fio2 in patients 1 and 2 on the first day were 60 l/min and 90% after day 5 the hfnc flow and fio2 oxygen in patient 1 were 40 l/min and 50%, the second patients were 30 and 50%. table 1 patient characteristics indicators case 1 case 2 gender male female age 52 years old 58 years old comorbid diabetes mellitus diabetes mellitus rox 3.19 2.95 south east asia nursing research, vol 3 no 1, march 2021/ page 33-39 37 sarinti sarinti / high flow nasal cannula oxygen therapy in long hauler covid-19 patients table 2 hemodynamic parameters and laboratory test results case 1 case 2 day 1 2 3 4 5 1 2 3 4 5 parameter hfnc flow 60 55 55 50 40 60 60 50 40 30 fio2 90 80 70 60 50 90 90 80 60 50 ph 7.45 7.47 7.45 7.45 7.46 7.46 7.46 7.45 7.46 7.47 po2 45 46 51 67 99 45 51 71 80 164 p/f ratio 50 57.5 72.8 111.6 198 50 56 88 133 328 breathing pattern (dyspnea) + + + + rr 26 26 21 26 22 35 26 24 22 19 spo2 94 94 94 95 97 92 95 97 98 99 rox index 4.02 4.52 6.39 6.09 8.82 2.92 4.06 5.05 7.42 10.42 discussion the results of this case study indicate that after maximal administration of hfnc oxygen at the start of each day of administration it can be reduced according to the patient's oxygen requirements. after giving hfnc oxygen therapy to this covid19 long hauler patient also showed a decrease in breathing frequency, changes in breathing patterns from shortness to shortness of breath, increased oxygen saturation, and an increase in the rox index, an increase in po2 and blood ph within normal limits. severe, progressive shortness of breath and complications of ards often experience a happy hypoxic condition characterized by compos mentis awareness, shortness of breath, desaturation and severe hypoxemia are symptoms that often occur in long hauler covid-19 patients.13 this is in accordance with the conditions that occurred in this case study. the patient characteristics in this case study were diabetes mellitus patients. the phenomenon of covid-19 and long hauler covid-19 patients requires intensive care and occurs in patients who have a history of diabetes mellitus because they have a very severe inflammatory response.14 the special surface glycoproteins in ace2 are the entry port for the covid-19 virus. ace2 is abundant in the alveolar type ii cells of the lungs. if the amount of ace2 in excess can worsen the patient's condition. this can lead to ards, damage to the liver, heart, kidneys, and even death. patients with comorbid diabetes mellitus tend to be twice as likely to suffer from severe symptoms of covid-19 and two times more likely to die from these symptoms.15 the principle of oxygen therapy with hfnc is based on a device capable of providing a high flow of oxygen demand through a warm and moist nasal cannula. this cannula can provide flows of up to 60 l/minute at a temperature of 31-37℃ with an absolute humidity of 44 mg h2o/l; fio2 varies between 21-100%. the advantages of hfnc include clearing the pharyngeal dead space, reducing respiratory effort, the effect of peep (positive end-expiratory pressure), providing a constant fraction of inspired oxygen, patient comfort and improved muco-ciliary clearance. hfnc is also known to provide a low peep, which can improve the condition of patients with mild-tomoderate respiratory failure. in addition, by providing a warm, humidified gas, hfnc reduces the metabolic effort required to condition the air. hfnc is more tolerable than other ventilatory supports and reduces the incidence of intubation thus providing a good clinical prognosis in patients with acute respiratory failure.16 hfnc was also studied to have an important role in correcting hypoxemia in about twothirds of patients with covid-19 with severe hypoxemic respiratory failure who were unable to achieve sato2 ≥ 92% with south east asia nursing research, vol 3 no 1, march 2021/ page 33-39 38 sarinti sarinti / high flow nasal cannula oxygen therapy in long hauler covid-19 patients standard oxygen therapy. a study showed 28 patients with severe covid-19 symptoms, about 67.8% of patients with hfnc improved and could be transferred to a normal room, 32.2% of patients failed using hfnc and needed niv, 17.8% required intubation.10 this improvement in oxygenation is related to air flow that is in accordance with ventilation requirements, high and stable fio2, cleaning of the upper airways, the presence of positive pressure (peep), and providing warm and humid air. patients with a pao2/fio2 ≤ 100 mmhg are at risk of failing hfnc therapy.10 this case study was the initial administration of hfnc oxygen therapy with a flow of 60 l/min and a fio2 of 90%. every day the patient's condition shows an improvement in the status of respiratory function so that the hfnc oxygen therapy is gradually reduced. until day 5, the hfnc oxygen therapy given was a flow of 40 l/min and fio2 of 50% in patient 1, flow of 30 l/min and fio2 of 50% in patient 2. a study also showed about 61.9% (65 subjects) patients show improved oxygenation and can be removed from hfnc.17 assessment of the rox index at 6 hours of hfnc administration provides a predictive value for the patient's oxygenation status and a predictor of the success of hfnc therapy.18 an rox index of more than 5.55 at 6 hours of hfnc administration was associated with hfnc success (sensitivity 61.1% specificity 84.6%). this assessment can help the clinician to prevent a late intubation that will lead to a poor prognosis. an rox index below 2.85 at 2 hours, below3.47 at 6 hours and below 3.85 at 12 hours is a predictor of failure of hfnc therapy.19 in this case study, the rox index results after administration of hfnc oxygen therapy on day 5 were 8.82 in patients and 10.42 in patients 2. the effectiveness and comfort of hfnc needed to be evaluated every 2 and 48 hours. thrombocytopenia, increased il-6 upon initiation of hfnc, rox index <5.31 in the first 4 hours of hfnc therapy were independent predictors of failure of hfnc therapy. prolonged use of hfnc is not associated with a poor prognosis. apache ii and psi scores can be used to determine when intubation is needed so that it is not late.20 conclusion nasal high-flow oxygen therapy is proven to be an additional option and alternative method of respiratory support in long hauler covid-19 patients. this is evidenced by an improvement in the respiratory function of covid-19 long hauler patients in critical rooms after being given hfnc oxygen therapy. this case report shows the results of improvement in respiratory function while being treated in the critical care room receiving oxygen therapy through hfnc. acknowledgments we would like to express our gratitude to the director of the tugurejo hospital for giving permission to carry out this case study. thanks also to the head of the nursing department who supported this case study, as well as the respondents who participated. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. baig amjjomv. chronic covid syndrome: need for an appropriate medical terminology for long‐covid and covid long‐haulers. 2020. doi: 10.1002/jmv.26624. 2. mahase ejb. covid-19: what do we know about “long covid”? 2020; 370. doi: https://doi.org/10.1136/bmj.m2815. 3. carfì a, bernabei r and landi fjj. persistent symptoms in patients after acute 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14. roncon l, zuin m, rigatelli g, et al. diabetic patients with covid-19 infection are at higher risk of icu admission and poor short-term outcome. 2020; 127: 104354. doi: https://doi.org/10.1016/j.jcv.2020.104354. 15. kumar a, arora a, sharma p, et al. is diabetes mellitus associated with mortality and severity of covid-19? a meta-analysis. 2020; 14: 535545. doi: https://doi.org/10.1016/j.dsx.2020.04.044. 16. procopio g, cancelliere a, trecarichi em, et al. oxygen therapy via high flow nasal cannula in severe respiratory failure caused by sars-cov-2 infection: a real-life observational study. 2020; 14: 1753466620963016. doi: https://doi.org/10.1177/1753466620963016. 17. hu m, zhou q, zheng r, et al. application of highflow nasal cannula in hypoxemic patients with covid-19: a retrospective cohort study. 2020; 20: 1-7. 18. panadero c, abad-fernández a, rio-ramirez mt, et al. high-flow nasal cannula for acute respiratory distress syndrome (ards) due to covid-19. 2020; 15. doi: 10.4081/mrm.2020.693. 19. suffredini da and allison mgjjoicm. a rationale for use of high flow nasal cannula for select patients with suspected or confirmed severe acute respiratory syndrome coronavirus-2 infection. 2021; 36: 9-17. doi: https://doi.org/10.1177/0885066620956630. 20. xu j, yang x, huang c, et al. a novel riskstratification models of the high-flow nasal cannula therapy in covid-19 patients with hypoxemic respiratory failure. 2020; 7: 912. doi: https://doi.org/10.3389/fmed.2020.607821. https://doi.org/10.1002/jmv.25757 https://doi.org/10.1016/j.eclinm.2020.100570 https://doi.org/10.1016/j.eclinm.2020.100570 https://doi.org/10.4081/monaldi.2020.1323 https://doi.org/10.1101/2020.12.24.20248802 https://doi.org/10.1101/2020.12.24.20248802 https://doi.org/10.1016/j.jcv.2020.104354 https://doi.org/10.1016/j.dsx.2020.04.044 https://doi.org/10.1177/1753466620963016 https://doi.org/10.1177/0885066620956630 https://doi.org/10.3389/fmed.2020.607821 the effectiveness of murottal al-qur'an therapy and virtual reality to reduce pain intensity in post operating patients corresponding author: kirnawan fadholi kirnawanf@gmail.com south east asia nursing research, vol 2 no 2, june 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.2.2020.74-81 original research the effectiveness of murottal al-qur'an therapy and virtual reality to reduce pain intensity in post operating patients kirnawan fadholi1, akhmad mustofa2 1 pku muhammadiyah hospital of temanggung, indonesia 2 universitas muhammadiyah semarang, indonesia article info abstract article history: accepted june 28th, 2020 keywords: murottal al-qur'an; islamic therapy; virtual reality; pain intensity pain management in postoperative patients so far in the shofa room of pku muhammadiyah hospital in temanggung is still limited to pharmacotherapy in the form of 1000 mg injection metamizole or 30mg ketorolac injection and the provision of deep breath therapy. giving this therapy is not optimal in dealing with patient pain. therefore other therapies need to be given for example non-pharmacology, one of them is a combination of murottal alqur'an therapy and virtual reality when the pharmacotherapy reaction is finished and the complementary therapy has never been done in the room. the purpose of this study was to determine the effect of a combination of murottal al-qur'an therapy and virtual reality on pain intensity in postoperative patients. the research design used in this study was quasiexperimental with a pre-posttest with a control group design approach. the subjects of this study were 32 post-operative patients at pku muhammadiyah temanggung hospital. the sampling technique used was purposive sampling. the instrument used in obtaining data is the numeric rating scale. the results showed that: 1) there were differences in the average pretest and posttest intensity of postoperative pain in the intervention group with a p-value of 0,000; 2) there is a difference in the average pretest and posttest intensity of postoperative pain in the control group with a p-value of 0.003; and 3) there is a significant difference in the decrease in intensity of postoperative pain in the intervention group and the control group with a p-value of 0.009 where the experimental group showed a decrease in intensity more effectively than the control group. the results of this study indicate that the combination of murottal al-qur'an therapy and virtual reality is effective in reducing pain intensity in postoperative patients. introduction perioperative nursing is all treatment that uses an invasive way by opening or displaying the part of the body to be operated on by making incisions starting from pre-operative, intra-operative, and post-operative stages (potter & perry, 2010). perioperative nursing aims to establish the diagnosis (biopsy, exploratory laparotomy), for healing (mass excision). each perioperative phase begins and ends in a specific time with a sequence of events that make up the surgical experience, and https://doi.org/10.26714/seanr.2.2.2020.74-81 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.2.2020.74-81&domain=pdf&date_stamp=2020-06-30 south east asia nursing research, vol 2 no 2, june 2020/ page 74-81 75 kirnawan fadholi / the effectiveness of murottal al-qur'an therapy and virtual reality to reduce pain intensity in post operating patients each includes a wide range of nursing behaviours and activities performed by nurses using nursing processes and nursing standards.1 some disease conditions require perioperative or surgical measures. data from the world health organization (who) is estimated that every year there are 230 million surgeries performed worldwide. research in 56 countries from 192 countries is estimated that 234.2 million surgical procedures are performed every year and have the potential to cause complications and death (who, 2013), while in indonesia surgical cases reached 1.2 million people in 2013 and is estimated to increase every year.2 perioperative action is very risky if it is not handled properly and properly according to the procedure and can cause various complications at every stage. the results of a preliminary study in the shofa room of pku muhammadiyah temanggung hospital showed that the prevalence of postoperative patients during the last three months from september to november 2019 has increased quite significantly, in september 112 patients, october 126 patients, and november 136 patients. a preliminary study conducted on 5 patients at 5 hours since the administration of postoperative analgesic therapy at h + 1, 5 of these patients still complained of moderate to severe pain (scale 4 7). these data are proven by a study conducted by other study that the half-life of intravenous administration of ketorolac injection is five hours in adult patients. after five hours post-injection, the drug concentration in the blood decreases, as a result of which the analgesic effect of the drug decreases. 3, 4 pain that arises as a result of tissue damage is subjective and causes discomfort.5 pain is a physiological mechanism that aims to protect yourself and as a warning sign that tissue damage is occurring, therefore, assessment of pain by nurses in postoperative patients is very important.6 after the pain assessment is carried out, it is necessary to collaborate to provide analgesic therapy with the right dose.7 the problems that arise when the use of analgesic therapy for a long enough time can cause adverse side effects, one of which is increased gastric acid secretion.8 therefore, it is also important to provide non-pharmacological therapy to reduce postoperative pain, one of which is by using murottal al-quran therapy.9 pain management in postoperative patients so far in the shofa room of pku muhammadiyah temanggung hospital is still limited to providing pharmacotherapy in the form of 1 gram of metamizole injection and 30mg of ketorolac injection (based on standard operational procedures of pku muhammadiyah temanggung hospital) and providing deep breath therapy. the administration of this therapy is deemed not optimal in dealing with patient pain because based on a study conducted by researchers on 5 patients, all of them still complained of pain. therefore, other therapies need to be given, for example non-pharmacological, one of which is a combination of murottal al-quran therapy and virtual reality when the pharmacotherapy reactions have run out and the complementary therapy has never been done in that room. this combination of therapy is expected to have a more effective impact in reducing the pain intensity of the patient because, with this combination of therapy, 2 nerves are simultaneously activated, namely the visual and auditory nerves. murottal al-quran is a recording of the reading of a letter in the al-quran chanted by a qori '(al-quran reader) in the form of sound.10 murottal al-quran is claimed to be one of the effective non-pharmacological pain management in postoperative patients. this is evidenced by a study that states that listening to the murottal al-quran can provide benefits in the healing process because it can reduce pain and can make you feel relaxed, this is due to a decrease in adrenal corticotropin hormone (acth) south east asia nursing research, vol 2 no 2, june 2020/ page 74-81 76 kirnawan fadholi / the effectiveness of murottal al-qur'an therapy and virtual reality to reduce pain intensity in post operating patients which is claimed to be stress hormone. besides, other research states that listening to the murottal al-quran for a few minutes can reduce pain intensity and can have a positive effect on the listener.11 besides, non-pharmacological therapy that can contribute to reducing pain by distracting attention is to use a virtual reality tool, because this tool can provide multimodal stimuli (visual, auditory, tactile, and olfactory).12 virtual reality is a sophisticated technology that can make users interact with an environment that is simulated by a computer (computersimulated-environment). this virtual reality uses a system that follows the user's head movements and gives the illusion of being surrounded by a virtual world.13 murottal al-quran therapy and the use of virtual reality have the same function, which is to activate the hearing and visual nerves. in the chanting of the sound of the al-quran physically containing human elements, the human voice is an amazing healing instrument and the most accessible tool. sound can reduce stress hormones, activate natural endorphins, increase feelings of relaxation, and divert attention from fear, anxiety and tension, improve the body's chemical system so that it lowers blood pressure and slows down breathing, heart rate, pulse, and brain wave activity. the rate of breathing that is deeper or slower is very good for causing calm, emotional control, deeper thinking and better metabolism.14 murottal al-qur'an therapy in the form of a sound recording containing surah alrahman is more familiar and has 78 verses and all the verses have a short character and 31 verses are repeated so that they are comfortable to listen to and can cause a relaxing effect for even lay listeners.15 murottal ar-rahman when combined with virtual reality using glasses / virtual box containing videos given to patients for 15 minutes can have a positive psychological effect. this is because when the combination of this therapy is played and shown then reaches the brain, this therapy will be translated by the brain.16 based on this phenomenon, the researcher was interested in conducting a study on the combination of murottal al-quran therapy and virtual reality on pain intensity in postoperative patients at pku muhammadiyah hospital, temanggung. methods the research design used in this study was quasi-experimental with a pre-posttest approach with a control group design, where the respondents were divided into two groups, namely the intervention group and the control group. the intervention group received routine actions in the room, namely intravenous analgesic therapy and deep breathing relaxation nursing actions, coupled with a combination of murottal alquran therapy and virtual reality. the control group received standard room therapy, namely intravenous analgesic therapy and deep breathing relaxation nursing measures. research subjects the subjects of this study were 32 post-operative patients at pku muhammadiyah hospital, temanggung. the sampling technique used is population sampling. the instrument used in obtaining data was the numeric rating scale (nrs). the data analysis technique used in this study was the shapiro wilk to find the normality of the data, then followed by the wilcoxon test to look for differences in the average pretest and posttest in each group and the mann whitney test to look for differences in the average pain intensity in the intervention group. and the control group. results the research subjects in this study were 32 postoperative patients at pku muhammadiyah temanggung hospital from february 2 to march 2, 2020. the results of the characteristics of respondents in this study were used to determine the south east asia nursing research, vol 2 no 2, june 2020/ page 74-81 77 kirnawan fadholi / the effectiveness of murottal al-qur'an therapy and virtual reality to reduce pain intensity in post operating patients general description of respondents based on age and gender, type of surgery, and level of anxiety. an overview of the characteristics of the respondents is presented in the following table: result of this study shows the distribution of research subjects. in the experimental group for the age category, the most were elderly as many as 7 people (43.8%) and at least 1 person for late adolescence (6.3%), the distribution of respondents for the most types of surgery was appendectomy as many as 7 people (43.7%) and the least was debridement and prostatectomy of 1 person (6.3%), while the distribution of respondents for the category of the highest level of anxiety was on the moderate anxiety scale, namely 9 people (56.3%), while for the control group the age category was the most elderly. as many as 7 people (43.7%) and at least 1 person for late adolescence (6.3%), the distribution of respondents for the most types of surgery was appendectomy as many as 8 people (50.0%) and the least amount of debridement and prostatectomy was 1 person (6, 3%), while the distribution of respondents for the category of the highest level of anxiety on the medium anxiety scale was 7 people (43.7%). based on the data normality test, it can be seen that the overall data is not normal, so the next hypothesis test uses a nonparametric test, namely the wilcoxon test and the mann whitney test. based on table 1, shows that in the intervention group the average pain intensity of respondents before being given treatment was 5.56 and after being given the treatment it became 3.44 with a mean difference of 2.12, the pain intensity value at the time of the pre-test got a minimum value of 4 and a maximum of 7 whereas in the post-test the minimum score is 2 and the maximum is 5. the p-value in the intervention group is 0,000. in the control group, the average pain intensity of respondents before being given treatment was 4.88 and after being given the treatment it became 4.31 with a mean difference of 0.57, the value of pain intensity at the pre-test got a minimum value of 3 and a maximum of 6 while in the post-test the minimum value is 3 and the maximum is 6. the p-value in the control group is 0.003. the results of the data analysis showed that there was a difference in the average pain intensity before and after the intervention was given, meaning that there was a significant decrease in postoperative pain intensity in both the intervention group and the control group. table 1 shows that the average (mean) of the intervention group on the post-test data was lower (3.44) than the average (mean) of the control group (4.31). this means that the pain intensity in the intervention group was lower after receiving treatment compared to the control group. the results of the data analysis showed that the p-value was 0.009, meaning that there was a significant difference in the reduction in pain intensity in the intervention group and the control group. table 1 the mean differences of post-operative pain intensity indicators intervention group control group p pain intensity before intervention 5.56 (±0.814) 4.88 (±0.885) 0.230 pain intensity after intervention 3.44 (±0.814) 4.31 (±0.875) 0.009 p 0.0001 0.003 discussion based on the results of the study showed that most of the respondents underwent appendectomy surgery as many as 16 people (66.6%). appendectomy surgery is a surgical procedure to remove the infected appendix or appendix (appendicitis). the results also showed that the age group of respondents were elderly as many as 14 respondents (29.2%) and the least for the late adolescence was 2 people (4.2%). age can be a factor affecting pain. elderly south east asia nursing research, vol 2 no 2, june 2020/ page 74-81 78 kirnawan fadholi / the effectiveness of murottal al-qur'an therapy and virtual reality to reduce pain intensity in post operating patients reported lower levels of pain than younger ages, especially children. this is because children have the highest level of distress and anxiety compared to adults or the elderly.9 the results of research conducted on allmale respondents. the results of this study indicate that before the combination of murottal al-qur'an therapy and virtual reality (pretest) in the intervention group the average pain intensity was 5.56 (moderate) and after the intervention (posttest) was 3.44 (mild) with the difference figure obtained p-value 0.000. in the control group, the pretest measurement results were 4.88 (moderate), and the posttest measurement results were 4.31 with a difference value obtained p-value 0.003, meaning that the two groups showed a difference in pain intensity before and after the intervention was given. the results of this study reinforce the previous study entitled the effect of visual distraction therapy with virtual reality media on the pain intensity of postlaparotomy patients. the average pain intensity before visual distraction therapy with virtual reality media was 5.18 with a standard deviation of 0.751. meanwhile, the pain intensity after therapy was 3.55 with a standard deviation of 1.036. the statistical test results obtained a p-value of 0.002 (pvalue 0.002 <α 0.05), it is concluded that there is an effect of visual distraction therapy with virtual reality media on pain intensity in post-laparotomy patients. post-surgery patients will experience different pain depending on the patient's condition at that time. the pain is caused by an incision wound in the area that was operated on (potter & perry, 2010). the pain can stimulate the sympathetic nervous system, increase heart rate and blood pressure which can interfere with the patient's hemodynamics. the action that must be taken is to provide maximum comfort, eliminate factors that increase pain perception. postoperative analgesic therapy in the form of intravenous injection of metamizole and/or ketorolac 1 ampoule and 500 mg tablet of mefenamic acid which is given three times a day. the pain will appear again after the reaction from the drug wears off, so the patient has to wait for the next drug administration hour according to the predetermined hour.3, 4 in this study, it showed that the decrease in the average pain intensity of the intervention group was higher than the control group with a difference in the mean reduction of 1.55 with a p-value of 0.009 (pvalue <0.05), this means that there is a difference in the decrease in intensity. pain relief after being given a combination of murottal al-quran therapy and virtual reality in the intervention group than in the control group in postoperative patients. in this study, it can be concluded that the combination therapy of murottal al qur'an and virtual reality is effective in reducing the intensity of postoperative pain. the results of this study are in line with the research of other research in her study that found that murottal therapy affected reducing pain in mothers who were treated with curettage. the results of this study are also in line with other research which states that murottal therapy has a major effect on reducing pain responses in post hernia surgery patients in cilacap. through the provision of al qur'an murottal therapy, there will be changes in the electric current in the muscles, changes in blood circulation, changes in heart rate and blood levels in the skin. murottal al qur'an therapy is proven to activate body cells by converting sound vibrations into waves that are captured by the body, reducing the stimulation of pain receptors so that the brain releases endogenous natural opioids because these opioids are permanent to block pain nociceptors. meanwhile, the use of virtual reality is for distraction or away from attention to something that is being faced, for example, pain (pain). south east asia nursing research, vol 2 no 2, june 2020/ page 74-81 79 kirnawan fadholi / the effectiveness of murottal al-qur'an therapy and virtual reality to reduce pain intensity in post operating patients the results showed that after a combination of murottal al-quran therapy and virtual reality (post-test) the average pain intensity value in the intervention group 3 (mild), with the lowest pain intensity 2 (mild) and the highest 5 (moderate). . these results indicate that there is a difference in the lowest pain intensity, previously on a scale of 4 after being given a combination of murottal al-quran therapy and virtual reality to the lowest on a scale of 2.pain management in postoperative patients in the shofa room of pku muhammadiyah hospital temanggung is still limited by providing pharmacotherapy in the form of intravenous injection of metamizole and/or ketorolac 1 ampoule and mefenamic acid 500 mg. administration of this therapy has begun to disappear drug reactions at 5 to 6 hours after administration. the combination of murottal al-quran therapy and virtual reality was given after the analgesic reaction disappeared, which was six hours after giving the analgesic while waiting for the analgesic therapy program the next hour to enter. after the bivariate test using the mann whitney test, it can be seen that there are differences in pain intensity in postoperative patients before and after being given a combination of murottal alqur'an therapy and virtual reality with pvalue = 0.009 (<α = 0.05), so that it can be concluded that there is an effect of a combination of murottal al-quran therapy and virtual reality on pain intensity in postoperative patients in the shofa room of pku muhammadiyah hospital, temangung. the distraction technique in the form of listening to the murottal al-qur'an can relieve and calm the patient's feelings of pain, it was found that there was a decrease in pain in postoperative patients.10 sound therapy can regulate stress-related hormones, including acth, prolactin and growth hormone and can increase endorphin levels, thereby reducing pain.9 endorphins are neuroregulatory types of neuromodulators involved in the analgesic system, found in the hypothalamus and areas of the analgesia system (limbic system and spinal cord). these analgesic properties make endorphins an endogenous opioid. endorphins are thought to cause presynaptic and postsynaptic inhibition of pain fibres (nociceptors) that are syncing on the dorsal horn. these fibres are thought to achieve inhibition through inhibition of pain neurotransmitters.17 therapy in the form of music or sound must be listened to at least 15 minutes to provide a therapeutic effect 5, while according to yuanitasari (2008) the duration of music or sound therapy for 1015 minutes can have a relaxing effect. the low sound intensity between 5060 decibels is comfortable and painless and has a positive impact on the listener. al-quran reading therapy has been shown to activate body cells by converting sound vibrations into waves captured by the body, reducing pain receptor stimuli and the brain is stimulated to release endogenous natural opioid analgesics to block pain nociceptors.18 another distraction technique is visual distraction using virtual reality. visual distraction or vision is a distraction directed into visual actions. the purpose of using this visual distraction technique is to obey or divert attention to something that is being faced, for example, pain.19, 20 distraction using virtual reality can stimulate the release of endorphins, the mechanism is to reduce pain according to the gate control theory.21 when getting normal stimulation (somatosensory), the cell projection gate signals, so that it does not cause pain perception. if pain stimulation is received, the stimulation signal will pass through the large and small nerve fibres causing the inhibitor cells to become inactive, so that the projection gate of the cells opens and causes the perception of pain in the brain. it can be concluded that the combination of murottal al-quran therapy and virtual reality is proven to reduce pain intensity in postoperative patients. this is because listening and seeing are some of the south east asia nursing research, vol 2 no 2, june 2020/ page 74-81 80 kirnawan fadholi / the effectiveness of murottal al-qur'an therapy and virtual reality to reduce pain intensity in post operating patients distraction techniques that can be done, the technique focuses on diverting the patient to something other than pain. distraction can stimulate the descending control system, thereby releasing endogenous opiates in the form of endorphins, dynorphins and reduced pain. conclusion there is a significant difference in the average pain intensity in the intervention group and the control group with a p-value of 0.009. the average pain intensity in the intervention group was 3.44, while in the control group it was 4.31, which means that the application of a combination of murottal al-quran therapy and virtual reality was proven to be effective in reducing pain intensity in postoperative patients. acknowledgments we would like to thank all respondents who were willing to be involved in this research. and to all those who have helped complete this research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. brunner and suddarth. keperawatan medikalbedah. 12 ed. jakarta: egc, 2010. 2. sulaiman l and amrullah m. pengaruh kombinasi terapi murottal al-quran dengan relaksasi nafas dalam terhadap penurunan tingkat kecemasan pada pasien pre operasi bedah umum di rsud provinsi ntb. jurnal kesehatan qamarul huda 2019; 7: 18-26. 3. chanif c, petpichetchian w and wimo w. acute postoperative pain of indonesian patients after abdominal surgery. nurse media journal of nursing 2012; 2: 409-420. 4. irmachatshalihah r and armiyati yjmki. murottal therapy lowers blood pressure in hypertensive patients. 2019; 2: 97-104. 5. potter ap and perry ga. fundamental of nursing: consep, procces and practice. 7 ed. jakarta: egc, 2010. 6. muttaqin a. buku ajar asuhan keperawatan klien dengan gangguan sistem persarafan. jakarta: salemba medika, 2008. 7. marrelli. buku saku dokumentasi keperawatan. jakarta: egc, 2008. 8. hayes er and kee jl. farmakologi pendekatan proses keperawatan. jakarta: egc, 2008. 9. prihati dr and wirawati mk. pengaruh terapi murrotal terhadap penurunan tingkat nyeri dan kecemasan saat perawatan luka pasien ulkus dm di rsud k.r.m.t. wongsonegoro semarang. indonesian journal of nursing research (ijnr) 2018. 10. hasanah z, huda n and rahmalia s. efektitas terapi murrotal al-qur’an surah arrahman terhadap penurunan nyeri pada pasien kanker. jurnal online mahasiswa (jom) bidang ilmu keperawatan 2016: 2313-2321. 11. rochmawati p and nanik. pengaruh murottal qur’an terhadap nyeri post operasi. stikes insan cendekia medika jombang, 2018. 12. c.rapetto, s.gaggioli, f.pallavinci, et al. virtual reality and mobile phnes in the treatment of generalized anxiety disorders: a phase-2 clinical trial. personal abd ubiquious computing. 2013; 17: 253-260. doi: 10.1007/s00779-011-04670. 13. andre.k p. mudah membuat game augmented reality (ar) dan virtual reality (vr) dengan unity 3d. jakarta: elex media, 2010. 14. heru. ruqyah syar’i berlandaskan kearifan lokal. 2011. 15. wirakhmi in and hikmanti a. pengaruh terapi murotal ar rahman pada pasien pasca operasi caesar di rsud dr. r. goeteng tarunadibrata purbalingga. in: prosiding seminar nasional & internasional 2016. 16. oriordan. seni penyembuhan alami : rahasia penyembuhan melalui energi ilahi. bekasi: gugus press, 2009. 17. nurul rf. pengaruh terapi murrotal al-qur'an terhadap intensitas nyeri pada pasien post operasi. skripsi 2014. 18. al-kaheel iad. pengobatan qur'ani. jakarta: amzah, 2013. 19. kozier b and dkk. buku ajar fundamental keperawatan : konsep, proses, & praktik, alih bahasa karyuni, p. e dkk. jakarta: egc, 2010. 20. rahayu da, hidayati tn and imam tajmki. the effect of murottal therapy in decreasing south east asia nursing research, vol 2 no 2, june 2020/ page 74-81 81 kirnawan fadholi / the effectiveness of murottal al-qur'an therapy and virtual reality to reduce pain intensity in post operating patients depression of patients undergoing hemodialysis. 2018; 1: 6-10. 21. yadi rd, handayani rs and bangsawan m. pengaruh terapi distraksi visual dengan media virtual reality terhadap intensitas nyeri pasien post operasi laparatomi. jurnal ilmiah keperawatan sai betik 2019; 14: 167-170. correlation knowledge to hypothermic handling practices in students corresponding author: dewi sinta windya kustina dewisetyawati@unimus.ac.id south east asia nursing research, vol 3 no 1, march 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.1.2021.23-27 original research correlation knowledge to hypothermic handling practices in students dewi sinta windya kustina1 1 master of nursing program, universitas muhammadiyah semarang, indonesia article info abstract article history: submit march 5th, 2021 accepted march 25st, 2021 published march 28th 2021 keywords: hypothermia; knowledge; practices hypothermia is a decrease in core body temperature to <35˚c due to heat loss. factors causing hypothermia are cold weather, exposure to cold winds at high altitudes, immersion in cold water, and prolonged exposure to cold. hypothermia is more common in hikers or mapala because they do activities exploring the highlands. the purpose of this study was to determine the relationship between knowledge of hypothermia and the practice of handling hypothermia in mapala. this study used a correlation study method with a cross-sectional approach. the population in this study were mapala unissula, unnes, and usm with a total of 52 students. the sampling technique was purposive sampling, the number of samples of this study was 30 students. the results of the spearman rank statistical test obtained a value of ρ value of 0.738 (ρ ≥ 0.05), so it was stated that there was no relationship between knowledge of hypothermia and the practice of handling hypothermia in nature lovers students. recommendations from research so that mapala members increase their knowledge and practice in handling emergency hypothermia by conducting ongoing training. introduction cold is a low-temperature environment compared to the human core body temperature which is 15℃, the human core body temperature is around 37℃. cold can cause injury when the body is unable to maintain core temperature.1–3 cold injuries that can occur are hypothermia, frostbite, chilblains, trench foot and allergic reactions to cold.1,2 hypothermia causes deaths of up to 700 people per year in the us during the 20 years from 1979-1998, half of them due to cold weather.3,4 in canada, 411 people died from hypothermia, frostbite, and other cold injuries during 1992-1996.5 hypothermia is a condition where the body temperature drops abnormally low below 35℃ due to heat loss. loss of body heat occurs in four ways: conduction, radiation, convection and evaporation. the severity of hypothermia was defined based on core temperature, namely: mild hypothermia (32˚-35℃), moderate hypothermia (28˚32℃) and severe hypothermia (below 28℃).3,6 factors causing hypothermia are cold weather, exposure to cold winds at high altitudes, immersion in cold water, and prolonged exposure to cold. factors that can aggravate hypothermia include wet clothes, fatigue, dehydration, poor food intake, alcohol intake and drugs.1,2,7 https://doi.org/10.26714/seanr.3.1.2021.23-27 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.1.2021.23-27&domain=pdf&date_stamp=2021-03-28 south east asia nursing research, vol 3 no 1, march 2021/ page 23-27 24 dewi sinta windya kustina / correlation knowledge to hypothermic handling practices in students complications that can occur from hypothermia are disturbances in the response to thermoregulation, cellular dysfunction, ischemia, oedema. hypothermia can reduce cardiac contractility due to tissue depletion, blood pressure will decrease until shock occurs. hypothermia can reduce consciousness to become apathetic, loss of reflex swallowing and aspiration. oedema and ischemia from hypothermia put the muscles in stiffness and are at risk for rhabdomyolysis. also, hypothermia can reduce cognitive function and impair neuron conduction which can lead to death.2,4,5,7 treatment of hypothermia is based on preventing further heat loss and rewarming the hypothermic victim. handling hypothermia based on severity, mild to moderate hypothermia reduces heat loss with an additional layer of dry clothes and increases physical activity slowly in a protected environment, intake of warm fluids and sugar helps provide calories plus a source of heat, providing blankets, bodyto-body contact. which is normothermic. severe hypothermia should be protected from any humidity in the environment, use multiple sleeping bags; blankets and clothing to keep a minimum distance of 10cm between the victim and the floor. active external heating using a hot water bottle, warm stone or warm compress towel is placed on the surface of the body that is the main artery, on the neck for the carotid, in the axilla for the brachial, in the groin for the femoral, on the palms for the arch of the artery. severe hypothermia causes gastroparesis but the stomach can absorb water and sugar, give warm sugar water every 15 minutes.2,4,5 hypothermia occurs because a person is in cold weather, exposed to cold winds at high altitudes, immersed in cold water, and prolonged exposure to cold.1,2,7 hypothermia is more common in climbers, climbers admit that hypothermia is a risk they will experience when exploring the highlands with cold temperatures and strong winds, as well as when using wet wear.8–10 factors that aggravate the occurrence of hypothermia in climbers besides using wet clothes are fatigue or the climber's stamina.11–13 a climber in semarang who joined the unissula nature-loving student community (mapala) died on the mountain due to fatigue and hypothermia while participating in a one-week education and sar training activity with 25 other students.14 besides, students of smkn 10 semarang died while climbing mount merbabu due to hypothermia.15 coldrelated injuries can be prevented by proper education, preparation and response to changes in ambient temperature.7 mountain climber first aid education should be improved, education should take into account the special demands of a mountain emergency.16,17 knowledge and attitudes are important to be maintained and improved in providing intervention in cases of hypothermia.18 the knowledge and practice of mothers and professional nurses regarding hypothermia are grossly inadequate in various evaluations.19 based on this description, research needs to find out more about "the relationship of knowledge about hypothermia to hypothermia management practices in nature lovers students (mapala)". methods this research is a quantitative study using a correlation study method (cross-sectional). the population in this study were all mapala unissula, unnes, and usm totalling 52 people. determination of the sample using purposive sampling technique and analyzed with the sample correlation technique, the sample must be taken at least 30. the inclusion criteria were joining mapala, having participated in climbing, having practised handling hypothermia while climbing, and students majoring in nonhealth majors. the exclusion criteria for the south east asia nursing research, vol 3 no 1, march 2021/ page 23-27 25 dewi sinta windya kustina / correlation knowledge to hypothermic handling practices in students study were being sick, members of mapala who were no longer active, students majoring in health, members of mapala who were not students. the research was conducted at the base camp each mapala in may-june 2017. collecting data using a questionnaire compiled by the researcher, the questionnaire has been carried out by expert testing on emergency nursing experts as well as validity and reliability tests.20–23 results based on table 1.1 the results of the research statistical test using the spearman rank correlation test, the correlation coefficient value is -0.064 with a ρ value of 0.738 (ρ≥0.05), meaning that ho is accepted so that it is stated that there is no relationship between knowledge about hypothermia and the practice of handling hypothermia. in nature lovers students (mapala). it is known that most of the respondents practised handling hypothermia in a good category as many as 16 people (53.3%), and 14 people (46.7%) had bad practices. there are still practices that are in the bad category of 46.7% because 40% of respondents have not received ppgd (emergency first aid) education while 60% have the possibility of getting ppgd education for a long time. apart from ppgd education, what affects bad practice is the experience of climbing the respondent at least 1 time, 4 people and only 1 person at most 27 times. table 1.1 correlation of knowledge about hypothermia with hypothermia management practices at mapala unissula, unnes, and usm, may june 2017 variable r p correlation of knowledge with hypothermic treatment practices 0,064 0,738 discussion factors that significantly affect knowledge are education, mass media or information, socio-culture and economy, environment, experience, and age. the results showed that most of the respondents' knowledge was categorized sufficient, namely as much as 56.7%, the good category was 40% and the poor category was 3.3%. respondents who have not received ppgd education are as much as 40% while those who have already been 60%. experience is used as a source of knowledge by repeating the knowledge obtained to solve a problem encountered in the past and as you get older, your perceptive power will develop as well as one's mindset so that the knowledge gained is getting better.24–29 the youngest respondents were 16 years old and the oldest was 23 years old with an average age of 20 years. the respondent has experienced climbing at least once, the value of his knowledge is sufficient and the practice is good. while the experience of climbing is at most 27 times, the value of knowledge is good and the practice is not good. knowledge is sufficient but good practice and good knowledge but bad practice are probably influenced by the number of times the respondent performs treatment practices on hypothermic victims.24–27 this research is supported by the fact that there is no relationship between maternal knowledge, mother's education and husband's support with the practice of exclusive breastfeeding.30 mothers who provide exclusive breastfeeding to their children have high knowledge, in addition to the experiences of mothers and information received by mothers from health workers and the work environment motivate mothers to exclusively breastfeed.31 mothers have satisfactory knowledge of hypothermia, practical applications of mothers who have very poor knowledge.25 conclusion hypothermia management practices in mapala unissula, unnes, and usm were in a good category. there is no correlation south east asia nursing research, vol 3 no 1, march 2021/ page 23-27 26 dewi sinta windya kustina / correlation knowledge to hypothermic handling practices in students between knowledge of hypothermia and the practice of handling hypothermia among nature lovers students (mapala). acknowledgments the author would like to thank the jati kudus public health center for permitting us to conduct research. besides, the authors also wish to thank all respondents for their participation in this study. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. angelova ra. working in cold environment: clothing and thermophysiological comfort. in: occupational health. intech, 2017. epub ahead of print february 2017. doi: 10.5772/65687. 2. nagpal bm, sharma r. cold injuries: the chill within. med j armed forces india 2004; 60: 165– 171. 3. setiati s. buku ajar ilmu penyakit dalam edisi iv. jilid i. jakarta: interna publishing, 2014. 4. gelb d. hypothermia. in: encyclopedia of the neurological sciences. elsevier inc., 2014, pp. 657–658. 5. biem j, koehncke n, classen d, et al. out of the cold: management of hypothermia and frostbite. cmaj 2003; 168: 305–311. 6. silverthorn du. fisiologi manusia : sebuah pendekatan terintegrasi. edisi 6. jakarta: egc, 2014. 7. fudge jr, bennett bl, simanis jp, et al. medical evaluation for exposure extremes: cold. wilderness environ med 2015; 26: 63–68. 8. moore gwk, semple jl. a tale of two climbers: hypothermia, death, and survival on mount everest. high alt med biol 2012; 13: 51–56. 9. alfiqri fr, prakoso h. studi mengenai pemaknaan mendaki gunung pada pendaki seven summits expedition mahitala universitas katolik parahyangan bandung. pros psikol 2015; 0: 16–19. 10. sastha hb. mountain ccimbing for everybody: panduan mendaki gunung. jakarta: hikmah, 2007. 11. firth pg, zheng h, windsor js, et al. mortality on mount everest, 1921-2006: descriptive study. bmj; 337. 12. burtscher m. effect of experience and commercialisation on survival in himalayan mountaineering: retrospective cohort study. bmj 2012; e4846. 13. wijaya h, christian. rekam jejak pendakian ke 44 gunung di nusantara. yogyakarta: andi, 2011. 14. setyawan eh. mahasiswi semarang tewas di gunung merbabu news liputan6.com. 9 februari 2014. 15. setiawan e. oky sempat ragu mendaki gunung merbabu. 9 februari 2016. 16. kuepper t, wermelskirchen d, beeker t, et al. first aid knowledge of alpine mountaineers. resuscitation 2003; 58: 159–169. 17. brustia r, enrione g, catuzzo b, et al. results of a prospective observational study on mountaineering emergencies in western alps: mind your head. high alt med biol 2016; 17: 116–121. 18. purwati t. pengetahuan dan sikap perawat tentang hipotermi dengan intervensi keperawatan bayi berat lahir rendah (nurse’s knowledge and attitude in hypothermic high risk infants). june 2012. epub ahead of print june 2012. doi: 10.5281/j ners community.v3i1.3. 19. gupta j. knowledge, attitude and practices to hypothermia amongst nursing professionals and mothers of neonates asian student medical journal. asian student med j. 20. effendi s, tukiran. metode penelitian survei. jakarta: lp3es, 2012. 21. nursalam. metodologi penelitian ilmu keperawatan: pendekatan praktis. 4th ed. jakarta: salemba medika, 2016. 22. nasir a, muhith a, ideputri me. buku ajar metodologi penelitian kesehatan : konsep pembuatan karya tulis dan thesis untuk mahasiswa kesehatan. yogyakarta: nuha medika, 2011. 23. notoatmodjo s. metodologi penelitian kesehatan. jakarta: rineka cipta, 2012. 24. chan mf. factors affecting knowledge, attitudes, and skills levels for nursing staff toward the clinical management system in hong kong. cin comput informatics, nurs 2009; 27: 57–65. 25. madhavi p, wickremasinghe r, jayasooriya kbn, et al. (pdf) title: mothers’ knowledge and practices on thermoregulation of neonates in south east asia nursing research, vol 3 no 1, march 2021/ page 23-27 27 dewi sinta windya kustina / correlation knowledge to hypothermic handling practices in students sri lanka. eur int j appl sci technol. 26. maniraju, chandra shekar m, williams s. a study to assess the knowledge and practice of staff nurses regarding thermoregulation of neonates selected hospital at mysuru. asian j nurs educ res 2018; 8: 94. 27. awadh a, hassali m, al-lela o, et al. factors affecting parents’ knowledge and practice about childhood immunization: experience from malaysia. value heal 2015; 18: a104– a105. 28. notoatmodjo s. promosi kesehatan dan ilmu perilaku. jakarta: rineka cipta, 2014. 29. notoatmodjo s. ilmu perilaku kesehatan. jakarta: rineka cipta, 2014. 30. sartono a&, utaminingrum h. hubungan pengetahuan ibu, pendidikan ibu dan dukungan suami dengan praktek pemberian asi eksklusif di kelurahan muktiharjo kidul kecamatan telogosari kota semarang. j gizi univ muhamadiyah semarang 2012; 1: 1–9. 31. andayani, r., setyowati, h., & mardiyaningsih e. hubungan pengetahuan ibu tentang asi eksklusif dengan praktik pemberian asi eksklusif pada ibu bekerja di kelurahan ngempon kecamatan bergas kabupaten semarang. the nursing experience of caring a patient with metastatic brain tumor in surgical pain management ward: a case study report corresponding author: sun sheng-feng alex810006@gmail.com south east asia nursing research, vol 2 no 4, december 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.4.2020.32-42 case study the nursing experience of caring a patient with metastatic brain tumor in surgical pain management ward: a case study report sun sheng-feng1 1 new taipei city general hospital sanchong branch, taiwan article info abstract article history: submit dec 2nd, 2020 accepted dec 27th, 2020 published dec 30th 2020 keywords: nursing care; brain metastases; pain management brain metastases are related to the poor prognosis of patients. it is not clear why certain cancers are more likely to metastasize to the brain than others. lung cancer, breast cancer and melanoma noted as the highest incidence of brain tumor metastasis. the purpose of this report was to describe the nursing care of a patient with malignant tumor on the left breast who received multiple chemotherapy and radiotherapy, targeted therapy and mastectomy, and the tumor metastasized to the right occipital lobe of the skull. this study was conducted in surgical pain management ward within 3 days observation. gordon's eleven health function types’ assessment framework was used. observations, physical assessments, interviews, medical records were attempted to collect physical, psychological, social and spiritual data. two specific nursing problems were found. special attention need to be paid for the pain situation and take individualized nursing measures by evaluating individual patients. introduction regardless of the primary or metastatic lesions, brain metastases are related to the poor prognosis of patients. the one-year survival rate of patients with symptomatic brain metastases is less than 20%. it is not clear why certain cancers are more likely to metastasize to the brain than others. but lung cancer, breast cancer and melanoma have a higher incidence of brain tumor metastasis.1 among all malignant tumors, breast cancer ranks second in the incidence of metastatic cancer. the overall prognosis of breast cancer brain metastasis is poor, and the untreated survival period is only 2 to 27 months.2 for cases of simple brain metastasis, although surgical resection may be restricted by anatomical location, neurosurgical resection can help reduce the mass effect in symptomatic patients and is still the primary treatment option.3 this article describes the nursing experience of a patient with malignant tumor on the left breast who received multiple chemotherapy and radiotherapy, targeted therapy and mastectomy, and the tumor metastasized to the right occipital lobe of the skull. the patient’s emotional fluctuations, doubts, and refusal to care for treatment due to tumor metastasis pain, postoperative wound pain, and catheter indwelling factors have triggered the author’s motivation, hoping to help the case to establish correct pain management https://doi.org/10.26714/seanr.2.4.2020.32-42 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.4.2020.32-42&domain=pdf&date_stamp=2020-12-30 south east asia nursing research, vol 2 no 4, december 2020/ page 163-172 164 sun sheng-feng / the nursing experience of caring a patient with metastatic brain tumor in surgical pain management ward: a case study report cognition through the team care experience. it can effectively alleviate the discomfort of patients after surgery to improve the comfort of patients, and serve as the care experience and sharing of similar cases in the future. treatment and care of metastatic brain cancer from breast cancer breast cancer is the second most common source of metastatic brain cancer, accounting for about 14-20%. the typical metastasis of breast cancer is mostly in the lung, liver or bone. and metastatic brain cancer usually does not appear until two to three years after breast cancer is diagnosed.4 there are several risk factors for metastatic brain cancer in breast cancer patients: aggressive tumor behavior, negative hormone receptor status, young women, c-erbb-2 excessive performance, and lung or liver metastases. compared with other tumors, metastatic brain cancers mostly die from systemic diseases, and patients with breast cancer complicated with metastatic brain cancers mostly die from neurological diseases. therefore, local control of metastatic brain tumors is very important for long-term survival.5 treatment: chemotherapy is not effective for brain lesions, because most drugs. neither can enter the brain, so you must rely on surgery or radiation therapy. if you receive brain radiation therapy, it can increase your survival time by 3 to 6 months on average. if there is brain metastasis, consider radiotherapy. if there is edema or compression at the metastatic site and cause headache, you must use antihypertensive drugs and steroids at the beginning of radiotherapy to effectively reduce the symptoms.6 because there are few systemic therapies that can penetrate the blood-brain barrier (bbb), the overall prognosis of brain metastases from breast cancer is poor. the most common symptoms of patients include headache (35%), vomiting (26%), nausea (23%), and hemiplegia (22%), vision changes (13%) and seizures (12%). most patients have multiple metastases (54.2%). the cerebellum and frontal lobe are the most common sites of metastasis (33% and 16%, respectively). the treatment of most patients usually adopts the following two or more multimodal methods: whole brain radiotherapy (52%), chemotherapy (51%), stereotactic radiosurgery (20%), surgical resection (14%). to reduce tumor angiogenesis or change blood permeability brain screen; factors affecting prognosis include tumor size and size, multiple metastases and extracranial metastases.3 pain care pain is a subjective and self-conscious symptom that not only stems from existing or potential physical or physiological factors, but also involves the direct or indirect influence of human life experience.7 pain after craniotomy may affect hospital stay, medication costs, quality of life and the development of persistent pain.8 although there have been considerable developments in drugs for postoperative sedation of pain, many drugs (morphine, etc.) have the effect of inhibiting respiration and anesthesia, resulting in not widely used in patients after neurosurgery. codeine has become a more accepted treatment option in recent years.9 pain care can be classified as cognitive behavioral or physical therapy measures through non-pharmacological pain relief measures. the goal of cognitive behavioral measures is to change the patient's perception of pain, change the behavior of pain, and provide patients with greater control over pain. the goal of physical therapy measures is to provide comfort, adjust to physical dysfunctions, physiological responses, and reduce the fear of pain-related movement or activity restrictions.10 patients with full-period surgery suitable for non-pharmacological treatment include: the patient has clear anxiety or fear, but the south east asia nursing research, vol 2 no 4, december 2020/ page 163-172 165 sun sheng-feng / the nursing experience of caring a patient with metastatic brain tumor in surgical pain management ward: a case study report anxiety is caused by a feeling of weakness caused by medical treatment or special treatment, and conditions that are good for avoiding or reducing drugs, such as: a history of adverse effects, physiological responses to avoid excessive sedation, conditions that may experience and need to cope with prolonged pain after surgery, and incomplete pain relief with medical measures.11 cognitive behavioral measures include: preoperative teaching information preparation, simple relaxation, meditation (imagery), hypnosis (hypnosis), biological feedback (biofeedback), etc. teach patients how to relieve their physical discomfort during activities. when fear or anxiety is present, it is important to evaluate psychological coping skills and provide pain management and maintain a positive view.12 when the patient is anxious or afraid before the operation, cognitive behavioral strategies can be provided to assist the patient in choosing measures and teaching how to use it, such as simple relaxation techniques or meditation. for some patients, especially those with high anxiety, too much information or too many requests for decision making can worsen anxiety and fear. therefore, the psychological evaluation of the patient is very important, including the patient’s obvious disability or confusion anxiety symptoms, such as emotional instability, restlessness, inability to fall asleep, slow thinking, etc. relaxation techniques preparatory actions: deep inhale/tension; exhale/relax; yawn for quick relaxation. 1. clench your fists; take a deep breath; pause for a few seconds. 2. exhale slowly, as soft as a doll. 3. start yawning. start action: 1. take a deep breath slowly. 2. when you exhale slowly, you feel that you start to relax. imagine the tension leaving the body with the exhale. 3. now inhale and exhale slowly and regularly, at the speed you feel most comfortable, try abdominal breathing. 4. concentrate on slow and regular inhalation and exhalation movements. when you breathe in, you say silently in your heart: "inhale, 2, 3"; when you exhale, you say silently in your heart: "exhale, 2, 3". i muttered in my heart: i am now "calm" or "relaxed". 5. imagine yourself relaxing in a certain place, for example; you are lying on the beach and sunbathing, feeling very calm and relaxing. 6. do steps 1 to 4 once or repeat steps 3 and 4 for 20 minutes. 7. finally, take a slow and deep breath, and tell yourself when you exhale, "i feel relaxed." family support or tapes can also keep the patient’s technique going. relaxation strategies can also use informal music to distract. in order to significantly reduce the pain after surgery, you can choose the music that the patient likes or relaxing music. after the operation, listen to the music selected by the patient for 30-60 minutes, provide the patient with a relaxed posture, and provide the patient with earphones to listen with their eyes closed. the environment should minimize stimulation. physiotherapy measures in addition to cognitive behavioral measures, there are several physical south east asia nursing research, vol 2 no 4, december 2020/ page 163-172 166 sun sheng-feng / the nursing experience of caring a patient with metastatic brain tumor in surgical pain management ward: a case study report therapy methods that can be used as pain management. common items include: cold or hot application, massage and acupoint stimulation. the main function of these physical therapy methods is to achieve pain relief through external stimulation. therapeutic massage can also relieve pain. the main benefit of this treatment is to stimulate the autonomic nerves and affect the physical, psychological and emotional levels through therapeutic contact. while relieving stress and pain intensity, it can also relieve long-term stress, anxiety and physical pain and discomfort. scholars such as nixon proposed that therapeutic massage can relieve pain in the following ways: (1) massage soft tissues to promote blood circulation and remove pain-causing agents such as lactic acid and inflammatory substances; (2) massage to stimulate secretion inhibit large nerve fiber nerve impulse conduction material; (3) stimulate endogenous analgesic morphine (endorphin) and activate midbrain, brain stem and spinal cord neurons, so that the spinal cord releases enkephalin to produce pain inhibition; (4) it can be induced by contact massage feeling of comfort and tranquility.7 therapeutic massage 1. for 20 to 45 minutes each time, the massage site can be "neck, face, neck, arms, legs, feet or back" and other parts of the body that have pain. 2. the massage environment must be quiet. pay attention to the privacy of the patient when the massaged area is exposed; use low-sensitivity massage lotion or massage oil; avoid the tumor site, the surgical site, the surrounding invasive catheter or the radiotherapy site and other areas massage. massage techniques and methods: the depth of deep massage is about 4-6 inches or the pressure is 0.0090 kg/cm². (1) the purpose of effleurage is the starting action of the whole therapeutic massage procedure. use one hand or both palms to push on the patient’s skin in all directions. when using both palms, both hands can be pushed synchronously or alternately. (2) the rubbing method (friction) is to press the ulnar side of the finger or palm against the skin, sliding the skin and the subcutaneous tissue, the sliding direction is perpendicular to the direction of the muscle fiber, and its purpose is to act on the skin and subcutaneous between the tissues, loosen the sticky scar tissue. (3) kneading works on deep tissues, especially muscles, and helps muscles to produce extension effects through the pushing effect. nursing staff must put their hands close to the skin and push them in a circle to produce alternate squeezing and relaxation effects between the subcutaneous tissues and deep muscles; they can use both hands or one hand, the entire palm or fingertips. when drawing a circle, squeeze with a heavier force in the direction of the center, and then release some pressure to return to the original point. during this process, the nurse's hands must be close to the skin, not sliding, and then gently slide to the next adjacent massage site. (4) pressing: applying a little heavier pressure than strokes to smoothly press on the patient's skin, so that the skin, subcutaneous tissue and deep muscles are pushed and twisted. (5) stroking: applying heavier pressure and alternately tapping the skin at a slightly faster speed to produce a stimulating effect, which is different from the previous two methods for relaxation; in each course of treatment, the entire area to be massaged can only be used for one tapping method, and the tapping method cannot be used repeatedly at the same fixed point to avoid excessive stimulation.7 methods this case uses gordon's eleven health function types as the assessment framework. the nursing period is from april 1 to april 3, 2019. use observations, physical assessments, interviews, medical records, etc. to collect physical, south east asia nursing research, vol 2 no 4, december 2020/ page 163-172 167 sun sheng-feng / the nursing experience of caring a patient with metastatic brain tumor in surgical pain management ward: a case study report psychological, social and spiritual related data of the case, and organize and analyze it. results basic information of the case participants ms. h, a 42-year-old female, graduated from high school. she works as a housekeeper. she speaks mandarin and taiwanese. she lives with her husband, son and daughter. the main caregiver is her husband. the family tree is shown in the picture. no history of food allergy to special drugs. past medical history since the second child was born in 2013, the patient felt pain and discomfort in the left breast while breastfeeding. he was diagnosed with breast cancer in june 2014. completed chemotherapy (2015-2017), mastectomy (2014), and breast reconstruction surgery (2014). medical treatment the patient had symptoms of headache and vomiting since the beginning of march 2019, and underwent brain ct: occipital brain tumors have been tracked in the outpatient clinic one after another. he was admitted to the hospital on 3/31, 4/1 underwent tumor resection and was admitted to the intensive care unit for observation, and 4/3 was transferred to the general ward for continued treatment. nursing assessment 1. health awareness and health management style the patient was diagnosed with breast cancer in 2014, and has been followed up and treated many times in this hospital. since the case was diagnosed in 2014, the case has paid considerable attention to their own health, regularly self-examined their breasts, and started regular exercises, using a treadmill for about 30 minutes a day. due to multiple hospitalizations for chemotherapy and radiotherapy, i am no stranger to the hospitalization process. this time i mainly hope that the headaches that have occurred since march can be improved after the operation. this assesses the patient's painful nursing problems. 2. nutrition and metabolic patterns the case was 164 cm tall, weighed 54 kg, and had a body mass index (bmi) of 20.08 kg/㎡; he had regular exercise habits; he had repeated headaches and nausea since the beginning of march, and his diet was reduced and lighter. assess the case with complete oral mucosa, red skin, warm limbs, no edema, jaundice, and pulse 2+. 4/01 after the operation, food can be taken by mouth, and there is no eating, swallowing disorder or coughing. use n/c 3l/min, breath frequency: 15-21 times/min, blood oxygen concentration: 99-100%, normal breath sounds, smooth breathing and no effort, can spontaneously cough a small amount of sputum. blood draw: na: 139 mg/dl, k: 3.2mg/dl, ica: 4.2mg/dl. therefore, it is estimated that the patient has no special care problems with this system. 3. excretion type the case can urinate on its own about 68 times a day, without frequent urination and urination discomfort, and normal stools can be relieved daily, without the need for drug assistance. during the nursing period, the color of urine is clear and there is no sediment, and there is no abnormal secretion and peculiar smell at the urethra. therefore, it is estimated that the patient has no special care problems with this system. 4. types of activities and sports the patient's occupation is a housekeeper. after the diagnosis of breast cancer in 2014, he began regular south east asia nursing research, vol 2 no 4, december 2020/ page 163-172 168 sun sheng-feng / the nursing experience of caring a patient with metastatic brain tumor in surgical pain management ward: a case study report exercise and used a treadmill for about 30 minutes a day. during the care, the patient has a clear consciousness, all limbs have 5 points of muscle strength, and can move according to the instructions. when the surgery was just performed on 4/01, due to postoperative wounds and duct pain, the patient did not want to move, did not want to eat, and was not willing to cooperate with turning over it is conventional treatment such as urinary catheter care, and during the treatment activities, there will be shallow breathing, tight muscles throughout the body, and a painful expression on the face for a few minutes until the pain is relieved; the class chief complained that "the place behind the head is so painful" and "the tube" when can i pull it out, it hurts.” “i knew that the operation would be so painful. i would not have it. it turns out that the head surgery is more painful than the chest cut before me.” in addition, the patient constantly fiddled with the upper tube due to the feeling of a foreign body; after the transfer on 4/01, there were multiple headaches, nausea, and retching, and the patient's posture changed slightly, that is, severe nausea, a small amount of saliva, and reduced physical activities such as turning over. the patient was evaluated as having acute pain nursing problems. 5. sleep and rest patterns the patient usually falls asleep at about 10 to 11 at night, and sleeps for about 67 hours a day. there is no need to take medicine or sleep interruption. the main complaint of the patient: "i will wake up painful when i go to bed at night. i only slept for an hour. i have intermittent sleep and awakening." the pain was scored 8-9 by the numerical rating scale (nrs). because of the pain of the wound and the position of the pipeline, the patient stays asleep for less than an hour at night. this assesses the patient's acute pain care problem. 6. cognitive and feeling patterns: the language used in the case is chinese and hokkien, conscious, pupil reflex, both eyes are 2.0-3.0mm, pupil reflex, behavioral cognitive assessment: judgment, orientation, memory, abstract thinking ability, calculation ability, and hearing. after the operation, the patient complained of continuous tingling at the position behind the occipital surgery. the pain score was about 8-9. moving or turning over would promote the increase in pain score, resulting in the patient's refusal to turn over, urinary tube care, and unwillingness to eat. pain can be relieved slightly after being stationary or applying analgesics. each time the pain lasts for about 10-20 minutes. i often ask whether i can apply analgesics. codeine 30mg iv is administered every 4 hours. when visiting family members, they said that the patient usually has a good tolerance for pain, and he rarely complained of pain during the previous hospitalization. this assesses the patient's acute pain care problem. 7. self-feeling and self-cognition patterns: the patient said that he had a good tolerance for pain, and he had undergone mastectomy and reconstructive surgery. only 1-2 times of painkillers were given. therefore, it is estimated that the patient has no special care problems with this system. 8. roles and relationship types: in the case, the wife, mother (housekeeper) and daughter-in-law lived with her husband, son, and daughter. because both children are still young (primary one and kindergarten), the focus of daily life is on the children; during the care, the patient is worried children who have been hospitalized for too long are worried, but relatively they don’t want to let the children know too much. usually, the decision maker at home is south east asia nursing research, vol 2 no 4, december 2020/ page 163-172 169 sun sheng-feng / the nursing experience of caring a patient with metastatic brain tumor in surgical pain management ward: a case study report the husband, and the couple get along well. the operation is also decided after discussion with the husband. there is no major conflict of opinion during the process, so it is estimated that the patient has no special care problems in this system. 9. sex and reproduction patterns: both children of the case were delivered by caesarean section, and the husband had a harmonious sex life. there was no abnormal appearance of the reproductive organs, and no abnormal secretions and odors in the vagina. therefore, it is estimated that the patient has no special care problems with this system. 10. response and stress tolerance type when faced with pressure or physical discomfort, exercise and listen to music will relieve stress. during the hospitalization period, the husband of the patient received frequent visits, informed the patient of the current situation of the child in the home, so that the patient was relieved, and followed the guidance of the nurse to give the patient a therapeutic massage and bring a music player to the patient. therefore, it is estimated that the patient has no special care problems with this system. 11. value and belief pattern: the case has no specific beliefs, and the family is taoist. the mother-in-law will put the peace symbol next to the bed, hoping to bless peace. therefore, it is estimated that the patient has no special care problems with this system. the nursing problems based on the evaluation and collection of the above-mentioned case data, it is established that the patient two specific nursing problems during this admission such as acute pain/postoperative wounds and pipelines; and impaired skin integrity/wound. the acute pain is the most troubled nursing problem experienced by patient. the main causes of common pain in patients undergoing craniotomy are: increased intracranial pressure, wound pain, indwelling tubing, etc. since the patient does not have an intracranial pressure monitor, it can be observed from vital signs and patient symptoms that the patient has no increased intracranial pressure signs: changes in consciousness, restlessness, blurred vision, unequal pupils in both eyes, slower heartbeat and breathing, and increased blood pressure. it can be inferred that the patient's pain is mainly due to postoperative wounds and ducts. here, the focus of care can be focused on this nursing problem: main nursing problems: acute pain/postoperative wounds and pipelines (care date: 4/01-4/03) subjective and objective data s1.4/1 "my head hurts, can i take painkillers?" s2 4/1 "why did it hurt so much there after i had the operation (the area where the fingers were operated on the pillow)" s3 4/1 "i had known that the operation would be so painful, i would not do it. it turns out that the operation on the head is more painful than the chest operation before." s4 4/1 "when i move, i feel a tingling sensation on the back of the head. i feel pain for 8-9 minutes. i have to stop moving or take painkillers each time to relieve slowly. each time the pain lasts for about 10 minutes." s5 4/1 "i don't want to move or wash the urinary tube, i don't want to move now, don't disturb me" south east asia nursing research, vol 2 no 4, december 2020/ page 163-172 170 sun sheng-feng / the nursing experience of caring a patient with metastatic brain tumor in surgical pain management ward: a case study report s6 4/1 "i don't want to eat now; can i talk about it tomorrow?" s7 4/2 "i think today's pain is probably 7-8 points, but when the painkillers are used up, it will come down to 3-4 points." s8 4/2 "i woke up with pain last night. i only slept for an hour. i would wake up intermittently in the middle." s9 4/2 "how long will these tubes (cvc, icp, h/v) be left? i always feel uncomfortable with something on my head." s10 4/2 "when i was in treatment, hospitalized, or uncomfortable, i would listen to crystal music, then close my eyes and meditate." o1 4/1 after the operation, the patient continued to frown and did not want to speak. o2 4/1 the patient refuses to turn over, urinary tube care, and appears unwilling to eat o3 4/1 when performing therapeutic activities, there will be rapid shallow breathing, tight muscles throughout the body, and painful expressions until the end of the activity. o2 4/1 pain assessment pqrst: position: behind occipital, quality: tingling, reaction: move to promote pain/immobility or use analgesics to relieve pain, severity: 8 points, timing: for 10-20 minutes o3 4/1 because the patient was informed of postoperative pain before the operation, i had discussed with the patient and family members about the use of painkillers at their own expense after the operation. the patient also complained of pain in the recovery room after the operation. use now o4 4/1 the painkiller will be given every 4 hours o5 4/1. poor eating situation on the day: the small night shift and the large night shift only drank 130ml of water 2 times and did not eat anything. o6 4/1-night shift sleeps and wakes up, every time you sleep for less than 1 hour, you will wake up. o7 4/2-day shift patients often fiddle with the pipeline on their own and are afraid to move their bodies. o8 4/2 assist the patient to change the lying position. the patient will have deep breathing, physical exertion and frowning o9 4/1-4/2 patient vital signs: body temperature 35.6-36.7°c, heartbeat: 67-105 beats/min, breathing 2025 beats/min, blood pressure 110-144/5069mmhg, spo2: 99100% care goals 1. controlled pain score within 24 hours, the numerical evaluation scale for pain (nrs) south east asia nursing research, vol 2 no 4, december 2020/ page 163-172 171 sun sheng-feng / the nursing experience of caring a patient with metastatic brain tumor in surgical pain management ward: a case study report dropped to 4 points. 2. the pain of the patient before transfer can be relieved: (1) the patient can use 2 nondrug measures correctly, (2) the frequency of using analgesics can be reduced from 6 times a day to less than 2 times. nursing evaluation 1-1. introduce yourself to the patient and establish a good trust and care relationship with the patient. 1-2. evaluate the patient's pain score every 2 hours, and re-evaluate each time 30-60 minutes after using analgesics. 1-3. collect chinese nursing care to reduce interference and interrupt the patient’s rest time, and communicate with the patient for a good time before treatment, so that the patient is psychologically prepared, so that the patient can smoothly cooperate with the treatment 1-4. assist the patient to adopt a comfortable lying position and adjust the position of the pipeline so as not to interfere with the patient's resting position. 1-5. provide patient tubing and wound location to help increase pain tolerance. 2-1 teach patients muscle relaxation techniques: 1. clench your fists; take a deep breath; pause for a few seconds. 2. exhale slowly. 3. take a deep breath slowly. 4. when exhaling slowly, i feel that i begin to relax, imagine being nervous and the pain leaves the body with exhalation. 5. slowly and regularly inhale and exhale to feel most comfortable perform abdominal breathing at a high speed. 6. concentrate on slow and regular inhalation and exhalation movements. 7. imagine yourself relaxing in a certain place 8. do steps 1 to 4 once or repeat steps 3 and 4 maintain for about 20 minutes. 2-2 teaching family members and assisting patients with massage: 1. there is pain in "neck, arm, back" etc. for 20 to 45 minutes each time the painful area. 2. use low-sensitivity massage lotion or massage oil; avoid swelling tumor site, surgical site, peripheral invasive catheter or radiation massage the area to be treated. 3. massage techniques and methods: the depth of deep massage is about 4-6 inches or the pressure is 0.0090 kg/cm². (1) pushing method it is the starting action (2) of the therapeutic massage procedure to slide by rubbing the direction is perpendicular to the direction of the muscle fiber to make it sticky scar group south east asia nursing research, vol 2 no 4, december 2020/ page 163-172 172 sun sheng-feng / the nursing experience of caring a patient with metastatic brain tumor in surgical pain management ward: a case study report weaving loosened. (4) pressure method: apply one more weight than the stroke method a little bit of pressure, steadily press on the patient’s skin, making the skin, subcutaneous tissue and deep muscles are pushed (5) percussion method: slightly faster the ground speed alternately hits the skin to produce irritation to the patient and discomfort therefore, it is not implemented. 2-3 assess the patient’s past experience in relieving pressure and pain. the medication measures are listening to music (crystal music), please bring home music player used 1. 4/2 within 24 hours, the patient indicated that the pain was relieved, and the nrs assessment can be reduced to 2-3 points, and 0-1 points when immobile. and the patient can cooperate with the nurse for treatment, and there is no rejection or discomfort during the process. in addition, the patient's appetite improved and he was willing to eat a small amount of soft food without nausea and vomiting during the process. 2. on 4/2, see the family members to help the patient with therapeutic massage. family members help patients it is equipped with a music player, and it can be seen that the patient uses it when relaxing. 3. 4/3 shows that the patient actively uses muscle relaxation techniques when painful and uncomfortable coincidentally, supplemented by music. 4. 4/3 of the patients only received intravenous painkillers once discussion this article describes the nursing experience of a patient with left breast malignant tumor metastasis to the brain and then surgical removal of the tumor. the patient has established nursing problems such as anxiety, pain, decreased intracranial adjustment ability, and impaired skin integrity due to factors such as tumor metastasis pain, wound pain, catheter indwelling and unknown prognosis. the patient’s pain and mood swings, questioning and refusal to care for treatment behaviors have been established with the case to establish a trusting relationship between the patient and the patient to assess the patient’s awareness of the current disease and understand the patient’s past pain experience. after intervention with medications and other medical measures, teach the patient to understand. after alleviating and enhancing the factors of one's own pain, aim and improve, and learn relaxation techniques, supplemented by non-drug nursing measures, to further improve the pain relief of patients. conclusion the biggest benefit of this care is that through the care of this case, it is understood that in the care of patients after surgery, not only drugs can relieve and south east asia nursing research, vol 2 no 4, december 2020/ page 163-172 173 sun sheng-feng / the nursing experience of caring a patient with metastatic brain tumor in surgical pain management ward: a case study report improve the comfort of patients, but there are also many non-pharmaceutical measures for us to use, the most important. the point is to understand the different characteristics of each patient to give individualized care. the symptoms and probability of recurrence and metastasis of breast cancer patients cannot be assessed. whether it is eradicated or not after the operation, follow-up is the limitation of the case care in this article. follow-up can only be carried out through the cancer manager; however, it is recommended that such patients should be cared for in the future. pay attention to the pain situation and take individualized nursing measures by evaluating individual patients. acknowledgments the author is thankful to new taipei city general hospital sanchong branch and the patient who took part in this study. conflicts of interest the author disclosures no potential conflicts of interest, financial or otherwise. references 1. custódio-santos t, videira m, brito ma. brain metastasization of breast cancer. biochim biophys acta rev cancer. published online 2017. doi:10.1016/j.bbcan.2017.03.004 2. krishnan m, krishnamurthy j, shonka n. targeting the sanctuary site: options when breast cancer metastasizes to the brain. oncology (williston park). published online 2019. 3. rostami r, mittal s, rostami p, tavassoli f, jabbari b. brain metastasis in breast cancer: a comprehensive literature review. j neurooncol. published online 2016. doi:10.1007/s11060016-2075-3 4. witzel i, oliveira-ferrer l, pantel k, müller v, wikman h. breast cancer brain metastases: biology and new clinical perspectives. breast cancer res. 2016;18(1):8. doi:10.1186/s13058015-0665-1 5. owonikoko tk, arbiser j, zelnak a, et al. current approaches to the treatment of metastatic brain tumours. nat rev clin oncol. 2014;11(4):203222. doi:10.1038/nrclinonc.2014.25 6. cheng h, chen h, lv y, chen z, li csr. prospective memory impairment following whole brain radiotherapy in patients with metastatic brain cancer. cancer med. published online 2018. doi:10.1002/cam4.1784 7. swarm r, abernethy ap, anghelescu dl, et al. adult cancer pain. j natl compr canc netw. 2010;8(9):1046-1086. doi:10.6004/jnccn.2010.0076 8. guilkey re, von ah d, carpenter js, stone c, draucker cb. integrative review: postcraniotomy pain in the brain tumour patient. j adv nurs. 2016;72(6):1221-1235. doi:10.1111/jan.12890 9. chou r, gordon db, de leon-casasola oa, et al. management of postoperative pain: a clinical practice guideline from the american pain society, the american society of regional anesthesia and pain medicine, and the american society of anesthesiologists’ committee on regional anesthesia, executive commi. j pain. 2016;17(2):131-157. doi:10.1016/j.jpain.2015.12.008 10. hsu jr, mir h, wally mk, seymour rb. clinical practice guidelines for pain management in acute musculoskeletal injury. j orthop trauma. 2019;33(5):e158-e182. doi:10.1097/bot.0000000000001430 11. rogers e, mehta s, shengelia r, reid mc. four strategies for managing opioid-induced side effects in older adults. clin geriatr. 2013;21(4):http://www.consultant360.com/a rticles/four-strateg. 12. appukuttan dp. strategies to manage patients with dental anxiety and dental phobia: literature review. clin cosmet investig dent. 2016;8:35-50. doi:10.2147/ccide.s63626 factors associated with psychological health issues in diploma nursing students: a cross-sectional study corresponding author: li kai jeffli08@163.com south east asia nursing research, vol 2 no 3, september 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.3.2020.117-122 original research factors associated with psychological health issues in diploma nursing students: a cross-sectional study li kai 1,2 1 staff nurse, operating room, stomatological hospital of chongqing medical university, china 2 nursing lecturer, chongqing medical and health college, china article info abstract article history: submit august 28th, 2020 accepted sept 18th, 2020 published sept 30th 2020 keywords: diploma nursing students; psychological health; the symptom checklist psychological health is the expression of harmonic, expression of human personality, and is often disrupted by multiple factors. the aim of this study is to assess psychological health status and its associated factors among diploma nursing students. a cross-sectional study design was employed. the sample comprised 542 nursing students attending this anonymous survey by completed the symptom checklist 90 questionnaire. descriptive statistics and logistic regression analysis were attempted to analyze overall data. the positive rate of psychological symptoms of diploma nursing students is 20.9%; the total score of scl-90 and the scores of each factor are higher than the national norm; grade, personality, number of friends, parenting style, love experience, whether it is an only child, and physical exercise are influential. the main factors of the mental health status of secondary vocational nursing students. the contribution of emotional intelligence and spirituality is crucial to the acquisition of well-being, happiness and meaning in life. introduction admission to a professional program marks the beginning of fulfilling a career goal. student life is characterized as the intermediate from adolescence to adulthood. they usually live alone and away from the family home and begin to bond with their peers who often come from other places.1 they, therefore, are leaving behind a safe and controlled environment of the family and their surroundings and come into contact with different habits and perceptions, while still possessing many of the adolescence features, are experiencing a process of moving away from the family environment.2 however, the rigors of professional education can be demanding. stress, depression, and anxiety (sda) can interfere with learning, affect academic performance, and impair clinical practice performance.3 during their studies, some individuals can experience mental difficulties that are related to their inability to leave their family in combination with the feeling of loneliness and difficulties to create relationships in a new environment. the ability of the individual to live alone reflects his or her emotional maturity and is the foundation for achieving autonomy.4 finally, a significant risk to students ’mental health is the intense feeling of insecurity regarding https://doi.org/10.26714/seanr.2.3.2020.117-122 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.3.2020.117-122&domain=pdf&date_stamp=2020-09-30 south east asia nursing research, vol 2 no 3, september 2020/ page 117-122 118 li kai / factors associated with psychological health issues in diploma nursing students: a cross-sectional study their financial and occupational rehabilitation. the high levels of unemployment, the financial crisis, the lack of recognition in some cases of qualification lead to discouragement and the creation of intense feelings of anxiety, insecurity and even mental disorders manifested by symptoms such as insomnia, shortness of breath, eating disorders and difficulties in concentration and organization.5 then students often develop dysfunctional ways of managing these problems, so their selfimage is affected, and they are experiencing feelings such as depression and anxiety.6,7 the existence of some mental disorder in the student has a more significant impact than on other groups in the general population as it affects his health, interpersonal relationships and academic performance.8 inappropriate diagnosis and treatment of these problems lead to chronicity and relapses, increasing the risk of discontinuation of studies and manifestation of future occupational distress syndrome.9 strengthening the mental health education of diploma nursing students has become a consensus in the higher education field.10 this research has investigated diploma nursing students as the research object, understood the mental health and its influencing factors, and provided psychological basis for the education and management among diploma nursing students more effectively. this study aims to assess psychological health status among diploma nursing students and to highlight its’ related factors. methods a cross-sectional study design was applied in this study. a stratified cluster random sampling method was adopted to randomly select 4 students in each of the first and second-year as the research participants. participants & settings a total of 550 students from chongqing medical and health college were voluntary recruited. this study was approved by the ethics committee of the thessaly university according to the ethical guidelines of the declaration of helsinki. in addition, a written consent of the students to participate in the process was obtained and they were each given an increasing serial number to ensure their anonymity. instrument a self-reported questionnaire of the symptom checklist 90 (scl-90) was used to collect the data.11 the scale has 90 evaluation items and contains a total of 10 factors, such as: somatization, obsessivecompulsive symptoms, interpersonal sensitivity, depression, anxiety, hostility, terror, paranoia, psychosis and others. each item adopts a five-level scoring system (1-5 point), 1 point means no such symptoms, 2 point means mild symptoms, higher scores, more severe symptoms, 5 point means most severe symptoms. scoring to the survey consists of two elements, such as the total score and the factor score. the total scores of 90 items are indicating the overall level of mental health which is divided into higher and lower level of mental health. factor score, the total score of each item that makes up a factor/the number of items that make up a factor. the high score of a factor indicates the seriousness of the mental health problem of items among factors. if a factor score ≥ 2, consider screening for positive symptoms.12 in addition, the research team also designed a general survey form on its own, including gender, age, source of birth, physical exercise, etc. the survey method adopts an anonymous questionnaire survey in class units, with trained professionals serving as investigators. the questionnaires are uniformly distributed and recovered. the survey process uses uniform methods and instructions. the students complete the south east asia nursing research, vol 2 no 3, september 2020/ page 117-122 119 li kai / factors associated with psychological health issues in diploma nursing students: a cross-sectional study questionnaire carefully and independently according to the actual situation, on the spot answer, collect and check on the spot. statistical analysis a logical regression analysis was used to carefully examine and minimizing error for all data entry by using epidata 3.02 software. two-person entry was attempted to establish a database to verify the accuracy of the entry. spss version 13.0 statistical software was utilized for data analysis. results participants’ characteristics initially, a total of 560 questionnaires was distributed. in the final stage, 550 questionnaires were returned, with a recovery rate of 98.2%. the valid questionnaires included in the statistics was 542, with an effective rate of 98.5%. among them, 280 (51.7%) were in the first year, and 262 (48.3%) were in the second year; the youngest was 15 years old and the oldest was 23 years old, with an average age of 16.67±2.78 years old; the survey subjects were all female nursing students. the overall scl-90 result the survey results of the overall scores of scl-90 measurements show that the positive rate of psychological symptoms in diploma nursing students is 20.9%. furthermore, the percentages of positive symptoms for each factor such as: obsessive-compulsive symptoms (19.1%), depression (10.8%), interpersonal relations sensitive (8.9%), anxiety (7.1%), hostility and paranoia (5.5%), psychosis (4.7%), somatization (3.6%), and terror (2.0%). comparison of each symptom factor of scl-90 with the national norm it can be seen from table 1. that the total scores of scl-90 and the scores of various factors of diploma nursing students are higher than the national norm, and the differences are statistically significant (p<0.05). logistic regression analysis of factors affecting the mental health of secondary vocational nursing students in order to understand the factors that affect the mental health of secondary vocational nursing students, we take whether the subjects have mental health problems as the dependent variable, and take the grade, personality, parental education level, parental rearing style, smoking, drinking, etc. fifteen variables were used as independent variables for quantification (personality is a multicategory variable, 3 dummy variables are set, and the remaining 14 variables are binary and rank variables). logistic regression is introduced, and the regression equation is established by stepwise forward p≤0.05 is used as the criterion for entering the equation, and finally there are 7 variables entering the regression equation. autocratic parenting style, only child and love experience are risk factors that affect mental health. see table 2. south east asia nursing research, vol 2 no 3, september 2020/ page 117-122 120 li kai / factors associated with psychological health issues in diploma nursing students: a cross-sectional study table 1 comparison of scl-90 factor evaluation results of secondary vocational nursing students with domestic norms (n=550) indicators diploma nursing student national norm t p somatization 1.45±0.29 1.37±0.48 11.424 0.022 obsessive-compulsive symptoms 1.71±0.54 1.62±0.58 0.046 0.020 interpersonal sensitivity 1.76±0.58 1.65±0.51 9.336 0.000 depression 1.64±0.53 1.50±0.59 2.297 0.000 anxiety 1.44±0.42 1.39±0.43 2.212 0.027 hostility 1.59±0.42 1.48±0.56 9.505 0.000 terror 1.30±0.34 1.23±0.41 1.339 0.031 paranoid 1.51±0.38 1.43±0.57 8.246 0.020 psychotic 1.37±0.40 1.29±0.42 0.064 0.019 total score 136.47±33.61 129.96±38.76 4.971 0.038 table 2 logistic regression analysis of influencing factors of suicidal ideation in diploma nursing students (n=550) variables assignment b p grade/years first year=1，second year=2 -0.536 0.000 characters introvert=1，neutral=2，extrovert=3 -0.274 0.000 parenting styles democracy=1，despotism=2 0.760 0.002 love experiences no=1，yes=2 0.793 0.000 single children no=1，yes=2 0.833 0.000 physical activity in a week 0 times=1，1times=2，,2 times=3, 3 times=4，4 times=5，5times=6，6times and above=7 -0.227 0.000 discussions the survey results show that the positive detection rate of psychological problems in diploma nursing students is 20.9%, which is similar to the results of other relevant domestic studies, and the total score of scl90 and the scores of all factors are higher than the national norm.13 and psychological status of diploma nursing students is not optimistic. technical diploma students are a special group, most of them are eliminated from the senior high school entrance examination. if the teacher does not properly guide them, it will be difficult for them to get rid of the shadow caused by the unsatisfactory advancement. in addition, there are some incorrect public opinions in the society under diploma schools are not promising and any students enter diploma schools in a helpless mood. most of the students are in their adolescence, which are at the stage of life when they are sensitive to external stimuli and psychological changes are the most complicated. they are more likely to experience negative emotions. factors affecting the mental health of diploma nursing students different grades of diploma students' mental health status have different survey results. the survey results show that firstyear students face more psychological problems than second-year students. the first-year students have just experienced the failure of the senior high school entrance examination. some people choose the secondary vocational health school due to the pressure of their families. moreover, they have just entered the school and cannot fully adapt to the new school environment and new interpersonal relationships. therefore, the first-year south east asia nursing research, vol 2 no 3, september 2020/ page 117-122 121 li kai / factors associated with psychological health issues in diploma nursing students: a cross-sectional study students it is more prone to psychological problems. introverted students are more prone to psychological problems. compared with extroverts, introverts are withdrawn, pessimistic and cautious. they tend to have low self-evaluation and lack of selfconfidence. they often adopt evasive, selfblame, and fantasy coping styles in the face of stress, so they are prone to psychological problems; extroverts have a wide range of communication, many friends, are good at seeking help, have a better social support network, and can respond appropriately in a passionate situation. therefore, their psychological condition is better.14 family factors are also the main factors influencing the psychological status of diploma nursing students.15 democratic parenting is more conducive to the healthy growth of children’s mental health than autocratic parenting. diploma nursing students are in their adolescence, and their personal independence consciousness is developing rapidly. democratic parenting methods give their children certain autonomy and positive and correct guidance, which is conducive to the formation of positive personality characteristics for children, and good personality characteristics are conducive to the formation of healthy psychology. autocratic parenting methods will lead to unstable personality characteristics of children, which is extremely detrimental to children's mental health.16 the mental health of only children is worse than that of non-only children. the only child has a strong sense of self, and has poor ability to take care of themselves in life. they cannot adapt well to living in school and are prone to bad emotional experiences. diploma students with love experience face more psychological problems than those without love experience. the sexual consciousness of vocational students in adolescence is quickly awakened and they are prone to premature love. however, due to their lack of social experience, their understanding of themselves and others is not comprehensive enough, they often have unrealistic ideas about the future, and are more susceptible to emotional frustration, leading to anxiety, depression and other emotions. the results of this survey also found that the mental health of people who regularly participate in physical exercise is better than those who do not exercise regularly. this result is consistent with the research results of wang`s paper.17 physical exercise can clear tension, maintain friendship, make people optimistic, and improve social adaptability. therefore, physical exercise has a good role in promoting mental health. there are several limitations in this study, there was a relatively small number of studies included. while the heterogeneity of the studies included, in particular the methodology, sample size and location of these studies makes it more difficult to generalize the settings, concentrated on only the nursing students who had been enrolled in one college and the other is this study only focused on one direction of influence. conclusion the results of this study indicated that the mental health status of diploma nursing students is not optimistic. the relevant departments should strengthen their mental health education work, provide psychological interventions to students with mental health problems, and regularly carry out psychological education activities to prevent problems before they occur. the contribution of emotional intelligence and spirituality is crucial to the acquisition of well-being, happiness and meaning in life. it is crucial to promote cultivation with significant benefits in the course of their lives and the campus community as a whole. acknowledgments the researcher would like to say thank you to all respondents who participated in this research. south east asia nursing research, vol 2 no 3, september 2020/ page 117-122 122 li kai / factors associated with psychological health issues in diploma nursing students: a cross-sectional study conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. burris j, brechting e, salsman j, et al. factors associated with the psychological well-being and distress of university students. j am coll heal 2009; 57: 536–544. 2. eisenberg d, gollust se, golberstein e, et al. prevalence and correlates of depression, anxiety, and suicidality among university students. am j orthopsychiatry 2010; 77: 534– 542. 3. hoying j, melnyk bm, hutson e, et al. prevalence and correlates of depression, anxiety, stress, healthy beliefs, and lifestyle behaviors in firstyear graduate health sciences students. worldviews evidence-based nurs 2020; 17: 49– 59. 4. kunnanatt jt. emotional intelligence: the new science of interpersonal effectiveness. hum resour dev q 2004; 15: 489–495. 5. gutiérrez garcía ra, amador licona n, sánchez ruiz a, et al. psychological distress, sanitary measures and health status in student’s university. nov sci; 13. epub ahead of print 2021. doi: 10.21640/ns.v13ie.2602. 6. hardeman rr, przedworski jm, burke se, et al. mental well-being in first year medical students: a comparison by race and gender. j racial ethn heal disparities 2015; 2: 403–413. 7. fan z, he s. beijing college students’ selfconsciousness: its level, structure and relationship with mental health. wei sheng yan jiu 2013; 42: 960–964. 8. rosenzweig s, reibel dk, greeson jm, et al. mindfulness-based stress reduction lowers psychological distress in medical students. teach learn med 2003; 15: 88–92. 9. watson r, gardiner e, hogston r, et al. a longitudinal study of stress and psychological distress in nurses and nursing students. j clin nurs 2009; 18: 270–278. 10. kanji n, white a, ernst e. autogenic training to reduce anxiety in nursing students: randomized controlled trial. j adv nurs 2006; 53: 729–735. 11. zhou j, yu j, zhou y, et al. study of item text in the chinese symptom checklist-90. medicine (baltimore) 2021; 100: e24841. 12. wang zh, ye y, shen z, et al. a meta-analysis of symptom checklist-90 assessment results in chinese nurses. chinese j ind hyg occup dis 2018; 36: 129. 13. zhang l, sun h. research on correlation between the psychological health and selfesteem level of technical secondary school student nurse. chinese j nurs adm 2009; 9: 57– 59. 14. lu x. relationship between personality, defense style, and mental health of technical secondary nursing students. chinese nurs j 2004; 18: 442– 443. 15. sun h, zhuang n, tian y, et al. correlation between general self-efficacy, coping style and mental health of nursing students. chinese j nurs educ 2008; 5: 243–246. 16. zhuang n, sun h, wang y, et al. correlation research between self-efficacy, mastery and mental health of practical nurses. chinese j nurs educ 2008; 14: 430–432. 17. wang j. correlation of self-rated health and selfefficacy of the college nursing interns or above. tianjin j nurs 2012; 20: 203–205. community knowledge and compliance indoing prevention of covid-19 corresponding author: dewi setyawati dewisetyawati@unimus.ac.id south east asia nursing research, vol 3 no 1, march 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.1.2021.16-22 original research community knowledge and compliance indoing prevention of covid-19 dewi setyawati1, mei yolla ningrum1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: submit feb 5th, 2021 accepted march 21st, 2021 published march 28th 2021 keywords: coronavirus disease; compliance; prevention; knowledge background: community compliance in taking measures to prevent transmission of covid-19 must be based on good knowledge about covid19 so that it can break the chain of transmission of covid-19. objective: to determine the relationship between the level of community knowledge about covid-19 with compliance to prevent covid-19 at the public health center of jati kudus. method: this study used a quantitative analysis with a cross-sectional approach. the population was 115 people treated at community health center of jati kudus with range aged 17-35 years, then got 89 respondents were obtained using the purposive sampling technique. the instrument used was a questionnaire. results: from the results of univariate data testing, 65 respondents (73%) had good knowledge of covid-19, while those who had sufficient knowledge were 24 people (27%). the results showed that all respondents complied with the prevention measures for covid-19 with a percentage of 100%. based on the bivariate test result, it was found that there was a relationship between the level of knowledge and compliance in preventing transmission of covid-19 with a p-value of 0.034 and r (correlation coefficient) of 0.225. conclusion: it can be concluded that there was a relationship between the level of community knowledge about covid-19 and compliance with covid-19 prevention at the public health center of jati kudus. introduction community knowledge about covid-19 is one of the serious and important things that must be known by the public. if the level of community knowledge about covid-19 is still low, it will have an impact on the increasing number of covid-19 cases worldwide. therefore, community knowledge about covid-19, especially the prevention of covid-19, is important to break the chain of transmission of covid19. coinciding on january 30, 2020, who declared covid-19 as a public health emergency of international concern (pheic). then, on february 12, 2020, who has determined that covid-19 in humans is known as coronavirus disease.1 according to who in the task force for the acceleration of handling covid-19 dated july 27, 2020, data on cases of the spread of covid-19 globally in 216 countries, 16,096,741 cases were confirmed positive for covid-19.2 the prevalence of positive confirmed cases of covid-19 in indonesia is still quite high. indonesia is in 24th position in the list of countries with the most cases of https://doi.org/10.26714/seanr.3.1.2021.16-22 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.1.2021.16-22&domain=pdf&date_stamp=2021-03-28 south east asia nursing research, vol 3 no 1, march 2021/ page 16-22 17 dewi setyawati / community knowledge and compliance indoing prevention of covid-19 covid-19 3. central java as of july 27, 2020, as a province that ranks fourth, namely 8,412 confirmed positive cases of covid-19 with the highest addition of positive patients in indonesia, after east java (20,539 confirmed positive cases of covid19), dki jakarta (19,125 confirmed positive cases) covid-19), and south sulawesi (8,881 confirmed cases of covid-19).4 kudus regency is one of the districts in central java that is still in the red zone along with three other areas in central java, namely the cities of semarang, jepara, and demak. based on the report of the task force for the acceleration of handling covid-19 in kudus regency on july 28, 2020, 8:00 p.m. wib, there were 769 confirmed cases with details of 595 cases in the area covering bae 60 cases, dawe 32 cases, gebog 30 cases, jati 137 cases, jekulo 84 cases, kaliwungu 64 cases, kota kudus 92 cases, mejobo 53 cases, undaan 43 cases. meanwhile, the number of cases outside the district of kudus was 174 cases.5 efforts to break the chain of the spread of covid-19 require good understanding and knowledge from all elements including society.6 according to mona, defining the knowledge of covid-19 patients is the result of the patient's curiosity about everything related to his disease. knowledge of covid-19 prevention with community compliance to take precautions has a very important role in anticipating recurring events.7 the results of the study 7 show that there is a relationship between public knowledge and compliance with using masks as an effort to prevent covid-19. the results of the study8 indicated that gender had a significant relationship with knowledge about the prevention of covid-19 with p = 0.013 <0.05. age, education, work status, and position in the family do not have a relationship with knowledge about covid19 prevention. based on these two journals, the author wants to develop existing research. devi & nabila's research only focuses on preventing covid-19 regarding compliance with the use of masks. so, in this study, the authors want to examine the level of compliance with covid-19 prevention, not only adherence to wearing masks but covering all covid-19 prevention measures. the results of the research on "survey data of covid-19-related knowledge, attitude, and practices among indonesian undergraduate students", show that gender, place of residence, education major, and occupation affect students' knowledge, attitudes, and practices towards the prevention of covid-19 in indonesia.9 success in carrying out covid-19 prevention depends on people's compliance with infection control measures, which are greatly influenced by their knowledge, perceptions, and practices of the covid-19 pandemic.10 according to h.m hartopo as the acting regent of kudus, conveying the level of compliance of the people of kudus regency with the prevention of covid-19, if previously it tended to increase by 60-70%, now it has decreased to 50%. from data from the kudus district health office, jati subdistrict is one of the sub-districts in kudus regency which is in the first position with the most covid-19 cases in kudus.11 so, the research aims to find out the relationship between the level of community knowledge about covid-19 and compliance with covid-19 prevention at jati kudus public health center. methods this research uses quantitative analytic research with a cross-sectional approach, which is a type of analytic research that focuses on time measurement and research of the dependent and independent variables simultaneously at one time. the variables of this study include the level of community knowledge about covid-19 as an independent variable and compliance south east asia nursing research, vol 3 no 1, march 2021/ page 16-22 18 dewi setyawati / community knowledge and compliance indoing prevention of covid-19 with covid-19 prevention as the dependent variable. the population in this study was 115 people. so that the sample of this study amounted to 89 people who were calculated by the proportion estimation formula. purposive sampling technique was used in determining the respondents who will be used as research samples, namely, visitors who seek treatment at jati kudus public health center, aged 17-35 years old and willing to become respondents by signing an informed consent which is part of the inclusion criteria. this research was conducted at blud upt jati kudus public health center in january-february 2021. the data collection procedure used a questionnaire. the questionnaire for the variable level of public knowledge about covid-19 uses the guttman scale and for the compliance variable to prevent covid19 using a likert scale that has been tested for validity and reliability. this research has received permission from the institution where the research was conducted by paying attention to ethics in research such as beneficence, respecting human dignity, and obtaining justice. before the respondents filled out the questionnaire, informed consent was explained first. so, respondents have the right to choose whether they are willing to be respondents or not. after the questionnaire is collected, data processing will be carried out. the steps in the data processing process include editing, coding, tabulating, and data entry. data analysis in this study used univariate analysis and bivariate analysis using spss. the statistical test uses parametric statistics, namely the pearson product moment correlation. results the results of the study are presented in a tabular form consisting of the characteristics of the respondents, univariate and bivariate results. based on table 1, it is found that the gender of the respondents is mostly women as many as 57 respondents (64%) with ages 26-35 years as many as 48 respondents (53.9%). the domination of the respondent's job, namely 18 respondents (20.2%) who had not worked, the latest high school / equivalent education was 63 respondents (70.8%), and as many as 46 respondents (51.7%) were married. table 1 the frequency distribution of respondent characteristics (n=89) variable f % gender male 32 36 female 57 64 age 17-25 years 41 46,1 26-35 years 48 53,9 occupation administration dan graphic design 1 1,1 pharmacist 1 1,1 unemployment 18 20,2 labor 7 7,9 factory workers 2 2,2 freelancer 1 1,1 teacher 4 4,5 housewife 14 15,7 general employees 12 13,5 contractor 1 1,1 college student 8 9 student 2 2,2 nurse 1 1,1 breeder 1 1,1 odd jobs 2 2,2 private workers 5 5,6 farmer 1 1,1 entrepreneur 8 9 education elementary school 2 2,2 junior high school 6 6,7 senior high school 63 70,8 diploma 3 3,4 bachelor degree 15 16,9 marital status married 46 51,7 single 43 48,3 source: primary data, 2021 based on figure 1, the results show that the most parameters for the level of public knowledge about covid-19 are about the south east asia nursing research, vol 3 no 1, march 2021/ page 16-22 19 dewi setyawati / community knowledge and compliance indoing prevention of covid-19 transmission of covid-19, which is as many as 84 respondents. while, the lowest level of knowledge was about the etiology of covid-19, namely 66 respondents. the result found that the respondents have good knowledge of as many as 65 people (73.0%) while those who have sufficient knowledge are 24 people (27.0%). figure 1 parameters about the knowledge level of covid19 the result shows the results of the mean scores of 3 and 4. for the statement, a score of 3 means agrees while a score of 4 means strongly agrees. for an unfavorable score of 3, it means disagree and a score of 4 means strongly disagree. the results showed that the most parameters regarding mistakes in preventing covid-19 were wearing masks as many as 88 respondents. while the lowest parameter regarding prevention of covid-19 is about keeping a minimum distance of 1 meter. based on the result showed that all respondents prevention covid-19 which is 89 respondents (100%). according to the indonesian ministry of health (2020), covid-19 transmission from one individual to another is indicated by symptoms of fever, sore throat, cough, shortness of breath, and some individuals test positive for asymptomatic covid-19.12 figure 2 the parameter description questionnaire regarding compliance to prevent covid-19 the results of the bivariate analysis using the pearson product moment correlation test in table 2 shows the results of the analysis of the relationship between the level of knowledge and adherence to prevention, obtained p-value = 0.034 < (0.05) so that ha is accepted and ho is rejected, meaning that there is a relationship between the level of community knowledge about covid-19 and compliance the prevention of covid-19 at jati kudus public health center. as for the value of the degree of correlation values obtained r = 0.225 means to have a weak correlation. if the pearson correlation value is 0.21 to 0.40, it is said that the correlation is weak. table 2 the analysis of the level of knowledge about covid-19 with compliance to prevent covid-19 (n=89) indicators compliance prevention of covid-19 p comply no comply f % f % level of knowledge good 65 73,0 0 0,0 0,034 sufficient 24 27,0 0 0,0 discussion the respondent's level of knowledge about covid-19 at the jati kudus public health center, it can be concluded that 68 66 84 70 81 67 0 10 20 30 40 50 60 70 80 90 87 86 88 80 76 70 75 80 85 90 wash your hands/ hand sanitizer correct coughing and sneezing etiquette wear a mask avoid touching eyes, nose, and mouth keep a minimum distance of 1 meter south east asia nursing research, vol 3 no 1, march 2021/ page 16-22 20 dewi setyawati / community knowledge and compliance indoing prevention of covid-19 respondents who had good knowledge were 65 people while those who had sufficient knowledge were 24 people. the results of this study are in line with research13, where the majority of the level of knowledge of the people of north sulawesi about covid-19 is in a good category, namely 388 people. "the people of north sulawesi already know that covid-19 can cause death, not all people infected with covid-19 show signs and symptoms, the incubation period for covid-19 is 2-14 days, signs and symptoms of being infected with covid-19, ways of transmitting covid-19, prevention of transmission of covid-19, and immediate isolation for people who have direct contact with someone infected with covid-19”.13 the other research is also in line with this research where most of the knowledge level of the people of murtajih village, pademawu district is good 32 people (51.6%).14 according to astutik, the factors that influence a person's knowledge are age, education, experience, information, socioculture and economy, and environment.15 in this study, most of the respondents were aged 26-35 years. this shows that the older a person gets, the more experience he gets so that the knowledge gets better, but the ability to remember knowledge will decrease as a person gets older.16 the results of the univariate analysis of compliance with covid-19 prevention showed that all respondents complied with the prevention of covid-19, with as many as 89 people. this is in line with research 7 which shows that most people obey using masks, as many as 46 respondents. the results of this study differ from other research showing that as many as 89 respondents of covid-19 volunteers did not comply with the protocol for preventing the transmission of covid-19.17 the majority of north sulawesi people have a positive attitude towards covid-19, as many as 396 respondents.13 "the positive attitude of the people of north sulawesi is the importance of wearing a mask when leaving the house during the pandemic, not traveling outside the house if there is no urgent need, having to maintain a distance of at least 1.5 meters, avoiding crowded places during the pandemic, washing hands using soap or hand sanitizer. , immediately take a shower and wash your hair after arriving at home and wash all used clothes outside the house and get adequate rest, exercise diligently, and consume nutritious foods to increase immunity.13” this positive attitude can also be interpreted as public compliance with covid-19 prevention measures. the results of the bivariate analysis of the relationship between the level of public knowledge about covid-19 and compliance with taking preventive measures for covid19 with the pearson product moment correlation test obtained p-value = 0.034 <α (0.05). this means that there is a significant relationship between the level of community knowledge about covid-19 and compliance with covid-19 prevention measures. as for the degree of relationship value, the value of r = 0.225 is obtained, meaning that it has a weak correlation. this research is in line with research conducted by sari and 'atiqoh (2020) which states that there is a relationship between public knowledge and compliance with wearing masks. evidenced by the results of the bivariate analysis to test the relationship between knowledge and compliance with the community using masks with the chi-square test using fisher exact, the value of p = 0.004 <α (0.05) was obtained. in the analysis of this study, most of the respondents had not worked, namely 18 people. this means that the majority of respondents in this study are not from the professional group. however, the results showed that the level of knowledge in the category was sufficient for 65 people, and for the category was enough for 24 people. as for the compliance variable in preventing covid-19, it shows that all respondents south east asia nursing research, vol 3 no 1, march 2021/ page 16-22 21 dewi setyawati / community knowledge and compliance indoing prevention of covid-19 have complied with covid-19 prevention measures. according to sumartini (2020), states that respondents who have not worked have a lot of time to explore and get information from various mass media sources. besides, people who have not worked can often attend counseling held by students or health workers because they have a lot of free time.16 in theory, a person's education level will affect their level of knowledge. if the level of education and knowledge is good, then the behavior will also be good.18 this study shows that most of the respondents' last education was senior high school or equivalent. this is in line with the other research that the highest educational characteristics were mostly senior high school as many as 59 people, while the smallest was master degree graduates as many as 4 people. apart from formal education, information or knowledge can be obtained from various sources, namely through other people and the mass media. so, low education does not mean having low knowledge. however, the higher a person's education, the easier it will be to receive the information obtained so that his knowledge will increase.16 education about health will affect one's health behavior, this is because the education obtained will gain knowledge and have an impact on one's behavior in preventing disease. so, someone who has good knowledge regarding healthy behavior will tend to have good behavior towards health. therefore, to increase healthy behavior, it is also necessary to increase knowledge. according to the preliminary study, the highest number of covid-19 cases was in jati district. however, after doing research it shows that the level of knowledge of the majority of the community is good. as for compliance with the prevention of covid19, all respondents fall into the obedient category. this happened because when researchers conducted a preliminary study in july 2020, kudus regency was included in the red zone and jati district was the district with the greatest number of covid-19 cases. while the research was conducted in january-february 2021, in which kudus regency has entered the green zone. so, during that time the community had received a lot of information from various media or the local government. conclusion after conducting the research, it can be concluded that there is a relationship between the level of public knowledge about covid-19 and compliance with covid-19 prevention at jati kudus public health center. acknowledgments the author would like to thank the jati kudus public health center for permitting us to conduct research. besides, the authors also wish to thank all respondents for their participation in this study. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. tim kerja kementerian dalam negeri. pedoman umum menghadapi pandemi covid-19 bagi pemerintah daerah : pencegahan, pengendalian, diagnosis dan manajemen. jakarta, 2020. 2. anwar f. 10 negara dengan kematian akibat corona tertinggi di dunia per 27 juli. detikhealth. 3. sukesih, usman, budi s, et al. pengetahuan dan sikap mahasiswa kesehatan tentang pencegahan covid-19 di indonesia. / j ilmu keperawatan dan kebidanan 2020; 11: 258– 264. 4. fatoni m. update sebaran kasus covid-19 di indonesia 27juli 2020 pagi, data rinci kasus baru di tiap provinsi tribun jogja. tribunjogja.com. 5. dinkes kabupaten kudus. laporan gugus tugas south east asia nursing research, vol 3 no 1, march 2021/ page 16-22 22 dewi setyawati / community knowledge and compliance indoing prevention of covid-19 percepatan penanganan covid-19 kabupaten kudus. kudus tanggap covid-19. 6. purnamasari i, raharyani ae. tingkat pengetahuan dan perilaku masyarakat kabupaten wonosobo tentang covid-19. j ilm kesehat 2020; 1: 33–42. 7. sari dp, ’atiqoh ns. hubungan antara pengetahuan masyarakat dengan kepatuhan penggunaan masker sebagai upaya pencegahan penyakit covid-19 di ngronggah. infokes j ilm rekam medis dan inform kesehat 2020; 10: 52– 55. 8. wulandari a, rahman f, pujianti n, et al. hubungan karakteristik individu dengan pengetahuan tentang pencegahan coronavirus disease 2019 pada masyarakat di kalimantan selatan. j kesehat masy indones 2020; 15: 42. 9. saefi m, fauzi a, kristiana e, et al. survey data of covid-19-related knowledge, attitude, and practices among indonesian undergraduate students. data br; 31. epub ahead of print 2020. doi: 10.1016/j.dib.2020.105855. 10. goruntla n, bhupalam p, jinka dr, et al. knowledge, perception, and practices towards covid-19 pandemic among general public of india: a cross-sectional online survey. curr med res pract. epub ahead of print 2020. doi: 10.1016/j.cmrp.2020.07.013. 11. nazaruddin a. menurun, kepatuhan masyarakat kudus terhadap protokol kesehatan antara news. antara. 12. livana; mubin, mohammad fatkhul & basthomi y. ‘tugas pembelajaran’ penyebab stres mahasiswa selama pandemi covid-19. j ilmu keperawatan jiwa 2020; 3: 203–208. 13. sembiring ee, meo mln. pengetahuan dan sikap berhubungan dengan resiko tertular covid-19 pada masyarakat sulawesi utara. ners j keperawatan 2020; 16: 75–82. 14. suprayitno e et. al. pengetahuan dan sikap masyarakat dalam pencegahan covid-19. j heal sci (jurnal ilmu kesehatan) 2020; 5: 68–73. 15. sanifah lj. hubungan tingkat pengetahuan dengan sikap keluarga tentang perawatan activities daily living (adl) pada lansia. sekolah tinggi ilmu kesehatan insan cendekia medika, 2018. 16. mujiburrahman, riyadi me, ningsih mu. pengetahuan berhubungan dengan peningkatan perilaku pencegahan covid-19 di masyarakat. persepsi masy terhadap perawatan ortod yang dilakukan oleh pihak non prof 2020; 2: 130–140. 17. quyumi e, alimansur m. upaya pencegahan dengan kepatuhan dalam pencegahan penularan covid-19 pada relawan covid. jph recode 2020; 4: 81–87. 18. gannika l, sembiring ee. tingkat pengetahuan dan perilaku pencegahan coronavirus disease 2019 (covid-19) pada masyarakat sulawesi utara. j keperawatan 2020; 16: 83–89. cucumber and honey soaking reduces hypertension in the elderly corresponding author: edy soesanto edysoes@unimus.ac.id south east asia nursing research, vol 3 no 2, june 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.2.2021.45-50 original research cucumber and honey soaking reduces hypertension in the elderly edy soesanto1, salsabella zulino1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: submit jan 25th, 2021 accepted may 9th, 2021 published june 23rd 2021 keywords: cucumber water soak; honey; hypertension; elderly hypertension is a condition of increasing a person's blood pressure beyond normal limits, causing increased morbidity and mortality. hypertension can be reduced by consuming cucumber which contains potassium which inhibits the release of renin so that there is an increase in sodium and water excretion. in addition, it can also be reduced by consuming honey which can prevent the formation of plaque attached to the walls of blood vessels so that it can eliminate bad cholesterol for the body. this study aimed to determine the effect of giving cucumber and honey water immersion on elderly hypertension. this study used a quasy experimental design with a pretest and posttest with control group design. sampling using a simple random sampling technique. the sample in this study amounted to 30 elderly people using the paired sample t-test statistical test. the results showed that the average blood pressure of the intervention group before being given the cucumber and honey water immersion was 153.6/84 mmhg and after it was 148.3/82.1 mmhg. the average blood pressure of the control group before being given the cucumber and honey water immersion was 158.5/80.2 mmhg and after it was 163.5/80.2 mmhg with p = 0.000. in the results of the independent sample test the intervention group before being given therapy, namely sig. (2-tailed) = 0.027, the control group before treatment was sig. (2-tailed) = 0.045. while the test results of the intervention group after being given therapy are sig. (2-tailed) = 0.124, the control group after being given therapy is sig. (2-tailed) = 0.139. there is an effect of giving cucumber and honey water immersion therapy on changes in blood pressure in the elderly with hypertension. but there is no difference in the average blood pressure of the hypertensive elderly. it is expected that the elderly with hypertension can make cucumber and honey water immersion as an alternative therapy to reduce hypertension. introduction hypertension is a disease related to the cardiovascular system where this disease is one of the health problems in the world which is considered quite dangerous because its work is very progressive.1 hypertension is a condition of increasing a person's blood pressure exceeding normal limits, causing increased morbidity and mortality.2 based on the 2018 riskesdas data, the prevalence of hypertension with a population aged 18 years is 34.1%, south kalimantan is the province with the highest incidence rate with a percentage (44.1%), and papua occupies the lowest position in https://doi.org/10.26714/seanr.3.2.2021.45-50 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.2.2021.45-50&domain=pdf&date_stamp=2021-06-23 south east asia nursing research, vol 3 no 2, june 2021/ page 45-50 46 edy soesanto / cucumber and honey soaking reduces hypertension in the elderly the incidence of hypertension with a percentage (22.2%). at the age of 31-44 years hypertension attacks with a percentage (31.6%), age 45-54 years (45.3%), and age 55-64 years (55.2%). the number of incidences of hypertension in the elderly is still quite high, with 60-80% aged over 65 years. hypertension occurs mostly in the elderly or at the age of over 75 years with a percentage (69.5%) and on average it affects women with a percentage (36.9%) compared to men (31.3%).3 based on the results of blood pressure measurements on a number of residents in central java in 2017, there were 8,888,585 residents (36.53%) aged 18 years and over who were at risk, there were 1,153,371 residents (12.98%) who suffered from hypertension. demak regency is in the second highest order with the number of hypertension sufferers as much as 76.7%.4 the prevalence of elderly hypertension sufferers at the mranggen 1 health center, demak regency in 2018 was 3,295 which increased by 1%.5 the cause of high blood pressure is not known with certainty, but a person's lifestyle becomes a big enough influence in this disease. there are many things that cause hypertension, including age, gender, smoking behavior, lifestyle and lack of exercise, resulting in obesity if it cannot be controlled properly. by reducing the presence of these risk factors, it becomes the basis for health workers to provide further interventions.6 one way that can be done to make lifestyle modifications in patients with hypertension is to adjust the diet. blood pressure can be controlled and lowered by consuming one of the vegetables, namely cucumber.7 based on a report from the united state department of agriculture (usda) branded food products database, every 100 grams of cucumber contains 147 mg of potassium and certainly does not contain sodium, and there are many other nutritional content in cucumbers. the potassium content in cucumbers can reduce systolic and diastolic blood pressure, the direction of the correlation is negative, so the higher the potassium content consumed, the more effective it is in lowering blood pressure in hypertensive patients.8 the absence of sodium content also further clarifies the benefits of the cucumber itself. one of the processed cucumbers that can lower blood pressure in most of the elderly is cucumber cut into pieces and then soaked in water for 12 hours. the results of this cucumber water immersion contain antioxidants by compounds that are bioactive, which can be maximally released and mixed with water due to the oxidation process by oxygen. cucumbers in this study were not crushed but only cut into pieces. this will allow the cucumber to release all the many antioxidants and can be directly mixed with water.9 besides cucumber, hypertension can also be overcome by consuming honey.10 said that honey contains sugar, enzymes, protein, minerals, vitamins, and flavonoids derived from flower nectar which is processed naturally by bees into a sweet thick liquid. honey can lower bad blood pressure called ldl (low density lipoprotein) which at the same time can also increase levels of good cholesterol called hdl, preventing the formation of plaque attached to the walls of blood vessels so that it can remove cholesterol. there was a significant effect of giving oral honey therapy on respondents before and after being given treatment.11 methods this study used a quasy experimental design with a pretest and posttest with control group design. the population in this study were all elderly with hypertension in kangkung village, mranggen, demak which amounted to 127 people. the sampling method used in this study was simple random sampling with a sample size of 30 respondents with inclusion criteria: willing south east asia nursing research, vol 3 no 2, june 2021/ page 45-50 47 edy soesanto / cucumber and honey soaking reduces hypertension in the elderly to be a respondent and follow the research procedure until the final stage, elderly hypertension is female, has suffered from hypertension for more than 6 months, aged above 60 years old, taking medication regularly, consuming cucumber and honey water bath in the morning 30 minutes after taking standard medication. the research was conducted in kangkung village mranggen, demak. the research process took place from march 4-10, 2021. data were analyzed univariately and bivariately (paired sample t-test). results based on figure 1 after the paired sample ttest test the average blood pressure of the intervention group before and after being given cucumber and honey water immersion was 153.6/84 mmhg and after was 148.3/82.1 mmhg. from the paired table, it can be seen that the t value is 20,124 and p = 0.000 (p < 0.05), it can be concluded that there is a difference before and after being soaked in cucumber and honey water. based on figure 2 after the paired sample ttest test the average blood pressure of the control group before and after being given cucumber and honey water immersion was 158.5/80.2 mmhg and after was 163, 5/80.2 mm hg. from the paired table, it can be seen that the t value is 39,840 and p = 0.000 (p < 0.05), it can be concluded that there is a difference before and after being soaked in cucumber and honey water. figure 1 distribution of the average value of systolic and diastolic blood pressure in the intervention and control groups before giving cucumber and honey water immersion 167,8 163,8 158,3 153,3 149,3 144,4 138,3 89,6 87,5 85,5 84 82,3 80,7 78,4 161,2 161,2 164,1 164,1 164,1 165,1 165,1 80,1 80,1 80,3 80,3 80,3 80,4 80,4 70 80 90 100 110 120 130 140 150 160 170 1 2 3 4 5 6 7 blood pressure before (pretest) systole (intervention) diastolic (intervention) systole (control) diastolic (control) south east asia nursing research, vol 3 no 2, june 2021/ page 45-50 48 edy soesanto / cucumber and honey soaking reduces hypertension in the elderly figure 2 distribution of the average value of systolic and diastolic blood pressure in the intervention and control groups after administration of cucumber and honey water immersion discussion blood pressure before cucumber and honey based on these results, it was found that on average the respondents in this study did not pay attention to their daily lifestyle, because for them eating modestly was enough. some of them said that they did not have enough money if they had to occasionally buy meat, fish, or fruit. in addition, it has also become a culture or habit of consuming salted fish. in fact, to be able to control their blood pressure, they can get it through green vegetables which are quite economical and easy to obtain because these green vegetables contain potassium and magnesium. another thing that the elderly can do is to do light exercise, drink enough water according to their activities. the elderly who experience hypertension increase because these respondents cannot manage their lifestyle well, unhealthy and nutritious eating habits where they rarely consume fruits, rarely consume vegetables and often consume fried foods. meanwhile, the increase in blood pressure caused by food, namely consuming foods with a high content of saturated fat, over time causes the formation of plaque or cholesterol which can inhibit blood circulation, which is where the blood vessels narrow and the elasticity of the blood vessels decreases.12 blood pressure after cucumber and honey soaking cucumber has good health benefits, namely it can help maintain salt and fluid balance, control blood pressure stability, help reduce hypertension. the benefits of other cucumbers are as the best diuresis, namely as a urine launcher (nugraheni, 2016). cucumber water bath and honey contain potassium which has benefits in cleaning carbon dioxide in the blood, which can regulate osmotic pressure along with 163,8 158,3 153,3 149,3 144,4 138,3 131,1 87,5 85,5 84 82,3 80,7 78,4 76,3 161,2 161,2 164,1 164,1 164,1 165,1 165,1 80,1 80,1 80,3 80,3 80,3 80,4 80,4 70 80 90 100 110 120 130 140 150 160 170 1 2 3 4 5 6 7 blood pressure after (posttest) systole (intervention) diastolic (intervention) systole (control) diastolic (control) south east asia nursing research, vol 3 no 2, june 2021/ page 45-50 49 edy soesanto / cucumber and honey soaking reduces hypertension in the elderly sodium, triggering the work of muscles and nerve nodes. the mineral content of magnesium and riboflavin also has a role in lowering blood pressure. the mineral magnesium helps in making blood flow smooth. other ingredients are riboflavin, a vasodilator, and high in vitamin c. this content has a role as a diuretic, so it can help lower blood pressure. while in honey itself contains flavonoids. giving cucumber and honey water immersion can lower blood pressure caused by vasodilation of blood vessels which can lower blood pressure. this cucumber can be used as a type of complementary medicine or non-pharmacological therapy that can overcome hypertension. this agrees with research (kusumastuty et al., 2017) who said that after giving infused water cucumber, the respondent's blood pressure decreased. the effect of cucumber and honey bathing on reduction in elderly hypertension in the results of the independent sample test the intervention group before being given therapy, namely sig. (2-tailed) = 0.027, the control group before treatment was sig. (2-tailed) = 0.045 so that there is a difference in the average blood pressure of the hypertensive elderly. while the test results of the intervention group after being given therapy are sig. (2-tailed) = 0.124, the control group after being given therapy is sig. (2-tailed) = 0.139 so it can be concluded that there is no difference in the average blood pressure of the hypertensive elderly in the kangkung mranggen village area, demak. in the other study produced a statistical test, namely there was a difference after giving the honey solution intervention to decrease blood pressure with p <0.05. which means that the intervention of cucumber and honey water immersion weighing 20 grams can help reduce blood pressure in the treatment group. in addition, the decrease in blood pressure in the elderly is also due to the vitamin c content in honey.13 the honey in this study was dissolved at normal temperatures. cucumbers contain high potassium so they are very good for consumption by people with hypertension, because in their research results, cucumbers are significantly related to a decrease in systolic blood pressure, because there is a potassium content in cucumber which is 1,000 mg/day.14 based on this description, the researcher argues that there is an effect on the blood pressure of the elderly before and after being given cucumber and honey water immersion. this study shows that cucumber and honey water immersion has an effect on reducing hypertension in the elderly so that this intervention can be applied in kangkung village mranggen, demak. although the statistical difference test showed that there was no significant difference in blood pressure results, it was possible to continue the therapy of giving cucumber water and honey immersion in this hypertension patient. conclusion the respondent's blood pressure before being given cucumber and honey water immersion in the intervention group was 153.6/84 mmhg and the control group was 163.5/80.2. the respondent's blood pressure after being given cucumber and honey water immersion in the intervention group was 148.3/82.1 mmhg and the control group was 163.5/80.2. there is an effect of giving cucumber and honey water immersion on reducing hypertension with a t value of 29,982 and p = 0.000 (p < 0.05) in the hypertensive elderly in kangkung village mranggen, demak, but there is no difference in the average blood pressure of the hypertensive elderly after being given the immersion. cucumber water and honey with sig. (2-tailed) = 0.132. this research is expected to be a source of literature for further researchers to deepen south east asia nursing research, vol 3 no 2, june 2021/ page 45-50 50 edy soesanto / cucumber and honey soaking reduces hypertension in the elderly complementary treatments, especially the use of indonesian herbal ingredients to reduce blood pressure of people with hypertension acknowledgments the researcher would like to say thank you to all the participated as research respondents. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. world health organization. hypertension [internet]. 2021 [cited 2021 jun 3]. available from: https://www.who.int/news-room/factsheets/detail/hypertension 2. sumartini np, zulkifli z, adhitya map. pengaruh senam hipertensi lansia terhadap tekanan darah lansia dengan hipertensi di wilayah kerja puskesmas cakranegara kelurahan turida tahun 2019. j keperawatan terpadu (integrated nurs journal). 2019;1:47–55. 3. riskesdas. hasil utama riset kesehatan dasar. kementrian kesehat republik indones. 2018;1– 100. 4. riskesdas. hasil utama riskesdas penyakit tidak menular 2018. hasil utama riskesdas penyakit tidak menular. 2018. 5. soesanto e, abdurrahman nn. the role of volunteers in improving services in elderly integrated service centers. south east asia nurs res. 2020;2:22–6. 6. tirtasari s, kodim n. prevalensi dan karakteristik hipertensi pada usia dewasa muda di indonesia. tarumanagara med j. 2019;1:395–402. 7. brusaferro s, toscani p, fiappo e, quattrin r, majori s. the balance between quality and resources in health care organizations: study on a hospital cleaning service managed in outsourcing. ann ig [internet]. 2004/11/24. 2004;16:387–95. available from: http://www.ncbi.nlm.nih.gov/pubmed/15554 543 8. kusumastuty i, widyani d, sri wahyuni e. asupan protein dan kalium berhubungan dengan penurunan tekanan darah pasien hipertensi rawat jalan. indones j hum nutr. 2017;2:19–28. 9. zhang n, zhao b, zhang h, weeda s, yang c, yang z, et al. melatonin promotes water‐stress tolerance, lateral root formation, and seed germination in cucumber (cucumis sativus l.). j pineal res. 2013;54:15–23. 10. arawwawala m, hewageegana sujatha. health benefits and traditional uses of honey: a review. j apitherapy. 2017;2:9. 11. aini r. pengaruh pemberian madu terhadap perubahan tekanan darah pada penderita hipertensi di wilayah kerja upk puskesmas khatulistiwa kecamatan pontianak utara. j keperawatan. 2018;24:1–12. 12. maryati h. hubungan kadar kolesterol dengan tekanan darah penderita hipertensi di dusun sidomulyo desa rejoagung kecamatan ploso kabupaten jombang the correlation of cholesterol levels with blood pressure hypertension patients in sidomulyo rejoagung village distric. j keperawatan. 2017;8:127–37. 13. husna f, damayanti ay, sari dd. comparation of antihypertensive effect of goldenberry, cucumber, and combination juice against systolic blood pressure on rats induced 8% nacl. nutr j gizi, pangan dan apl. 2019;3:43–51. 14. liu f, zhang x, zhao l, wang y, liao x. potential of high-pressure processing and hightemperature/short-time thermal processing on microbial, physicochemical and sensory assurance of clear cucumber juice. innov food sci emerg technol. 2016;34:51–8. culture and community partnership approach to making a healthy indonesian society (germas) with the helix method corresponding author: angga irawan angga_irawan10@yahoo.co.id south east asia nursing research, vol 2 no 4, december 2020 issn:2685-032x doi: https://doi.org/10.26714/seanr.2.4.2020.8-19 original research culture and community partnership approach to making a healthy indonesian society (germas) with the helix method angga irawan1, ahmad hidayat2, jami hariyadi3 1,2,3 university of sari mulia, indonesia article info abstract article history: submit dec 5th, 2020 accepted dec 12th, 2020 published dec 30th 2020 keywords: healthy living; community movement (germas); partnership germas is a movement with the aim of improving people's healthy life and leaving unhealthy habits and behavior of society. one of the areas that become national priorities based on the decree of the minister of villages for disadvantaged areas and trans-migration of the republic of indonesia number 126 of 2017 concerning the determination of priority villages for village development targets, development of underdeveloped areas and transmigration, including the village assistance of banjar regency, south kalimantan problems in the health sector in banjar regency can be seen from the health profile data for banjar regency in 2017 which shows the incidence of infectious and non-communicable diseases that are still experienced by many people in banjar regency such as ispa, hypertension, rheumatism, gastritis, duodenitis, diarrhea, dermatitis and pulmonary tb. one of the concepts that can be used in the implementation of the germas action program is the concept of a partnership with an approach to religious figures, educational institutions, society, and the media. this study uses a quantitative descriptive-analytical design with a quantitative descriptive survey method with a random sampling technique. by using the instrument used in this study is a questionnaire sheet. based on the research results obtained as follows: knowledge level as much as 53%, physical activity 70%, eating fruit and vegetable foods 75%, alcohol consumption 56%, health checks 15%, environmental hygiene 45%, using a latrine 23%, use of media as much as 80% and social activities as much as 80%. the results of this study hope that the people of desa pembantanan will implement a community movement for healthy living which includes 4 indicators, namely increasing knowledge, not drinking alcohol, environmental hygiene, and not using latrines, so that they can avoid health problems from noncommunicable diseases. introduction germas is a movement with the aim of improving people's healthy life and leaving unhealthy habits and behavior of society.1 one of the areas that become national priorities based on the decree of the minister of villages for disadvantaged areas and trans-migration of the republic of indonesia number 126 of 2017 concerning the determination of priority villages for village development targets, development of underdeveloped areas and transmigration, including the village https://doi.org/10.26714/seanr.2.4.2020.8-19 https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.2.4.2020.8-19&domain=pdf&date_stamp=2020-12-30 south east asia nursing research, vol 2 no 4, december 2020/ page 139-150 140 angga irawan / culture and community partnership approach to making a healthy indonesian society (germas) with the helix method assistance of banjar regency, south kalimantan.2,3 problems in the health sector in banjar regency can be seen from the health profile data for banjar regency in 2017 which shows the incidence of infectious and non-communicable diseases that are still experienced by many people in banjar regency such as ispa, hypertension, rheumatism, gastritis, duodenitis, diarrhea, dermatitis and pulmonary tb.3 one of the concepts that can be used in the implementation of the germas action program is the concept of a partnership with an approach to religious figures, educational institutions, communities, and media, which are expected to collaborate and synergize in community activities in the germas program.4–7 the germas program through partnerships will consider aspects of local culture.8 this is intended to be well accepted by the target community, so that this action becomes a behavior that is inherent in everyday life. in the interests of disseminating the program in order to create an image of the program among the target audience, cooperation between the media, educational institutions, community leaders, health services and community leaders is required.9 pembatanan village is one of the underdeveloped villages in the sungai tabuk subdistrict, banjar regency which is the national priority area based on the decision to describe the villages of disadvantaged areas and transmigration of the republic of indonesia number 126 of 2017. regarding the determination of priority villages for village development targets, development of disadvantaged areas. problems in the health sector in banjar regency can be seen in the 2018 banjar district health profile which shows that health problems are a priority in reducing the sustainable development goal (sgds) target.10 in addition, the prevalence of tuberculosis, hypertension, asthma and dermatitis experienced by the people of pembantanan village is in the area of sungai tabuk district which is a village on the banks of the river. meanwhile, the total population of the assistance village is 3,345, 1,746 male and 1,599 female in the district. sungai tabuk, banjar regency, south kalimantan 70653. based on the existing resources in the village of pembantan, as follows: health workers, farmers, craftsmen, construction workers and carpenters. there are public service facilities in the assistance village such as health services (2 puskesmas and 1pustu), education centers (paud = 1, tk = 3, sd = 2, islamic boarding schools = 3, madrasah ts = 2, madrasah itthadiyah = 3, madrasyah aliyah = 1). in addition, there is a village fund to develop bumdes (bumdes which has already run kelotok rental and sale of farm products). the community in the assistance village area is a heterogeneous community that is more receptive to change and has an impact on population dynamics from the center of community activities around it. the form of activities in the assistance village area consists of 2 activities, namely: 1) government: government programs such as pnpm and pamsimas while; 2) community self-help activities consisting of youth activities, recitation, and posyandu meanwhile, the village infrastructure infrastructure is still very limited, such as: (suspension bridges, with wing ropes that are about to break and wooden bridges with many holes), which are the main connecting roads between villages and the transkalimantan road axis. the facilities in the village area include: health services consisting of 2 health centers and 1 pustu, education centers consisting of paud = 1, tk = 3, sd = 2, islamic boarding schools = 3, madrasah ts = 2, madrasah itthadiyah = 3, madrasyah aliyah = 1, badminton court and hall. while developments in the assistance village area are such as the office of the village head, while the organizations come from the community such as pustu and posyandu, while there are several party organizations. government such as pnpm south east asia nursing research, vol 2 no 4, december 2020/ page 139-150 141 angga irawan / culture and community partnership approach to making a healthy indonesian society (germas) with the helix method and pamsimas meanwhile; 2) community self-help activities consisting of youth activities, recitation, and posyandu meanwhile, the village infrastructure infrastructure is still very limited, such as: (suspension bridges, with wing ropes that are about to break and wooden bridges with many holes), which are the main connecting roads between villages and the transkalimantan road axis. the facilities in the village area include: health services consisting of 2 health centers and 1 pustu, education centers consisting of paud = 1, tk = 3, sd = 2, islamic boarding schools = 3, madrasah ts = 2, madrasah itthadiyah = 3, madrasyah aliyah = 1, badminton court and hall. while developments in the assistance village area are such as the office of the village head, while the organizations come from the community such as pustu and posyandu, while there are several party organizations. the purpose of this study is to determine the factors that influence society in the healthy indonesian society movement. methods this research is a quantitative research with a descriptive research design. the research approach used was cross sectional. this study examines the factors that influence the community in the healthy indonesian community movement in the village of assistance. respondents of this study were members of the village community in south kalimantan. respondents totaled 80 people according to the inclusion and exclusion criteria. the sampling technique used was simple random sampling. research variables have been measured using a questionnaire. the questionnaire used has been declared valid and reliable based on the results of the validity test and reliability test. researchers have provided explanations to potential respondents before the researchers conducted data collection. the explanation that has been done includes the objectives of the research, the benefits of the research and the consequences that must be borne in the research. after giving an explanation to the respondent, the researcher asked the respondent to sign the informed consent sheet. the researcher did not include the identity of the respondent in the research results. results the results of this study describe the results of research on the description of the partnership with the healthy living community movement with the penta helix approach. data collection was carried out in august from 5 to 9 october 2020, with a total of 80 respondents. the number of clients who dropped out during the research process did not exist, because the researcher did this by directly visiting clients, so that the total results of this study were 80 respondents. this research was conducted in the village of banjar regency. description of the characteristics of respondents in the healthy living community movement in the assistance village area. the results of the study show that the gender of the most respondents is male, namely 56 people (70%) while 24 (30%) women. the description of the education level of the most respondents is high school graduation, namely 27 (36.2%) while the lowest is college graduated 9 respondents (11.2%). the most respondents' education level is income, namely 41 (26%) while the lowest is 39 respondents (48.8%). the job description of the most respondents is income, namely 30 (37.5%) while the lowest is 6 respondents (7.5%). south east asia nursing research, vol 2 no 4, december 2020/ page 139-150 142 angga irawan / culture and community partnership approach to making a healthy indonesian society (germas) with the helix method description of factors affecting society in healthy indonesian community movement in assistance villages. table 1 distribution of respondents characteristics in assistance villages 2020 (n = 80) indicators f % knowledge knowing 53 66.2 don't know 27 33.8 physical activity knowing 70 87.5 don't know 10 12.5 fruit and vegetable diet knowing 75 93.8 don't know 5 6.2 smoking behavior smoke 73 91.2 do not smoke 7 8.8 consuming alcoholic drinks not consuming 24 30 consume 56 70 consuming drinks, health checks to do 15 18.8 do not do 65 81.2 environmental cleanliness done 45 56.2 is not done 35 43.8 using latrines done 23 28.8 is not done 57 71.2 maintaining environmental cleanliness done 80 100 is not done 0 0 social support and community leaders get social 80 100 the results of the study show that the knowledge of germas knowing is 53 people (66.2%), 27 people do not know (33.8%). the description of physical activity carried out by respondents is 70 people (87.5%), not done by 10 people (12.5%). most of it was done, namely 75 people (93.8%), not 5 people (6.2%). most of the people smoked, namely 73 people (91.2%), 7 people (8.8%) did not smoke. the pattern of consuming alcoholic drinks is 56 people (70%), not consuming 24 people (30%). most of them did not do as many as 56 people (81.2%), did as many as 15 people (18.8%). most people who do cleanliness in the environment are 45 people (56.2%), 35 people (43.8%) do not. most of the people who do not use as many as 57 people (71.2%), use 23 people (28.8%). most of it is done as much as 80 (100%) maintaining environmental cleanliness. most of the village people get information by socializing as many as 80 people (100%). discussion this section describes the results of research based on literature reviews and previous research results. this discussion includes the interpretation and discussion of the results, limitations and implications of the research obtained from the research conducted as follows: identifying the characteristics of the community based on the healthy living community movement. one of the government's efforts to control and prevent the increasing number of noncommunicable diseases is through germas, which is a systematic and planned action. this is in accordance with presidential instruction no. 1 of 2017 concerning the healthy living community movement, this has a major impact on the family and the lifestyle of each head of the family. "starting from us as women, then later developing in the family environment and spreading in the wider community.11 therefore, every woman must become a pioneer of the healthy living society movement (germas) by maintaining a healthy lifestyle in their respective family environment so that family health is maintained, family productivity increases, the environment becomes clean and costs for medical treatment are reduced.6 based on the results of the study, it was shown that 56 people (70%) were male, while 24 were female (30%). this shows that the head of the family and family members tend to be dominated by men. based on the culture of decision making in the family, it is the head of the family. the role of the head of the family takes the decision to take the right action. however, south east asia nursing research, vol 2 no 4, december 2020/ page 139-150 143 angga irawan / culture and community partnership approach to making a healthy indonesian society (germas) with the helix method not all family heads are held by men, the fact is that women / wives are the backbone of the family due to the condition of their husbands who do not work either because of illness or other.12 education level plays an important role in public health. community education can affect people's knowledge. education is one of the community organizing efforts to improve health because the level of education can affect the healthy behavior of a family with a less supportive level of education which will lead to low environmental awareness, the better the level of formal education so that it will mature understanding of knowledge about germas. based on the results of the study, it shows that the highest level of education is 29 people (36.2%) graduated from high school and the lowest is 4 people (5%) who did not graduate from elementary school. based on the results of other research, it shows that education will influence a person's behavior in life patterns.13 the results of this study are supported by other research which states that most respondents with secondary education (sma) will influence family behavior in implementing healthy living behaviors because respondents have sufficient insight.8 the pattern of healthy living behavior in riverbank communities is by regulating diet, getting enough rest, exercising regularly and eating vegetables. all of this is done regularly to maintain health in life. if the body is in a healthy condition, you can do your usual activities, namely as a farmer. the income earned will affect the economy and health welfare in the family.14,15 work is a grouping of one's duties and responsibilities to meet needs that must be met and achieve a better standard of living.16 in addition, based on the research results according to other study, it is stated that work affects the ability of parents to provide nutrition for family members.17 it is proven in this study that the occupation of most respondents is self-employed 99 (30%). in indonesia, fishermen usually live in rural areas. the stability of food availability at the household level is measured based on the adequacy of food availability and the frequency of meals for household members in a day. the combination of the two as an indicator of food sufficiency produces an indicator of the stability of food availability.18 if this availability is sufficient, the family will be able to realize health and apply germas properly.5 the researcher got the income of the community in the village of pembantanan <rp. 2,000,000; 41 people (51.2%) while income> rp. 2,000,000 totaling 39 (48.8%) so that the purchasing power of the community in the village of pembatanan is still very low, both primary and secondary needs. as is the case according to the other study, which states that family income is one of the factors affecting the purchasing power of families to provide health needs.19 family. the higher the family income, the higher the pattern of family purchasing power in meeting the health needs of family members. based on othe research as a result, most of the head of the family who played a poor role in the health of family members was a family head whose economy was low.20 low-income families tend not to be able to meet their food needs, the diversity of foodstuffs is not guaranteed, because with limited money there are not many choices of foodstuffs to be consumed. the pattern of healthy living behavior in riverbank communities by adjusting the diet, getting enough rest, exercising regularly eating vegetables. all of this is done regularly to maintain health in life. the income earned will affect the economy and health welfare in the family. based on the results of research conducted, it was found that the highest number of private workers was 30 (37.5%) and the lowest was civil servants (3.8%). work is a grouping of south east asia nursing research, vol 2 no 4, december 2020/ page 139-150 144 angga irawan / culture and community partnership approach to making a healthy indonesian society (germas) with the helix method one's duties and responsibilities to meet needs that must be met and achieve a better standard of living. research conducted by other research states that work affects the ability of parents to provide nutrition for family members.18 the stability of food availability at the household level is measured based on the adequacy of food availability and the frequency of meals for household members in a day. the combination of the two as an indicator of food sufficiency produces an indicator of the stability of food availability. if this availability is sufficient, the family will be able to realize health.21 the research that was obtained based on people's knowledge about the germas program was 53 people (66.2%) and 27 people (33.8%) did not know. the low number obtained by researchers is a basic reference and is not in line with other study, namely the main objective in providing health education, namely changing a person's knowledge, attitudes and behavior while knowledge is the result of "knowing", and this occurs after people do sensing of a particular object. knowledge or cognitive is a very important domain for the formation of one's actions (overt behavior).16 the research that was done got physical activity that did as many as 70 (87.5%) and those who did not do 10 people (12.5%). based on research by other research on the relationship of physical activity, it shows that there are several things that can affect activity, including age, gender, occupation, education.22 meanwhile, research according to other study on the relationship of physical activity shows that people with good physical activity are less at risk of contracting non-communicable events than people who have less physical activity.23 adequate consumption of vegetables and fruits plays a role in maintaining normal blood pressure, blood sugar and cholesterol levels. adequate consumption of vegetables and fruits will reduce the risk of having difficulty defecating (defecating / constipation) and obesity. this shows that adequate consumption of vegetables and fruits plays a role in preventing chronic non-communicable diseases. the healthy living society movement (germas) invites people to consume 2-3 servings of vegetables and fruit every day, especially local vegetables and fruits, which are sufficient to consume vegetables and fruits. the fiber content in 100 grams of watermelon is 0.5 grams, oranges 0.1 grams, bananas 0.63 grams, salak is 0.5 grams and apples 0.65 grams. the fiber content of the vegetables consumed by respondents was 2.6 grams of cassava leaves, 1.1 grams of carrots, 0.7 grams of chayote, 0.2 grams of mustard greens and 1 g of kale.24 in accordance with the theory that hypertension is the majority of women and the risk factors for a family history of hypertension are 197 people (58.3%). the age factor is very influential on hypertension because with increasing age, the higher the risk of hypertension. this is often caused by natural changes in the body that affect the heart, blood vessels and hormones. based on the results of the research conducted in the assistance village, data were obtained for as many as 73 smokers (91.2%) and 7 non-smokers (8.8%). actually information about the dangers of smoking has often been socialized by the government through the ministry of health. the ministry of health also has a community movement program (germas), which is a healthy life without smoking with modules that are easily accessible on the internet, and information accompanied by pictures that are interesting to read.25 however, programs like this need to be intensified again in order to reduce the prevalence of teenage smoking in indonesia. the results showed a number of respondents (57.3%) had knowledge that the subject affected by the dangers of smoking was only for people around smokers. this shows that there are still many smokers in the village and this south east asia nursing research, vol 2 no 4, december 2020/ page 139-150 145 angga irawan / culture and community partnership approach to making a healthy indonesian society (germas) with the helix method does not stop the negative effects of smoking. the results of the study found that the behavior of consuming alcohol in the village community was very high. out of 80 samples, 56 (70%) consumed and 24 (30%) did not consume alcohol. research conducted by other research found that alcohol consumption is influenced by factors of lack of self-confidence, curiosity or trying, flight from problems, lack of knowledge, bad family, bad environment significantly increases alcohol addiction (addiction).26 the rampant circulation of alcohol causes people to freely buy it. alcohol is known to be intoxicating and makes you unconscious and some even lead to death. currently, various types of mixed liquor are also circulating in the market that mix various types of alcoholic drinks with harmful ingredients such as mosquito repellent creams. the risks faced can clearly lead to death. the school and related agencies must be aware of this and should follow the development of various information so that it can be disseminated to school students. health checks in the assisting village community who carried out as many as 15 people (18.8%) and those who did not do 65 people (81.% 2), according to the researchers there was a very lack of public awareness of the importance of awareness in terms of conducting regular health checks. the average reason why respondents do not carry out routine health checks is because they are afraid of the results of the examination or know about their health problems, and are considered to be activities that waste money because they are carried out when the person is in a state that looks fit.27 the quality of education also affects their awareness to carry out routine health checks. in contrast to the results of other research regarding the educational results of respondents having routine health checks, it shows that 72% of respondents who routinely carry out health checks are college graduates. in addition, the higher a person's economic capacity, the more routine that person will take medical tests. business at work also affects a person in routine health checks, besides that the time for health checks at health service places is during working hours. the environment is an external variable that affects policy implementation. the environment in implementing the germas policy includes socio-economic conditions and community technology. most of the informants agreed that the socio-economy of society had an effect on policy implementation, especially in terms of behavior. increasing the willingness, awareness and ability of the community to have a healthy lifestyle is the goal of germas. research from yuliandari and herya states that families or communities with low socioeconomic status have five times greater opportunities for not behaving in a clean and healthy life than families / communities with high socioeconomic conditions.27 based on the results of the study, it was shown that the environmental hygiene behavior in the community in the assistance village was carried out by 45 (56.2%) and not done by 35 (43.8%). this is in line with research conducted by iskandar (2018) which found that environmental cleanliness is carried out by all residents together with full awareness so as to produce a clean and healthy environment. the results of the study found that the behavior of using healthy latrines in the community in the village of assistance 23 (28.8%) used latrines and 57 (71.2%) still did not use latrines. people still lack awareness of the importance of latrines in terms of the requirements for a healthy home, namely the availability of clean and proper latrines and the availability of clean water at home. other research found that there is a relationship between ownership south east asia nursing research, vol 2 no 4, december 2020/ page 139-150 146 angga irawan / culture and community partnership approach to making a healthy indonesian society (germas) with the helix method of a healthy latrine with education, knowledge, attitudes, and family income. the results of the study found that the media provided information related to the germas program with a total of 80 (100%). overall, this indicates that the village community in the village of pembantanan used the media as a means of obtaining information in the health sector. this research is in line with research conducted by other study which found that the cultivation of clean and healthy living or healthy living habits has an impact on: 1). increased knowledge about the importance of maintaining health through the healthy life community movement (germas), 2). increase public awareness about the importance of health and phbs, 3). the community can apply phbs directly in their daily life.27,28 information in the implementation of the germas policy includes transmission, clarity and consistency. transmission is the process of delivering policy information to both implementers and groups. information on germas is carried out using media such as printed media (leaflets, posters, stickers, billboards, brochures and others), electronic media (radio and television), and social media (twitter, instagram, facebook, youtube and whatsapp). apart from these media, germas socialization was provided through meetings / meetings, posyandu activities, posbindu activities and other health education activities. the submission of information that has been carried out has not been received thoroughly, this is because there are still schools that have never received socialization from the health office.29 the transmission process in the communication of media information affects the clarity of policy implementation. clarity of communication can be assessed how the implementers and target groups know the intent, content and objectives of the policy itself. the results of the interviews that have been carried out, the delivery of germas information carried out by the health office and puskesmas has been carried out clearly in accordance with the objectives and indicators of germas.23,30 based on the results of interviews conducted by researchers, the community has been given socialization related to germas in accordance with the indicators. in addition, the delivery of germas is provided by integrating it into existing programs / activities. this is because each of the germas indicators already has its own program / activity, while the germas socialization in particular is only carried out at certain times and the schedule for each puskesmas to hold it varies. a public figure according to the law of the republic of indonesia number 8 of 1987 is "a person who because of his social position receives honor from the community and / or the government" (government of the republic of indonesia, 1987). the position of public figures is obtained by individuals because of their knowledge, wisdom and wisdom, and their success in living life in society. the wisdom and knowledge possessed by community leaders usually become role models for people who are in their respective fields. because of their activities, skills and characteristics, community leaders are people who are respected and respected. based on the results of the study, it was found that social activities and community leaders got a score of 80 (100%) that played a role as community leaders, among others, as a social controller, guardian and enforcer of values and norms that apply in society. in addition, community leaders also play a role in solving various problems that occur. community leaders have an obligation to provide support, guidance, motivation and direction to the community. community leaders also act as support providers. support from community leaders can be divided into emotional support, reward support, instrumental support and south east asia nursing research, vol 2 no 4, december 2020/ page 139-150 147 angga irawan / culture and community partnership approach to making a healthy indonesian society (germas) with the helix method informative support. emotional support is indicated by expressions of empathy, care and concern. appreciative support is indicated by expressions of respect and encouragement to move forward. instrumental support is indicated by providing direct assistance according to community needs. informative support is indicated by providing advice, hints, suggestions and feedback. implementation of germas program activities germas or healthy living community movement is a movement launched to achieve spm and pis pk. so that it is in line with germas's goal of realizing a better degree of public health. as an effort to increase awareness, willingness, and ability to behave in a healthy society, presidential instruction number 1 of 2017 concerning the healthy living community movement (germas) has been issued.25 the current health problem in the assisting village faces a major challenge, namely the triple burden of disease, because there are still infectious diseases, an increase in noncommunicable diseases and diseases that should have been resolved do not reappear. non-communicable diseases such as hypertension, stroke, heart disease and diabetes are in the highest rank. the morbidity and mortality rates as well as the demand for health services (treatment) are expected to continue to increase. this is driven by changes in the lifestyle of people who tend to be physically inactive (for example spending a lot of time watching tv), low consumption of fruits and vegetables (eating lots of processed, readyto-eat food, high in sugar, salt, etc.), lack of concern for check or detect early disease.31 public health status is influenced by behavior, environment, health services, and heredity. behavior and the environment play a role for more than 73% of the health status of the community and a number of risk factors for health behavior that occur, namely the population lack of physical activity (70%), less consumption of fruits and vegetables (75%). as is known at this time, poor diet, unbalanced nutritional intake, lack of physical activity, lack of concern in routine health checks, have been inherent in most of the people's daily lives. this actually needs to be watched out for because the worst events that can be lifethreatening are generally triggered by these bad behaviors. the ministry of health develops a healthy indonesia program, healthy living community movement through a family approach.32 germas is a national movement that cannot only rely on the role of the health sector alone. the role of ministries and institutions in other sectors also determines and is supported by the participation of the community in practicing a healthy lifestyle. the socialization of germas is expected to be able to invite people to cultivate a healthy life, in order to be able to change unhealthy habits or behavior. based on the results of the study, the results showed that questionnaires were distributed to 80 respondents who were randomly taken from 12 rts in the assistance village area. this data can be seen from 10 indicators, there are 4 indicators that have not been implemented properly in the community in implementing the germas program. the main activities carried out within the framework of germas are: increasing physical activity, enhancing clean and healthy living behavior (phbs), providing healthy food and accelerating nutrition improvement, increasing prevention and early detection of disease, improving environmental quality, increasing healthy living education. the results showed the application of the healthy community movement (germas) in the village assistance, banjar regency. it can be seen that respondents can carry out activities, consume fruits and vegetables and prevent disease by adopting a healthy and regular lifestyle. south east asia nursing research, vol 2 no 4, december 2020/ page 139-150 148 angga irawan / culture and community partnership approach to making a healthy indonesian society (germas) with the helix method most of the respondents still use the latrine a lot as much as 57% while the community hygiene pattern in cleaning the house is 45%, and the lack of awareness in carrying out health checks is 65% and the smoking behavior pattern is 73%. this is in line with the germas program organized by the ministry of health that in order to improve the quality of life, germas invites the public to cultivate a healthy life, in order to be able to change unhealthy habits or behavior. the implementation of germas must start from the family, because the family is the smallest part of society that shapes personality. based on the results of research on basic health research, it was stated that many respondents did not carry out routine health checks, including checking blood pressure, blood sugar, weighing, measuring abdominal circumference, checking cholesterol.33 from several research results, it is stated that there is a lack of understanding related to government programs, namely germas, one of the reasons for not understanding health problems. implementation of germas program activities using the penta helik approach the bureaucratic structure in implementing the germas policy includes standard operating procedures (sop) and division of tasks (fragmentation). the regulations that have been used as sop guidelines in implementing germas implemented by the health office and bappeda are presidential instruction number 1 of 2017 and central java governor regulation number 35 of 2017. furthermore, there is a follow-up from the regional secretary by issuing circular number 440/6192 dated 7. november 2018 aimed at regional apparatus organizations (opd) to play an active role in germas. based on the results of the study, it was found that there were no regional regulations and rad on germas in the assistance village. regional regulations are deemed necessary not just implementing regulations from higher legislation, but can become a forum for community aspirations, as well as being able to absorb and accommodate the special conditions of a region.5 the basis of the sop because rad can be used as a guide for each opd to prepare germas activities, as well as a guide in monitoring the evaluation of the implementation of germas activities. sops have an influence on policy implementation. sops are used in harmonizing actions for policy implementers in a complex and widespread organizational structure, which can lead to flexibility and equality in implementing regulations. sops that are flexible are more adaptable to responsibilities compared to rigid sops.11 fragmentation relates to the distribution of responsibilities and the division of tasks to those who implement policies. based on the results of interviews with informants, it was stated that the implementation of germas was coordinated by the health office. the division of tasks between organizations or implementing agencies requires coordination. according to winarno, the greater the coordination needed, the less likely the success of the policy will be.11 this is in accordance with other research which states that the division of tasks and coordination between overlapping implementers will cause the implementation process to be less effective.6 conclusion characteristics of respondents based on the results of the description of the community movement to live a healthy life, most of the respondents did physical activity, consumed fruits and vegetables, did not have regular health checks, did not carry out community movement activities to live well. community suggestions are expected to implement a healthy living community movement which includes the results of this south east asia nursing research, vol 2 no 4, december 2020/ page 139-150 149 angga irawan / culture and community partnership approach to making a healthy indonesian society (germas) with the helix method research. hopefully, the people of assistance village will implement a healthy living community movement which includes 4 indicators, namely increasing knowledge, not drinking alcohol, environmental cleanliness, and not using latrines, so that health problems are not contagious. the community is expected to implement a healthy living community movement which includes 4 indicators, namely indicators, namely increasing knowledge, smoking behavior, environmental hygiene, and not using latrines, so as to avoid health problems from non-communicable diseases. acknowledgments the researcher would like to say thank you to all respondents who participated in this research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. notoatmodjo s. promosi kesehatan: teori dan aplikasi. pt rineka cipta; 2010. 2. kemenkes ri. profil kesehatan indonesia. in: depkes ri; 2018. 3. banjar d. profil kesehatan kota banjar tahun 2018.; 2016. 4. zainul j, nasrul m. inisiasi gerakan masyarakat sehat (germas) di poltekkes kemenkes palu. poltekita j ilmu kesehat. 2019;13(1):54-61. 5. suryani d, nurdjanah ep, yogatama y, jumadil m. membudayakan hidup sehat melalui gerakan masyarakat hidup sehat (germas) di dusun mendang iii, jambu, dan jrakah kecamatan, tanjungsari, gunungkidul. j pemberdaya publ has pengabdi kpd masy. 2019;2(1):65. 6. noor n. studi implementasi germas pada penderita hipertensi di puskesmas tapin utara tahun 2020. universitas islam kalimantan mab; 2020. 7. junita e, handayani y, alfiah ln. germas (gerakan masyarakat hidup sehat) di desa rambah hilir. kumawula j pengabdi kpd masy. 2020;3(1):100-105. 8. rahmawaty e, handayani s, sari mhn, rahmawati i. sosialisasi dan harmonisasi gerakan masyarakat hidup sehat (germas) dan program indonesia sehat dengan pendekatan keluarga (pis-pk) di kota sukabumi. link. 2019;15(1):27-31. 9. kementerian kesehatan republik indonesia. pedoman umum program indonesia sehat dengan pendekatan keluarga. kementerian kesehatan ri; 2016. http://library1.nida.ac.th/termpaper6/sd/255 4/19755.pdf 10. habibie wl. health reform in indonesia towards sustainable development growth (case study on bpjs kesehatan, health insurance in indonesia). rev integr bus econ res. 2017;6(3). accessed november 16, 2018. http://buscompress.com/journal-home.html 11. winarno b. kebijakan publik era globalisasi. yogyakarta caps. published online 2016. 12. retnowulandari w. kepala keluarga dalam hukum keluarga di indonesia: tinjauan perspektif gender dalam hukum agama, adat, dan hukum nasional. j huk prioris. 2017;5(3):235-245. 13. angela m, sianturi sr, supardi s. hubungan antara pengetahuan, sikap dan perilaku pencegahan hiv/aids pada siswa smpn 251 jakarta. j penelit dan pengemb pelayanan kesehat. 2019;3(2):67-72. 14. aida pm. analisis pelaksanaan gerakan masyarakat hidup sehat di wilayah kerja puskesmas susoh kabupaten aceh barat daya tahun 2019. published online 2020. 15. notoatmodjo s. pendidikan dan perilaku kesehatan, cetakan 2. pt rineka cipta jakarta. published online 2007. 16. notoatmodjo soekidjo. promosi kesehatan dan prilaku kesehatan edisi revisi 2012. rineka cipta; 2012. 17. hdj m. promosi kesehatan. 5th ed. egc; 2009. 18. rosyadi dw. hubungan antara pengetahuan ibu bekerja, jam kerja ibu dan dukungan tempat bekerja dengan keberhasilan pemberian asi eksklusif di wilayah kerja puskesmas banyudono i. j univ muhammadiyah surakarta. published online 2016. 19. taylor c. fundamentals of nursing : the art and science of nursing care. 7th ed. wolters kluwer health/lippincott williams & wilkins; 2011. 20. nugroho k, sanubari t, rumondor j. faktor south east asia nursing research, vol 2 no 4, december 2020/ page 139-150 150 angga irawan / culture and community partnership approach to making a healthy indonesian society (germas) with the helix method risiko penyebab kejadian. j kesehat kusuma husada januari 2019. published online 2019:32-42. 21. spronk i, kullen c, burdon c, o’connor h. relationship between nutrition knowledge and dietary intake. br j nutr. 2014;111(10):17131726. doi:10.1017/s0007114514000087 22. mila m, anida a, ernawati y. hubungan aktifitas fisik dengan tekanan darah pada lansia di dusun miri desa sriharjo imogiri bantul yogyakarta. j kesehat masy. 2017;10(1). 23. nurfitriani n, anggraini e. pengaruh pengetahuan dan motivasi ibu rumah tangga tentang gerakan masyarakat hidup sehat (germas) di kelurahan talang bakung kota jambi. j ilm univ batanghari jambi. 2019;19(3):532-538. 24. graham dj, laska mn. nutrition label use partially mediates the relationship between attitude toward healthy eating and overall dietary quality among college students. j acad nutr diet. 2012;112(3):414-418. doi:10.1016/j.jada.2011.08.047 25. kementerian kesehatan republik indonesia. pedoman umum program indonesia sehat dengan pendekatan keluarga.; 2016. 26. enander j, ivanov vz, mataix-cols d, et al. prevalence and heritability of body dysmorphic symptoms in adolescents and young adults: a population-based nationwide twin study. psychol med. 2018;48(16):2740-2747. doi:10.1017/s0033291718000375 27. yuliandari dw, ui nh. pengaruh pengetahuan dan sosial ekonomi keluarga terhadap penerapan perilaku hidup bersih dan sehat (phbs) tatanan rumah tangga di wilayah kerja puskesmas x kota kediri. j wiyata penelit sains dan kesehat. 2017;3(1):17-22. 28. trisnowati h, daduk ss. hubungan pengetahuan dan sikap terhadap phbs di rumah tangga dengan perilaku merokok dalam rumah kepala rumah tangga di dusun karangnongko yogyakarta. med respati j ilm kesehat. 2017;12(4):1-11. 29. printina ab. pengaruh promosi kesehatan melalui video vlog terhadap tingkat pengetahuan tentang penyalahgunaan narkoba pada siswa siswi di smp strada marga mulia jakarta selatan. j ris kesehat nas. 2018;2(1):59. doi:10.37294/jrkn.v2i1.89 30. adha ay, wulandari dr, himawan ab. perbedaan efektivitas pemberian penyuluhan dengan video dan simulasi terhadap tingkat pengetahuan pencegahan tb paru (studi kasus di ma husnul khatimah kelurahan rowosari kecamatan tembalang kota semarang). j kedokt diponegoro. 2016;5(4). 31. dedi k. aksi bersama melakukan gerakanmasyarakat hidup sehat. kemenkes, ri ed. 2017;1:2017. 32. heryati gs. faktor-faktor yang berhubungan dengan kepatuhan diet diabetes mellitus pada pasien dm. j keperawatan. 2014;1(3):97-107. 33. ri k. laporan riskesdas 2013. nurses' anxiety amid of covid-19 pandemic corresponding author: dewi setyawati dewisetyawati@unimus.ac.id south east asia nursing research, vol 3 no 2, june 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.2.2021.59-65 original research nurses' anxiety amid of covid-19 pandemic dewi setyawati1, rasti sastro2, siti aisah1 1 universitas muhammadiyah semarang, indonesia 2 undergraduate student of nursing program, faculty of nursing and health sciences, universitas muhammadiyah semarang article info abstract article history: submit april 2nd, 2021 accepted may 23rd, 2021 published june 23rd 2021 keywords: anxiety; covid 19; pandemic the psychological response toward pandemics experienced by medical workers is increased due to the anxiety about their health condition and the risk to infect the family member. this research was aimed to describe the nurses’ anxiety amid the covid 19 pandemic at piru hospital. this research was descriptive quantitative research with the cross-sectional approach. the research was conducted from december 29, 2020, to march 4, 2021. the population was 125 medical workers at rsud piru, with 95 respondents taken as a sample by using the random cluster sampling technique. the instrument used was hamilton rating scale for anxiety (hrs-a). the data was then analyzed by using frequency distribution data classified in a table. the result of univariate data analysis showed that 91 respondents (95.8%) didn’t experience anxiety, and 2 respondents (2.1%) experienced anxiety. in case of anxiety, 95.8% of nurses at piru hospital in west seram regency, maluku didn’t experience anxiety. the research finding shows the importance of prevention and early detection of anxiety disorder to minimize further impact. individual identification on the early stage of psychological disorder could be an effective intervention strategy. introduction the disease caused by the novel coronavirus sars-cov-2 has become a global public health emergency and has been designated by the world health organization (who) as a pandemic in march 2020.1 coronavirus infection 2019 or often referred to as covid-19 is a disease that associated with respiratory symptoms with death due to acute respiratory distress syndrome.2 it was recorded that until july 2020 globally there were 216 regions affected by covid19 cases with more than 12,000,000 positive confirmed cases and more than 500,000 confirmed deaths.3 the number of cases indicates that the global health system could be overwhelmed by the covid-19 disease. health workers are on the front line who must be protected as the most valuable resource of every country.4 according to data from the task force for the acceleration of handling covid 19, 45 medical personnel were infected with covid 19 while on duty to treat patients at health centers and several hospitals in maluku and the first death case of health workers in https://doi.org/10.26714/seanr.3.2.2021.59-65 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.2.2021.59-65&domain=pdf&date_stamp=2021-06-23 south east asia nursing research, vol 3 no 2, june 2021/ page 59-65 60 dewi setyawati / nurses' anxiety amid of covid-19 pandemic maluku died from covid on july 2, 2020. according to data from the head of the task force acceleration of handling covid 19 on may 11, 2020, in maluku kasrul selang said 32 medical personnel were infected with covid 19 and the haulussy hospital, which is the covid referral hospital in maluku, was temporarily closed for the next 14 days for sterilization of all rooms in the hospital, the closure was carried out after 14 medical personnel, including the director of the hospital, tested positive for covid-19 on friday, june 12, 2020. the psychological response experienced by health workers to infectious disease pandemics is increasing because it is caused by feelings of anxiety about one's health and the spread of the family.5 various psychological disorders have been reported and publicized during the covid19 outbreak in china, both at an individual, national and international community levels. at an individual level, people are more likely to experience fear of contracting and experiencing severe or dying symptoms, feel helpless, and stereotype others. the pandemic even causes a psychological crisis.6 identification of individuals in the early stages of psychological disorders makes intervention strategies more effective. the health crisis of the covid-19 pandemic causes psychological changes such as fear, anxiety, depression, or discomfort. this disorder is not only felt by health workers or all people who work in the medical field but also by all citizens7. previous research has shown that mental disorders from a major disaster have a broader and longerlasting impact than physical injuries, while attention to mental health is much less, both in terms of providing personnel for planning and resources.8 health workers who treat covid-19 patients are a group with a very high risk of exposure. research has shown that the probability of medical personnel being infected with covid-19 is 3.8%, mainly due to unprotected initial contact with infected patients.9 covid-19 infection has a higher transmission and mortality rate than those caused by severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers).10 health workers must wear protective clothing and n95 masks to avoid exposure to infection, this makes the service much more difficult and tiring than under normal conditions, in addition, the fear of contracting and being infected has been reported to be a trigger for adverse psychological problems such as anxiety, stigmatization, and depression. this can have an adverse effect on the quality of care.11 mental health problems are also reported to affect the attention, understanding, decision-making, and abilities of health workers.12 many nursing staff has mental health problems, because they not only carry a work overload, are at high risk of infection and prolonged fatigue. so that it leads to an increased risk of infection, therefore it is very necessary for health workers and makes policies to pay attention to protection factors and a successful adaptation process in the covid19 pandemic conditions for health workers.13 the lack of focus on the mental health of health workers has the potential to disrupt and even turn off health services and will affect the handling of the covid-19 pandemic. anxiety is a symptom of early psychological disorders and is still very likely to be overcome. this is what underlies the author to research on the description of nurse anxiety amid of the covid-19 pandemic at the piru hospital. methods this research uses descriptive quantitative with a cross-sectional approach, namely the type of research that is carried out only once or at the same time by looking for variable south east asia nursing research, vol 3 no 2, june 2021/ page 59-65 61 dewi setyawati / nurses' anxiety amid of covid-19 pandemic relationships, where data is collected momentarily, or data is obtained right now. the variable in this study is a univariate variable, namely the anxiety of nurses amid the covid-19 pandemic. the population in this study were 125 people. the sample in this study amounted to 95 people. the cluster random sampling technique was used in determining the number of respondents who would become the research sample, namely nurses who currently work in the piru hospital treatment room, who were willing to become respondents by signing an informed consent which was an inclusion criterion. this research was conducted at the piru hospital in december-march 2021. this research has been approved by the ethics committee of the university of muhammadiyah semarang with no. 098/unimus.g2/ep.pm.lj/2021 and considers the principles of research. the data collection procedure used a questionnaire. the questionnaire for the anxiety variable uses the hamilton rating scale for anxiety (hrs-a) which is the standard in measuring anxiety, especially in trial clinic research. the hrs-a scale has been proven to have high enough validity and reliability to measure anxiety levels in trial clinic research, namely 0.93 and 0.97. the research has received permission from the research agency by paying attention to ethics in research such as beneficence, respecting human opinions and getting justice. before the respondent filled out the questionnaire, informed consent was first explained. so the respondent has the right to choose whether he is willing to be a respondent or not. after the questionnaires were collected, data processing was carried out. the steps in the data processing process include editing, coding, tabulating, and data entry. data analysis in this study used univariate analysis with spss. using chi square statistical test. result the results of this study are presented in the form of a table consisting of the characteristics of the respondents and the level of anxiety of the univariate test results. based on table 1, the characteristics of respondents 76 (80%) are female, 72 (75,8%) are in the 26–35-year age group. 56 (58,9%) respondents are unmarried. in the workplace, most respondents are meranti as many as 16 people (16,8%) and for the number of children, most of them do not have children 63 (66,3%). tabel 1 the frequency distribution of respondent characteristics at piru hospital, march 2021 (n=95) indicators f % gender male female 19 76 20,0 80,0 age 26-35 36-45 46-55 72 23 75,8 24,2 work place emergency room comprehensive emergency neonatal obstetric service meranti agatis gupasa makila kid’s room makila class lenggua zikki covid isolation 11 7 16 10 7 7 8 9 9 11 11,6 7,4 16,8 10,5 7,4 7,4 8,4 9,5 9,5 11,6 marital status married single 39 56 41,1 58,9 number of children no children less than 2 children or equal more than 2 children or equal 63 24 8 66,3 25,3 8,4 based on table 2, it is found that the characteristics of respondents at most do not experience anxiety by 95,8%, and moderate anxiety by 2 people (2,1%). south east asia nursing research, vol 3 no 2, june 2021/ page 59-65 62 dewi setyawati / nurses' anxiety amid of covid-19 pandemic table 2 the frequency distribution of respondents' anxiety levels based on the hrs-a questionnaire, march 2021 at piru hospital (n= 95) indicators f % no anxiety 91 95,8 mild anxiety 1 1,1 moderate anxiety 2 2,1 severe anxiety 1 1,1 discussion another research that supports is yulia dewi (2018) states that as they age, there is a tendency for their anxiety to decrease at work, those who have a lot of work experience are better able to control their emotions and control the situation when interacting directly with patients. so that older people will be able to manage stress management well. the analysis of this study shows that the majority do not experience anxiety because respondents can manage stress management well and the more mature a person is, the more mature they are in thinking rationally and more adaptable to the environment, but there are still respondents who experience moderate anxiety, 2 respondents are supported by kozier (2011). mild anxiety creates a state of mild arousal that enhances perceptual, learning, and productive abilities. most individuals who experience mild anxiety may be healthy as a mild feeling of anxiety that prompts a person to seek information and ask questions. from the results of the univariate analysis, it was found that the characteristics of respondents based on gender were more female than male. this research analysis is because the total sample is dominated by women. this is in line with the research sample conducted by14 involving 170 hospital workers in spain showed that the number of female genders (58,%) was more than male (41,2%). fortinesh said that women are twice as likely to experience anxiety. a study conducted by maryam and kurniawan which stated that the gender factor could significantly affect the patient's level of anxiety, in the study it was also stated that the female gender was more at risk of experiencing anxiety compared to the male gender15. this research16 stated that significantly higher scores in anxiety were found in women. this research is supported by research conducted by the university of calgary in alberta (2011) which states that women are more susceptible to stress due to work than men. according to ramli (2017) said that women have high levels of anxiety due to excessive autonomic nervous reactions. in addition, in women there is a change in hormone secretion, especially estrogen which affects anxiety. the imbalance of estrogen hormone levels in women causes the emergence of effects on women which include cognitive and emotional 17. analysis of this study women is more susceptible to stress due to hormonal changes. supported by videbeck (2018) suggests that women and men have different levels of anxiety where women are more easily offended, very sensitive, and highlight their feelings, while men have masculine characteristics that tend to be dominant, active, more rational, and don't accentuate their feelings. based on the results of the study, it was found that 39 (41,1%) marriages were married. based on purqoti's research (2017), married individuals will have a more adaptive adaptation response to stressors than unmarried individuals. according to heriyanto (2011), people who are married have a life partner whose mental condition is relatively stable when compared to those who are not married. analysis of this research respondent who is not married and married have an adaptive response. based on the results of this study, it was found that 63 respondents (66,3%) had less than two children, 24 (25,3%), and had more than two children, 8 respondents (8,4%). likewise, the study of chang et al, 2020 stated that 12 (18,5%) symptoms of south east asia nursing research, vol 3 no 2, june 2021/ page 59-65 63 dewi setyawati / nurses' anxiety amid of covid-19 pandemic anxiety and depression during this pandemic were due to having babies. in contrast to this study, most of them did not experience anxiety. in the analysis of this study respondents did not experience anxiety because they had good knowledge about covid transmission and prevention. because parental anxiety during the pandemic could be due to parental ignorance about covid 19. based on the results of this study, it was found that nurses working in the treatment room were not evenly distributed. in the emergency room, there are 11 nurses (11,6%), in the comprehensive emergency neonatal obstetric service there are 7 nurses (7,4%) meranti there are 16 nurses (16,8%), agatis there are 10 nurses (10,5%), gupasa there are 7 nurses (7,4%), makila kid’s room there are 7 nurses (7.4%), makila class there are 8 nurses (8,9%), lenggua there are 9 nurses (9,5%), zikki there are 9 nurses (9,5%), and the isolation of covid there are 11 nurses (11,6%). the selection of nurses who work in each room is usually based on hospital policy. room rotation is almost 5 months or once a year rotation. the analysis of this study reduces work anxiety and stress due to frequent room rotation and environmental changes that reduce boredom. other research explained that 69 nurses from 80 nurses in the rspg inpatient room experienced a moderate level of work stress with a working period of 6 months to 3 years as much as 50%. mahastuti et al (2017) in the difference in work stress in the emergency room with nurses at the "s" hospital inpatient in denpasar city in 2017 explained that 39 nurses (67,2%) who worked in the emergency room and 29 nurses who worked in the emergency department. hospitalization (50%) experienced moderate stress. other research shows that health workers who are on the front line experience moderate to severe stress 10,7% and 12, 4%, respectively.18 furthermore, based on research by liu and liu (2020) it is known that the anxiety level of nurses in the emergency unit is higher than in the isolation room or polyclinic. according to other research that from 180 respondents, the results of respondents who were not anxious were 13 (7.2%), respondents who were at a mild level of anxiety, namely 37 (20.6%), respondents who were at a level of anxiety. moderate, namely 59 (32.8 %), and respondents who are at the level of severe anxiety are 71 (39.4%). based on this research, most nurses experience moderate and severe anxiety, this is due to the covid-19 disease for which there is no cure, causing excessive fear, in addition to the nurses who treat covid-19 patients feel that even though personal protective equipment has been facilitated does not guarantee that they will be free from covid-19 transmission. nurses who do not treat covid-19 patients always feel excessive anxiety and worry because in providing services to patients because nurses have not been provided with the same personal protective equipment facilities as nurses who treat covid-19 patients, and some of these nurses have illnesses. morbid or comorbidities so that from the results of a positive swab examination, nurses experience a dilemma in caring for patients, because apart from the patient and the patient's family, they have not fully implemented the health protocol even though it is repeatedly delivered by the rsud or by nurses, this is what always makes people worry and worried about the spread of covid-19. the anxiety felt by nurses cannot be separated from initial contact with patients.19 this is inversely proportional to the results of research obtained by researchers. it was found that most did not experience anxiety. this difference can occur due to several factors such as internal and external factors. south east asia nursing research, vol 3 no 2, june 2021/ page 59-65 64 dewi setyawati / nurses' anxiety amid of covid-19 pandemic internal factors can be in the form of age, gender, marital status, latest education, and coping mechanisms owned by nurses. meanwhile, external factors can be in the form of excessive work environment demands such as an increase in the number of patients seeking treatment and a shortage of ppe by officers. following other study that two factors influence psychological distress, namely interpersonal factors (personality) and situational factors in the form of physiological, cognitive and social influences.20 hospital management carries out room rotation activities very often to minimize psychological distress. the level of anxiety in this study was categorized into four categories, namely, no anxiety, mild anxiety level, moderate anxiety level, and severe anxiety level. in contrast to the results of the other research regarding health workers who are at risk of experiencing psychological disorders in treating covid-19 patients, the results show that there are 50,4% of respondents have symptoms of depression and 44,6% have symptoms of anxiety due to feeling depressed. a similar study also showed from 13 participants experienced anxiety because protective supplies had not been met when taking action on patients.21,22 in overcoming mental health problems for health workers, it is necessary to intervene by forming a medical team in psychological treatment and applying a health belief model for health workers.22 this research stated that respondents experienced an increase in fear of 79%, anxiety 83%, and depression 38%.23 many health workers must isolate themselves from their family and closest people even though they do not have covid-19, this is a difficult decision and can cause a significant psychological burden on them.12 working in the middle of the media and public that intense duration of a long, massive and perhaps unprecedented in some health workers have additional implications in the trigger psychological effects of negative including emotional disorders, depression, stress, mood low, irritability, panic attacks, phobias, insomnia symptoms, anger, and emotional exhaustion.24 the severity of the covid-19 outbreak influences negative emotions, which can cause sleep disturbances7. and the covid19 pandemic situation causes feelings of anxiety and uncertainty.25 the results of the analysis of this study that nurses in hospitals do not experience anxiety due piru is not a referral hospital covid 19 in maluku also because there are patients with severe complaints, so nurses do not feel anxious. this shows an adaptive response from nurses to pandemic outbreaks in hospitals. in addition, because nurses already have good knowledge about information about preventing covid, how to transmit and how to prevent it. conclusion after conducting the research, it can be concluded that the anxiety of nurses at the piru hospital, west seram district, maluku province 95,8% did not experience anxiety. acknowledgement thank you to those who supported this research, including education and training agency of piru hospital, national and political unity agency which has given permission to conduct research. in addition, the authors would also like to thank the nurses for their participation in this study. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. jawad mj, abbas mm, jawad mj, hassan sm, south east asia nursing research, vol 3 no 2, june 2021/ page 59-65 65 dewi setyawati / nurses' anxiety amid of covid-19 pandemic hadi nr. mental health and psychosocial considerations post covid-19 outbreak. wiad lek. 2021;74:3156–9. 2. huang c, wang y, li x, ren l, zhao j, hu y, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet. 2020;395:497–506. 3. culp wc. coronavirus disease 2019: in-home isolation room construction. a&a pract. 2020;14:e01218. 4. armitage r, nellums lb. protecting health workers’ mental health during covid-19. public health. 2020;185:18. 5. chen q, liang m, li y, guo j, fei d, wang l, et al. mental health care for medical staff in china during the covid-19 outbreak. the lancet psychiatry. 2020;7:e15–6. 6. xiang y-t, zhao y-j, liu z-h, li x-h, zhao n, cheung t, et al. the covid-19 outbreak and psychiatric hospitals in china: managing challenges through mental health service reform. int j biol sci. 2020;16:1741. 7. zhang j, lu h, zeng h, zhang s, du q, jiang t, et al. the differential psychological distress of population affected by the covid-19 pandemic. 2020;49–50. 8. allsopp k, brewin cr, barrett a, williams r, hind d, chitsabesan p, et al. responding to mental health needs after terror attacks. bmj. 2019;366. 9. wu z, mcgoogan jm. characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention. jama. 2020;323:1239–42. 10. mahase e. coronavirus: covid-19 has killed more people than sars and mers combined, despite lower case fatality rate. british medical journal publishing group; 2020. 11. du j, dong l, wang t, yuan c, fu r, zhang l, et al. psychological symptoms among frontline healthcare workers during covid-19 outbreak in wuhan. gen hosp psychiatry. 2020; 12. kang l, li y, hu s, chen m, yang c, yang bx, et al. the mental health of medical workers in wuhan, china dealing with the 2019 novel coronavirus. the lancet psychiatry. 2020; 13. hassannia l, taghizadeh f, moosazadeh m, zarghami m, taghizadeh h, dooki af, et al. anxiety and depression in health workers and general population during covid-19 in iran: a cross-sectional study. neuropsychopharmacol reports. 2021;41:40–9. 14. herrero a, martin s, parra j, diaz t. sleep characteristics in health workers exposed to the covid-19 pandemic. sleep med. 2020;75:388– 94. 15. vellyana d, lestari a, rahmawati a. faktorfaktor yang berhubungan dengan tingkat kecemasan pada pasien preoperative di rs mitra husada pringsewu. j kesehat. 2017;8:108–13. 16. stanton r, to qg, khalesi s, williams sl, alley sj, thwaite tl, et al. depression, anxiety and stress during covid-19: associations with changes in physical activity, sleep, tobacco and alcohol use in australian adults. int j environ res public health. 2020;17:4065. 17. danu vk, ningsih os, suryati y. faktor-faktor yang mempengaruhi kecemasan perawat selama pandemi covid-19 di kabupaten manggarai. j wawasan kesehat. 2021;6:21–31. 18. liu k, chen y, wu d, lin r, wang z, pan l. effects of progressive muscle relaxation on anxiety and sleep quality in patients with covid-19. complement ther clin pract. 2020;39:101132. 19. banna t, gurning m, sahetapy v. t ingkat kecemasan perawat dalam pelayanan kesehatan di masa pandemi covid-19. an idea heal j. 2022;2:15–9. 20. azzahra f. pengaruh resiliensi terhadap distres psikologis pada mahasiswa. j ilm psikol terap. 2017;05:80–96. 21. lai j, ma s, wang y, cai z, hu j, wei n, et al. factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. jama netw open. 2020;3:e203976–e203976. 22. chen b, wang y, yang t, li c, xu c, shen y, et al. mental health among covid-19 survivors and healthcare workers exposed to covid-19 in wuhan, china: a cross-sectional study. authorea prepr. 2020; 23. croll l, kurzweil a, hasanaj l, serrano l, balcer lj, galetta sl. the psychosocial implications of covid-19 for a neurology program in a pandemic epicenter. j neurol sci. 2020;416:117034. 24. brooks s, amlôt r, rubin gj, greenberg n. psychological resilience and post-traumatic growth in disaster-exposed organisations: overview of the literature. bmj mil heal. 2020;166:52–6. 25. tysiąc-miśta m, dziedzic a. the attitudes and professional approaches of dental practitioners during the covid-19 outbreak in poland: a cross-sectional survey. int j environ res public health. 2020;17:4703. risk factors affecting intradialytic hypertension in hemodialysis patients corresponding author: nugroho lazuardi nugroho.lazuardi@unimus.ac.id south east asia nursing research, vol 3 no 4, december 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.4.2021.167-171 original research risk factors affecting intradialytic hypertension in hemodialysis patients heryanto adi nugroho1, nugroho lazuardi1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: submitted: nov 2nd 2021 accepted: dec 11th 2021 published: dec 24th 2021 keywords: intradialytic hypertension; hemodialysis; chronic kidney disease hemodialysis is a ckd therapy that functions as a kidney replacement. the side effect that often occurs when patients undergoing hemodialysis is intradialytic hypertension (hid), namely an increase in systolic blood pressure >10 mmhg during hemodialysis, due to an increase in cardiac output mediated by volume overload, especially in patients with excess body weight and cardiac dilatation. the objective of this research is to determine the risk factors that influence the occurrence of intradialytic hypertension in ckd patients undergoing hemodialysis at tugurejo hospital. risk factors consist of age, duration of hemodialysis, quick blood (blood velocity), ultrafiltration (volume overload), urr. the design used in this research is analytic observational with a cross-sectional approach, the number of respondents is 53 people. the sampling technique used in this research is total sampling. the results showed that age (p-value = < 0.01), duration of hemodialysis (p-value = 0.07), quick blood (p-value = 0.06), ultrafiltration (p-value = 0.04), and urr (p-value = < 0.01) is a protective factor or risk factor for the incidence of intradialytic hypertension. based on the spearman rank test, it is known that p-value > means that there is a relationship between age, ultrafiltration and urr with the blood pressure of patients with chronic kidney failure. age, ultrafiltration, and urr are protective factors or risk factors that influence the incidence of intradialytic hypertension. introduction chronic kidney disease (ckd) is progressive and irreversible kidney damage, which has lasted for 3 months or more, in the form of structural abnormalities of the kidney or impaired kidney function, with or without a decrease in the glomerular filtration rate, characterized by pathological abnormalities or signs of kidney damage, including abnormalities in blood or urine composition, or abnormalities in radiological evaluation, or a decrease in the glomerular filtration rate to less than 60 ml per minute/1.73 m2 with or without renal impairment.1–3 hemodialysis is a ckd therapy that functions as a kidney replacement, performed 2-3 times a week with a duration of 4-5 hours. hemodialysis aims to remove metabolic waste and correct fluid and electrolyte balance disorders. hemodialysis is proven to be effective in removing fluids, electrolytes, and waste from the body's metabolism, thus indirectly extending the patient's life. although hemodialysis is safe and beneficial for patients, it is not without https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.4.2021.167-171&domain=pdf&date_stamp=2021-12-24 south east asia nursing research, vol 3 no 4, december 2021/ page 167-171 168 nugroho lazuardi / risk factors affecting intradialytic hypertension in hemodialysis patients side effects. the side effect that often occurs when patients undergo hemodialysis is intradialytic hypertension.4,5 intradialytic hypertension (hid) is an increase in systolic blood pressure >10 mmhg during hemodialysis. intradialytic hypertension occurs as a result of increased cardiac output mediated by volume overload, especially in overweight and dilated patients. in addition, during the hemodialysis process, endothelial dysfunction can occur which can significantly lead to hemodynamic changes. the process of ultrafiltration, mechanical factors, and pathological hypertension during hemodialysis causes a response in the form of synthesis of humoral factors by endothelial cells that affect blood pressure homeostasis.6–8 the incidence of chronic kidney disease undergoing hemodialysis is increasing every year. the indonesian renal registry in 2018 recorded that there were 66,433 new patients and 132,142 active hemodialysis patients. data on hemodialysis complications that are often the subject of discussion is intradialytic hypertension and is still the most complicated at 38%.9 the results of the preliminary study in december 2020 at the hemodialysis installation of the tugurejo hospital 87 patients were undergoing routine hemodialysis. from 15 hemodialysis patients per shift, on average there are 3-4 patients experiencing intradialytic hypertension. one of the efforts to prevent it is to know the risk factors for intradialytic hypertension. based on patient characteristics and the underlying pathophysiological mechanism: age, duration of hemodialysis, quick blood (qb), ultrafiltration, and urea reduction ratio are associated with the incidence of intradialytic hypertension, but there is still much debate about these factors. methods the design used in this research is analytic observational with a cross-sectional approach, the method is carried out to find correlations between independent variables and dependent variables by approach, observation, or data collection where the measurement of the variable is only done once a time (point time approaches). the population in this study were ckd patients who underwent hemodialysis from july – to august 2021 at the tugurejo hospital, central java province. the sample in this study were 53 respondents using a sampling technique in the form of total sampling. data were analyzed univariately and bivariately (spearmank rank). results the subjects in this study were 53 patients (table.1). most of the respondents' gender is male with a total of 30 people (56.60%). there are slightly more male patients than female patients, this proportion is appropriate with the hemodialysis patient profile found in several other countries. the 2018 indonesian renal registry noted that the number of patients undergoing hemodialysis based on gender was 57% male and 43% female.9 table 1 frequency distribution of respondents based on intradialytic blood pressure characteristics f % gender male female 30 23 56,60 43,40 total 53 100 south east asia nursing research, vol 3 no 4, december 2021/ page 167-171 169 nugroho lazuardi / risk factors affecting intradialytic hypertension in hemodialysis patients table 2 relationship between hemodialysis duration, qb, ultrafiltration, urr on intradialytic hypertension risk factors incidence of intradialytic hypertension p rp (ik 95%) yes (%) no (%) age > 60 < 60 3 (5,7) 18 (34,0) 8 (15,1) 24 (45,3) < 0,01 1,57 (-0,011 0,296) duration > 4.30 < 4.30 18 (34,0) 3 (5,7) 22 (41,5) 10 (29,4) 0,07 1,95 (0,795 1,300) qb > 200 < 200 19 (35,8) 2 (3,8) 31 (58,5) 1 (1,9) 0,06 0,57 (0,355 0,788) ultrafiltration > 2500 < 2500 13 (24,5) 8 (15,1) 17 (32,1) 15 (28,3) 0,04 1,25 (0,406 0,832) urr > 65 < 65 17 (32,1) 4 (9,4) 26 (45,3) 6 (11,3) < 0,01 0,91 (0,5750,949) discussion based on the data obtained (table.2), intradialytic hypertension was found in 21 (39.6%) of the study subjects. this is appropriate with data from the indonesian renal registry, 2018, which states that intradialytic hypertension is still the most complicated, namely 38%.9 furthermore, an analysis was conducted on several factors that may be associated with the incidence of intradialytic hypertension in chronic kidney disease patients undergoing hemodialysis. age the results of the study showed that most of the subjects with intradialytic hypertension were <60 years old. these results differ from those of inrig et al.10 who found that the majority of subjects with intradialytic hypertension were 60 years of age. the results of statistical tests with a 95% confidence level showed that there was a statistically significant relationship between age and the incidence of intradialytic hypertension (p-value: < 0.01). in addition, the prevalence ratio (rp) =1.57 with a 95% confidence interval (-0.011 0.296) can be concluded that age is one of the factors that has a 1.57 chance of experiencing intradialytic hypertension. theoretically, the incidence of hypertension, in general, is more common at a young age because at an advanced age it is associated with comorbid diseases such as heart failure and high drug therapy for hypertension, resulting in many cases of hypotension. if it is associated with the pathophysiological theory of intradialytic hypertension regarding the loss of antihypertensive drugs during the hemodialysis process and the presence of endothelial dysfunction which is common in the elderly, the elderly are more likely to experience intradialytic hypertension.8,11 hemodialysis duration the results of the research analysis showed that more than half of the patients who were respondents in this study were in the group performing hemodialysis for >4.30 hours, namely 18 people (34%). the results of statistical tests with a 95% confidence level showed no statistically significant relationship between the duration of hemodialysis and the incidence of intradialytic hypertension (p-value:0.07). this shows that the duration of south east asia nursing research, vol 3 no 4, december 2021/ page 167-171 170 nugroho lazuardi / risk factors affecting intradialytic hypertension in hemodialysis patients hemodialysis does not affect the incidence of intradialytic hypertension. this is in line with luluk ulya's research (2020) which concluded that there was no relationship between the duration of hemodialysis and the blood pressure of patients with chronic kidney failure in the hemodialization room of rsi pati (p-value :0.624). this shows that a person does not always experience changes in blood pressure after hemodialysis, because other factors can maintain a person's blood pressure, one of which is blood viscosity (blood viscosity). during hemodialysis and after hemodialysis, if proper monitoring is carried out during the fluid withdrawal process, it can maintain blood pressure.12 quick blood (qb) the incidence of intradialytic hypertension mostly had quick blood of more than 200 ml/minute. 19 (35.8) patients, with an average qb of 275 ml/minute. patients with chronic kidney disease stage 5 all had a quick dialytic of 500 ml/minute. the results of the 95% ci statistical test showed that there was no significant relationship between blood velocity and the incidence of intradialytic hypertension (p-value: 0.06). this shows that blood velocity (qb) does not affect the incidence of intradialytic hypertension. ultrafiltration based on fluid withdrawal/ hemodialysis ultrafiltration, 13 (24.5) patients underwent ultrafiltration of more than 2500 ml. the results of statistical tests with a 95% confidence level showed that there was a statistically significant relationship between hemodialysis ultrafiltration and the incidence of intradialytic hypertension (p-value:0.04). in addition, the obtained prevalence ratio (rp) = 1.25 with a 95% confidence interval (0.406-0.832) it can be concluded that ultrafiltration is one of the factors that has a 1.25 chance of experiencing intradialytic hypertension. these results are consistent with the study of inrig et al. who found that patients with intradialytic hypertension are likely to experience chronic volume overload due to a large and unexpected increase in vascular resistance that causes an increase in blood pressure during dialysis. body fluids removed during ultrafiltration affect volume. preload volume preload of the heart that affects blood pressure during hemodialysis. 10,13 urea reduction rate based on the value of renal urea ratio as many as 17 patients with urr >65. the results of statistical tests with a 95% confidence level showed that there was a statistically significant relationship between urr and the incidence of intradialytic hypertension (p-value:>0.01). in addition, the prevalence ratio (rp) = 0.91 with a 95% confidence interval (0.5750.949) can be concluded that urr is one of the factors that has a 0.2 chance of experiencing intradialytic hypertension. contrary to the results. based on the results of this study, most of the subjects with intradialytic hypertension had a urr of 65%.8 the urr was used to evaluate the adequacy of hemodialysis which was known to be associated with cardiovascular complications. the minimum target urr according to the nkf k/doqi standard for hemodialysis less than 5 hours is 65%. the condition of uremia in ckd patients on hemodialysis is related to volume overload and abnormal calcium and phosphate metabolism. based on the hypothesis test with 95% ci, it can be concluded that age, ultrafiltration, and urr are protective factors or risk factors that influence the incidence of intradialytic hypertension. this is due to the fulfillment of statistical test values (p-value) and clinical trials (prevalence ratio and confidence level). weaknesses of this research include the methodology used to collect data, namely south east asia nursing research, vol 3 no 4, december 2021/ page 167-171 171 nugroho lazuardi / risk factors affecting intradialytic hypertension in hemodialysis patients analytical observation with a crosssectional approach. the research will be more optimal if observations are carried out regularly. in addition, researchers have not controlled for other variables that can affect the incidence of intradialytic hypertension such as cardiac dilatation, serum catecholamine levels, serum renin, serum electrolytes, and dry body weight due to limited funds. research with a larger number of samples and a better research design is expected to complete this research. conclusion based on the results of the study, intradialytic hypertension was found in 21 (39.6%) of the study subjects. based on the hypothesis test with 95% ci, it was concluded that age, ultrafiltration, and urr are protective factors or risk factors that influence the incidence of intradialytic hypertension. suggestions for nurses dialysis settings can be seen from various factors such as age, speed of dialysis, ultrafiltration, duration of hemodialysis, the right urr for each patient can provide comfort and reduce intradialytic complications. acknowledgment the researcher would like to say thank you to all the participated as research respondents. references 1. suharyanto t ma. asuhan keperawatan pada klien dengan gangguan sistem perkemihan. tim, editor. jakarta; 2009. 2. suwitro k. buku ajar ilmu penyakit dalam. iv. setiasi s, alwi i, sudoyo aw sm, editor. jakarta; 2014. 2061–7 p. 3. levey as, coresh j, bolton k, culleton b, harvey ks it et al. k/doqi clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. am j kidney dis. 2002;39:s1–266. 4. hidayati wahyu. metode perawatan pasien gangguan sistem perkemihan : aplikasi konsep orem “ self care defisit” dan studi kasus. jakarta: kencana; 2013. 5. lazuardi n. pengaruh intervensi support group terhadap kualitas hidup pasien penyakit ginjal kronis yang menjalani hemodialisa. 2016;1–80. 6. armiyati y. hipotensi dan hipertensi intradialisis pada hemodialisis di yogyakarta. 2010;1–9. 7. ferdinan d, suwito j, padoli. faktor-faktor yang mempengaruhi hipertensi intradialitik pada klien gagal ginjal kronik yang menjalani terapi hemodialisis di rsi jemursari surabaya. j keperawatan. 2019;xii:30–9. 8. naysilla a, partiningrum d. faktor risiko hipertensi intradialitik pasien penyakit ginjal kronik. j kedokt diponegoro. 2012;1:115925. 9. pernefri. 11th report of indonesian renal registry 2018. indones ren regist. 2018;1–46. 10. liani na. hubungan penambahan berat badan interdialisis dengan hipertensi intradialisis pada pasien penyakit ginjal kronik yang menjalani hemodialisis di rsd dr. soebandi. skripsi prodi pendidik dr univ jember. 2016; 11. tajili r, ridwan a, garina l. faktor-faktor risiko hipertensi intrahemodialisis pada pasien gagal ginjal kronis stadium 5 di rsud al-ihsan bandung. 2020;510–5. 12. ulya l, krisbiantoro p, hartinah d, karyati s. hubungan durasi hemodialisa dengan tekanan darah pasien gagal ginjal kronik di ruang hemodialisa rsi pati. indonesia jurnal perawat. 2020. 13. nuriya nuriya. effect ultrafiltration rate on blood pressure chronik kidney disease patient during hemodyalisis: a literature review. 2019;1:77–8. the correlation between nurses’ knowledge regarding patient safety and nurses’ behaviors in drug management corresponding author: anita rachmawati anitarachmawati85@yahoo.com south east asia nursing research, vol 3 no 2, june 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.2.2021.51-58 original research the correlation between nurses’ knowledge regarding patient safety and nurses’ behaviors in drug management anita rachmawati1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: submit may 26th, 2021 accepted june 9th, 2021 published june 23rd 2021 keywords: behaviors; drug management; knowledge; patient safety nurses’ knowledge regarding patient safety affects nurses’ behaviors in managing drugs related to patient safety. a preliminary study at sultan agung islamic hospital semarang showed that nurses’ knowledge regarding patient safety was still low, especially about drug management, including storing, ordering/prescribing and recording, administering, and monitoring drugs. this study aimed to determine the correlation between nurses’ knowledge regarding patient safety and nurses’ behaviors in drug management among nurses in the inpatient units of sultan agung islamic hospital, semarang. this research was an observational study with a crosssectional design. the population was 178 nurses in the inpatient units of the specified hospital with a total sample of 123 respondents. the data were collected using a questionnaire and analyzed using spearman’s rank correlation test. the results showed a correlation between nurses’ knowledge regarding patient safety and nurses’ behaviors in storing drugs (p=0.001 <ά=0.05), ordering and recording drugs (p=0.000 <ά=0.05), administering drugs (p=0.001 <ά=0.05), and monitoring drugs (p=0.003 <ά=0.05). it is expected that nurses evaluate the drug management implementation in the inpatient units so that patient safety is guaranteed as well as plan and manage their behaviors in managing drugs in the hospital to ensure patient safety. introduction safety has become a global issue, including for hospitals. there are five important issues related to safety in hospitals, including patient safety, worker or health worker safety, building and equipment safety that affects patient and staff safety, environmental safety (green productivity) that affects environmental pollution, and hospital business safety that is related to the hospital survival.1 implementing patient safety in hospitals is expected to minimize errors in handling patients in emergency units, inpatient units, and polyclinics.4 this target can be achieved by providing excellent services based on nursing codes of ethics to maintain patient safety; all of which should be carried out by health workers.2,3 health services are provided to save patients according to what hippocrates stated 2,400 years ago, i.e., primum, non nocere (first, do no harm). however, along with the development of science and https://doi.org/10.26714/seanr.3.2.2021.51-58 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.2.2021.51-58&domain=pdf&date_stamp=2021-06-23 south east asia nursing research, vol 3 no 2, june 2021/ page 51-58 52 anita rachmawati / the correlation between nurses’ knowledge regarding patient safety and nurses’ behaviors in drug management technology, it is realized that health services, especially in hospitals, are becoming complex and have the potential for adverse events if not delivered carefully. adverse events in hospitals can occur due to errors in administering drugs. there are hundreds of types of drugs, tests and procedures, tools with different technologies, and diverse professions and non-profession workers who are ready to provide 24-hour patient care. if not appropriately managed, the diversity and regularity of these services can lead to adverse events.4 a study by auburn university in 36 hospitals and nursing homes in colorado and georgia, usa in 2002 showed that out of 3,216 types of drug administration, 43% were given at the wrong time, 30% were not given, 17% were given with a wrong dose, and 4% were given with wrong drugs. a study by the institute of medicine in 1999 also stated that medical errors had caused more than one million injuries and 98,000 deaths a year. the data obtained by jcaho also showed that 44,000 and 98,000 deaths occur in hospitals each year due to medical errors. a report by the institute of medicine, usa, in 2000, “to err is human: building a safer health system,” followed by who data in 2004 from various countries, reported that there were 3-16% of adverse events in the provision of services to inpatients in hospitals. such a statistic is relatively small but has a significant impact on patient safety.5,6 data on the report of adverse events in the inpatient units of sultan agung islamic hospital semarang showed that in 2012, there were incidents of medication errors that led to allergies in two patients; one of them died due to this incident. furthermore, in 2013, other incidents of medication errors also occurred in eight patients; six experienced wrong drug administration, and two experienced drug allergies. this statistic showed a significant increase by 200% in the number of medication errors from 2012 to 2013.7 the implementation of the patient safety program in the hospital related to drug management was still suboptimal. in this regards, the problems included the patients dying due to allergies and wrong drug administration, wrong procedures in administering drugs, incorrect writing of prescriptions, and switched drugs between patients in the hospital.5 the results of observations and interviews with 12 nurses from four inpatient units in the hospital where this study too place showed that there were eight nurses (66.6%) who did not understand how to administer the right drugs. problems of drug management in the inpatient units included problems of storing drugs. there were the look-alike sound-alike (lasa) drugs in the inpatient units, but the placement was not separated. this situation can lead to errors in taking medicine. problems with ordering and recording drugs in the inpatient units were associated with unclear or unreadable doctor’s writing, making it difficult for nurses and pharmacists to immediately serve the patients’ drugs since they had to reconfirm with the doctor who wrote the prescription. problems in administering drugs in the inpatient units were related to nurses who did not wash their hands and re-identify patients before giving drugs, as well as administering wrong medication to other patients. meanwhile, problems in monitoring drugs in the inpatient units were associated with nurses who did not conduct initial assessments related to allergies that might occur in patients after the patients took medication, and if allergies occurred, the nurses just knew it after the patients and families reported the incidents regarding drug allergies.8 methods this research was a quantitative and observational study with a cross-sectional approach. it was conducted to determine the correlation between nurses’ knowledge regarding patient safety and nurses’ south east asia nursing research, vol 3 no 2, june 2021/ page 51-58 53 anita rachmawati / the correlation between nurses’ knowledge regarding patient safety and nurses’ behaviors in drug management behaviors in storing, ordering and recording, administering, and monitoring drugs.9 this study involved 123 nurses in inpatient units who met the inclusion and exclusion criteria. the exclusion criteria included: (a) nurses who were resting due to sickness and were unable to be involved in data collection, and (b) nurses who were on maternity leave. this study was conducted in the inpatient units of sultan agung islamic hospital semarang. the study was conducted in may 2014 for two weeks (the first to the second week). the data were collected by using a selfadministered questionnaire. the validity of the instrument was tested using content validity and construct validity. the reliability in this study was carried out using one shot or one measurement. bivariate analysis was carried out on two variables that were suspected to be correlated.10 the correlation test was conducted by ensuring whether the data had a normal or abnormal distribution. since the number of samples was more than 50, the kolmogorov–smirnov test was used to examine the data normality.11 the result of the normality test showed a pvalue of 0.000 for nurses’ knowledge regarding patient safety and a p-value of 0.032 and 0.041 for nurses’ behaviors in storing drugs and ordering and recording drugs, respectively. furthermore, nurses’ behavior in administering drugs and monitoring drugs showed a p-value of 0.000 and 0.010, respectively. it could be concluded that the data were abnormally distributed; therefore, the spearman rank correlation was used to determine the correlation between the variables. results this study investigated the correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in drug management in the inpatient units of sultan agung islamic hospital semarang. this study involved 123 nurses from 10 inpatient units in the specified hospital. the hospital where this study took place is an islamic hospital with 302 beds and 178 nurses12. table 1 describes the characteristics of respondents. the mean age was 27.79 years old, the youngest was 22, and the oldest was 55. the median was 26. the average working period was 4.53 years, the longest was 30 years, and the lowest was one year. most nurses obtained d3 of nursing education (87.8%), while the remaining 12.2% obtained a bachelor of nursing education. the majority were female (82.9), and the remaining were male (17.1%). table 2 illustrates the median value of the nurses’ behavior in drug management, including storing (median=27; minmax=16-32), ordering and recording (median=26; min-max=15-32), administering (median=18; min-max=820), and monitoring (median=24; minmax=728). furthermore, the median value of nurses’ knowledge regarding patient safety was 10 (min-max=2-12). the correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in storing drugs in the inpatient unit table 3 shows a correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in storing drugs in the inpatient units. the correlation coefficient of the spearman test was 0.304, showing a moderate and positive correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in storing drugs; the better the nurses’ knowledge, the better their behavior in storing drugs. the correlation between nurses’ knowledge regarding patient safety and nurses’ behaviors in ordering and recording drugs in the inpatient unit table 4 shows a correlation between nurses’ knowledge regarding patient safety south east asia nursing research, vol 3 no 2, june 2021/ page 51-58 54 anita rachmawati / the correlation between nurses’ knowledge regarding patient safety and nurses’ behaviors in drug management and nurses’ behavior in ordering and recording drugs in the inpatient unit. the correlation coefficient value of the spearman test was 0.436, indicating that the correlation was moderate and positive. it means that the better the nurses’ knowledge regarding patient safety, the better their behavior in ordering and recording drugs. the correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in administering drugs in the inpatient unit table 5 shows a correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in administering drugs in the inpatient unit. the correlation coefficient value of the spearman rank test was 0.288, indicating that the correlation was weak and positive. it implies that the better the nurses’ knowledge regarding patient safety, the better their behavior in administering drugs. the correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in monitoring drugs in the inpatient unit table 6 shows a correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in monitoring drugs in the inpatient unit. the correlation coefficient value of the spearman rank test was 0.270, which means that the correlation was weak and positive. it implies that the better the nurses’ knowledge regarding patient safety, the better their behavior in monitoring drugs. table 1 characteristics of respondents (n=123) characteristics f % mean ± sd (min-max) age 27.79 ± 3.88 (22-55) length of work 4.53 ± 3.50 (1-30) gender male female 21 102 17.1 82.9 education d3 s1 108 15 87.8 12.2 table 2 characteristics of variables (n=123) variable mean ± sd median modus min-max storing 26.72 ± 4.193 27.00 32.00 16 32 ordering 26.45 ± 3.978 26.00 31.00 15 32 administering 17.44 ± 2.63 18.00 20.00 8 20 monitoring 24.22 ± 3.599 24.00 28.00 7 28 knowledge 10.08 ± 1.528 10.00 10.00 2 12 table 3 the correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in storing drugs r-count z-count p-value 0.304 3.36 0.001 south east asia nursing research, vol 3 no 2, june 2021/ page 51-58 55 anita rachmawati / the correlation between nurses’ knowledge regarding patient safety and nurses’ behaviors in drug management table 4 the correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in ordering and recording drugs r-count z-count p-value 0.436 4.82 0.000 table 5 the correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in administering drugs r-count z-count p-value 0.288 3.18 0.001 table 6 the correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in monitoring drugs r-count z-count p-value 0.270 2.98 0.003 discussion the correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in storing drugs in the inpatient unit the result of the study showed that the correlation coefficient value of the spearman rank test was 0.304, which means that there was a moderate and positive correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in storing drugs in the inpatient unit. it means that the better the nurses’ knowledge regarding patient safety, the better their behavior in storing drugs. the nurses’ behavior regarding patient safety programs is determined by their knowledge, attitudes, beliefs, and traditions. also, the availability of facilities, attitudes, and behaviors of health workers will support and reinforce the formation of specified behaviors. nurses who do not want to implement patient safety maybe because they do not know the benefits of the patient safety program for themselves (predisposing factors). other reasons are probably because the facilities are not available and the equipment is incomplete (enabling factors), and that health workers or other community leaders around them have never provided examples/counseling about patient safety programs (reinforcing factors).8 nurses who have good knowledge regarding patient safety will demonstrate good behavior in storing drugs so that the implementation of the patient safety program in the hospital can be achieved. the result of the study regarding nurses' behavior in storing drugs in the inpatient unit showed that 113 (91.9%) nurses always checked the names of similar types of drugs every day in the inpatient units. this is in line with the standard operating procedure (sop) in the hospital, which states that the pharmacy officers provide the “look-alike sound-alike (lasa)” label on the drug container or package by making the drug name with a dose of more than one type in all pharmaceutical centers visible. the result of the study also showed that 48 (39%) nurses always checked the completeness of the types of emergency drugs in the inpatient unit. this is in line with the sop in the hospital in this study. pharmacy officers, nurses, and midwives south east asia nursing research, vol 3 no 2, june 2021/ page 51-58 56 anita rachmawati / the correlation between nurses’ knowledge regarding patient safety and nurses’ behaviors in drug management increase their awareness of specially labeled drugs that will be given to patients. the correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in ordering and recording drugs in inpatient unit the results of this study showed that the spearman test’s correlation coefficient value was 0.436, which means that there was a moderate and positive correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in ordering and recording drugs in the inpatient unit. it indicates that the better the nurses’ knowledge regarding patient safety, the better their behavior in ordering and recording drugs. the selection of drugs for patient treatment requires specific knowledge and experience. each hospital is responsible for identifying knowledgeable and experienced persons according to the required standards and are also permitted under license, certification, statute, or regulation to prescribe or order medication. the hospital can set limits for prescribing or ordering drugs by individuals, such as controlled substances, chemotherapy agents, or radioactive and investigative drugs. the workers who are allowed to prescribe and order drugs are recognized by the pharmacy service or other people that dispense drugs. in emergency situations, the hospital can identify additional personnel who are permitted to prescribe or order drugs.8 nurses with good knowledge will show good behavior in ordering and recording drugs in the hospital. in recording each patient receiving the drug, the medical record will contain a list of the drugs prescribed or ordered for the patient along with the dosage and the number of times the drug is administered, including the ‘if necessary’ drugs. if this information is recorded on a separate medication sheet, this sheet should be inserted in the patient’s medical record when discharged or transferred.8 this study also showed that nurses separated the emergency drug substitutes from doctors after used by patients. this is in accordance with the sop at the hospital, which states that pharmaceutical officers should separate drugs with more than one dosage according to the type of the drug supply. the correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in administering drugs in the inpatient unit the results of this study showed that the spearman test’s correlation coefficient value was 0.288, indicating a weak and positive correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in administering drugs in the inpatient unit. it implies that the better the nurses’ knowledge regarding patient safety, the better their behavior in administering drugs. in managing drugs related to patient safety, nurses need to pay attention to the six correct principles of drug administration. these principles include: (1) the right patient, (2) the right drug, (3) the right dose, (4) the right time, (5) the right route, and (6) the right documentation. such principles are required by nurses as a guideline for their actions as in the inpatient unit, nurses have to give various kinds of drugs to several different patients. the administration of drugs by nurses that considers the six right principles will affect the success of the patients’ treatment and recovery.1 administering drugs to treat a patient requires specific knowledge and experience. each hospital is responsible for identifying any knowledgeable and experienced persons according to the required standards and are also permitted under license, certification, statute, or south east asia nursing research, vol 3 no 2, june 2021/ page 51-58 57 anita rachmawati / the correlation between nurses’ knowledge regarding patient safety and nurses’ behaviors in drug management regulation to administer drugs. the hospital can set limits for prescribing or ordering drugs by individuals, such as controlled substances, chemotherapy agents, or radioactive and investigative drugs. in emergency situations, the hospital can identify any additional personnel who are permitted to administer drugs.8 the result of the study regarding nurses’ behavior in storing drugs in the inpatient unit revealed that nurses always doublechecked the name of the drug between the prescription and the doctor’s instructions every day. this is in line with the sop in the hospital, which states that nurses review the drugs according to the sop. this review includes checking the drugs with the seven correct principles (correct patient, correct drug, correct dose, correct time, correct method of administration, correct documentation, and correct information), ensuring the correctness of the patient and the drug by matching the patient’s name and date of birth, visiting the patient’s room while taking the drug to be delivered, and providing a written information sheet about the drug to the patient. the correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in monitoring drugs in the inpatient unit the result of the study showed that the spearman test’s correlation coefficient value was 0.270, indicating that the correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in monitoring drugs in the inpatient unit was at a weak level. the direction was positive, which means the better the nurses’ knowledge regarding patient safety, the better the nurses’ behavior in monitoring drugs. nurses who have good knowledge will be able to perform the task to evaluate the effect of the treatment on patients’ symptoms or disease, as well as blood count, kidney function, liver function, and other monitoring for selective drugs. nurses will also be able to evaluate patients for adverse events based on monitoring and make an adjustment on the dose or type of drug, if necessary. nurses should closely monitor the patient’s response to the first dose of the drug given to this patient. such monitoring is intended to identify the anticipated therapeutic responses and allergic reactions, unanticipated drug interactions, and changes in patient balance that will increase the risk of falls.8 the results of the study regarding nurses' behavior in storing drugs in the inpatient unit also showed that every time a nurse received a new patient, the nurse did an initial detection of drug side effects in the inpatient room. the nurse provided information and education to the patient and family about drugs causing side effects. the nurse also wrote in the medical record when the side effect of certain drugs occurred in the patient; the nurse recorded the drug side effect in a particular sheet. this is in accordance with the sop in the hospital, which states that nurses open the patients’ records and write on the pharmaceutical care sheet regarding the data related to the therapy (drugs, laboratory data, clinical data, diagnosis, and others). nurses examine the drugs that the patients receive and make an analysis on the appropriateness of the choice of therapy, the effectiveness of the therapy, and the side effects that have occurred or are likely to occur. conclusion this study concluded that there was a correlation between nurses’ knowledge regarding patient safety and nurses’ behavior in storing drugs, ordering and recording drugs, administering drugs, and monitoring drugs in the inpatient units in the hospitals. south east asia nursing research, vol 3 no 2, june 2021/ page 51-58 58 anita rachmawati / the correlation between nurses’ knowledge regarding patient safety and nurses’ behaviors in drug management acknowledgments the researcher would like to say thank you to all the participated as research respondents. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. depkes ri. buku panduan nasional keselamatan pasien rumah sakit. jakarta. 2006. 2. persi, kars, kkp-rs. membangun budaya keselamatan pasien rumah sakit, lokakarya program kp-rs. 17 november 2006. 3. emi, suheimi. etika keperawatan: aplikasi pada praktek. jakarta. egc. 2006. 4. direktorat jenderal bina upaya kesehatan kementerian kesehatan ri dengan komisi akreditasi rumah sakit (kars). standar akreditasi rumah sakit. jakarta. september 2011. 5. kinnenger t & reeder l. estabilishing for technology to reduce medication error is both a science and an art. january 2014. retrieved from http://www.brigmedical.com/media. 6. who. world alliance for patient safety, forward programme. geneva. 2004. 7. rekam medik. laporan tahunan rekam medik rsi sultan agung. semarang. rekam medik. 2012-2013. 8. nine life saving patient safety solution. 3 january 2010. retrieved from http://www.who.int. 9. nursalam. konsep dan penerapan metodologi penelitian ilmu keperawatan, pedoman tesis, skripsi dan instrumen keperawatan. edisi 2. jakarta. salemba. 2011. 10. sugiyono. metode penelitian kuantitatif, kualitatif dan r&d. bandung. alfabeta. 2012. 11. da de vaus, survey in social research, 5th edition (new south wales: allen and unwin, 2002) p. 259. 12. martini. hubungan karakteristik perawat, sikap, beban kerja, ketersediaan fasilitas dengan pendokumentasian asuhan keperawatan di rawat inap bprsud kota salatiga. tesis. semarang: undip. 2007. 13. gibson. 2004. perilaku struktur dan proses. jakarta: binarupa. 14. suhaeni, eni. 2005. sikap bidan puskesmas pasca pelatihan poned terhadap pelayanan emerjensi dasar, kabupaten brebes. (tesis). semarang: undip. http://www/ http://www.who.int/ community stigma on the health care providers during covid-19 pandemic corresponding author: arief yanto arief.yanto@unimus.ac.id south east asia nursing research, vol 3 no 2, june 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.2.2021.66-72 original research community stigma on the health care providers during covid-19 pandemic arief yanto1, muhammad athfal faroby1, tri hartiti1, amin samiasih1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: submitted: mar 6th 2021 accepted: june 1st 2021 published: june 23rd 2021 keywords: stigma; health workers; pandemic; covid-19 stigma can be an obstacle in efforts to prevent, treat and treat covid19 patients. negative stigma can cause psychological problems for health workers during the covid-19 pandemic. stigma is often associated with health problems including covid-19 which is caused by fear and lack of knowledge. this study aims to determine the image of the community's stigma against health workers during the covid-19 pandemic. this study used a quantitative descriptive research design with a survey approach using a questionnaire filled out via google form. sampling was done through convenience sampling. the sample of this study was 138 respondents who met the inclusion criteria. most of the respondents did not give stigma labelling 82.6%, did not give stigma stereotype 81.9%, did not give stigma separation 89.9% and did not give stigma discrimination 77.5% to health workers. the results showed that the community did not give stigma of labelling, stereotype, separation and discrimination to health workers during the covid-19 pandemic. it is hoped that this research can be used as input to prevent the emergence of a negative stigma against health workers during a pandemic. introduction the coronavirus pandemic, well known as covid-19, has been declared as a public health emergency of international concern1 and it also has spread out worldwide. the world health organization (who) has released more than 63,965,092 confirmed cases with a death toll of 1,488,120 cases.2 in indonesia the confirmed covid-19 cases is 549,508 with 17,199 mortality cases.3 however, among all of the provinces, semarang became the highest confirmed cases in central java province, indonesia with a total of 30,217 confirmed cases.4 the increasing number of the daily confirmed cases of covid-19 requires high demand of healthcare workers to take care the patients.5 nurses, midwives and other health workers who dealing with the covid-19 outbreak face new challenges including stigma and discrimination by the community6 such as discrimination and difficulty getting the daily needs.7 similar incidents occurred in other countries including india, the united states and australia where the healthcare workers were threatened, beaten and expelled from their homes.5 in indonesia at least 135 healthcare workers who experienced to be expelled from their homes because of negative stigma, 66 of them said the https://doi.org/10.26714/seanr.3.2.2021.66-72 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.2.2021.66-72&domain=pdf&date_stamp=2021-06-23 south east asia nursing research, vol 3 no 2, june 2021/ page 66-72 67 arief yanto / community stigma on the health care providers during covid-19 pandemic expulsion was accompanied by threats.8 the previous study defined that there were 140 covid-19 nurses had experienced being humiliated by community.9 stigma is a degrading distinction that is socially considered discredited, and associated with various negative stereotypes.10 it can be formed as social rejection, gossip, physical violence and denial of service.11 stigma can be an obstacle in efforts to prevent, treat and care of the covid-19 patient.12 the dangers of stigma can encourage people to hide the disease to avoid discrimination, prevent people from seeking immediate care and prevent them from adopting healthy behaviors.13 the indonesian ministry of health revealed that the stigma and negative stereotypes given by individuals or community groups to health workers or covid-19 patients contribute to the high death rate from the coronavirus.14 consequently, it will only aggravate the mental health condition and disease itself.15 community stigma that subjected to nurses can cause psychological distress because of discrimination.6 psychological distress and depression decreasing the immune system of health workers16 which contribute to fatal condition on the nurses health, and it affecting their nursing care delivery in hospitals. lack of knowledge among community and excessive fear about covid-19 transmission is one of the risk factors for stigma to healthcare workers.17 people tend to fear with the unknown things and more easily connect fear to different community.18 nurses and other healthcare providers working in hospital are included in the high risk group of covid-19 exposure because they contact with covid-19 patients directly.19 preliminary studies showed that 40% of commuity desired that health workers should be shunned or avoided during the covid-19 pandemic. it highlighted that many people do stigmatize to the healthcare workers during the covid-19 pandemic. this study aims to find out how the community stigma on the health workers during the covid-19 pandemic. methods this study applied a cross-sectional quantitative descriptive design. measurement of community stigma carried out once to find out the description of the community stigma. the stigma indicators used in this study included: labelling, stereotype, separation and discrimination. a total of 138 semarang residents were recruited in this study by using random sampling from july 2020 to february 2021 with the inclusion criteria included: the participant should be a permanent resident of semarang city with more than 1 year length of stay, have interacted with health workers during the covid-19 pandemic, and capable to complete the google forms. the sample size of this survey was calculated by using the g power 2.1.9.2 application, with 0.95 power and 0.05 errors. previously developed instruments were used to measure community stigma. the questionnaire comprised 16 statement items and it has been confirmed for the validity by using expert tests, and pilot test with a value of r =0.381-0.815. the reliability of the instrument also has confirmed with cronbach’s alpha of 0.894. the questionnaire was distributed by using google form platform and collected directly by researchers and chief of villages. researchers previously have provided explanations about the purpose, benefits, and consequences to all of the respondents before data collection virtually by using the whatsapp application video call. the involvement of respondents in this study was voluntary and without any coercion from researchers. after respondents agreed, respondents were asked to fill out south east asia nursing research, vol 3 no 2, june 2021/ page 66-72 68 arief yanto / community stigma on the health care providers during covid-19 pandemic an informed consent sheet and upload a closeup photo as evidence. researchers have rewarded the respondents with the internet data volume. researchers maintained the confidentiality of respondents by excluding the participants’ names and identities in the research report. this research has been approved by institutional reviewing board (irb) with the following number: 746/ec/kepkrsdk/2021. the data was analyzed by using the spss application version 22. the descriptive statistics was used to analyze the data. the analysis presented an average community stigma score based on the criteria of respondents who have been measured. result the data collection of this study was conducted in gemah village of pedurungan district of semarang city from february 8th to 12th, 2021. a total of 138 respondents with the characteristics included: gender, age and level of education was participated. the results showed majority of the participants were female (61.9%), graduated from with high school and undergraduate education levels and with averagely age range of age of 34.6-38.4 years old. the average labelling scores among respondents was 75.59 (± 12,753), while the non-stigmatizing score ranged from 32 to 100. confidence interval values (95%) can be assumed that community scores in the population were ranged from 73.45 to77.74 years. according to the distribution of respondents' answers about stigma labelling, it showed that respondents more expressed disagree (57.3%) with the statement of "covid-19 is contagious if we talk or close to health workers". respondents' average stereotype scores were 79.51 (± 12,974) with the range score of 50 to 100. confidence interval values (95%) can be predicted that community scores in the population was ranged from 77.13 to 81.50 years. according to participants’ responses, it showed that more respondents stated disagree (52.9%) with the statement of "do not live at home with health workers during the covid-19 pandemic". the average score of participants’ separations was 84.31 (± 12,917) with the score ranged from 40 to 100. confidence interval values (95%) can be predicted that community scores in the population were in the range of 82.14 86.49 years. based on the respondents' answers, it descripted those respondents expressed more disagree (52.9%) with the statement "prohibiting families from associating with health workers during the covid-19 pandemic". discrimination's average score among participants was 75.56 (±15,715) with score ranged from 40 to 100. confidence interval values (95%) assumed the range of community scores in the population were ranged from 72.91 to 78.20 years. according to respondents’ responses, it concluded that more respondents stated disagree (56.5%) with the statement "do not eat together with health workers in the covid-19 pandemic". south east asia nursing research, vol 3 no 2, june 2021/ page 66-72 69 arief yanto / community stigma on the health care providers during covid-19 pandemic tabel 1 distribution of stigma labelling responded by the community to health care workers (n = 138) indicators f % labelling stigma score stereotype stigma score separation stigma score discrimination stigma score gender male 54 39,1 76,4 79,7 82,6 79 female 84 61,9 75 79,1 85,4 73 education level elementary school 1 1 80 95 100 87 junior high school 5 4 76,8 86 93 83 senior high school 54 39 77,1 79,6 84,7 75 diploma 35 25 74,2 79,6 82,7 78 bachelor/undergraduate 40 29 74,3 77,6 83,5 73 post graduate 3 2 78,7 76,7 86,7 69 age teenager (11-19 y/o) 0 0 0 0 0 0 adult (20-60 y/o) 136 98,6 75,5 79,4 84,2 75,7 older adult (>60 tahun) 2 1,4 83 75 90 63,5 discussion characteristics of respondents in the gender categories, majority respondents were female (61.9%) which supported by previous finding that female tend to be more stigmatized male.20 in contrast with the present result, prior study also highlighted that male are more do stigmatization compared to female.21 therefore, the previous evidence showed that gender was not significantly associated with the stigmatization attitudes. female and male have their own individual perceptions. this study found the average age of respondents was 36.55 years old (adult). the finding is in line with prior study mentioned that younger respondents were more stigmatized compared to older adult respondents.20 this is in contrast to other prior studies that older respondents tend to be more stigmatized compared to younger/adult respondents..21 the majority level of education of gemah village residents was senior high school (39.1%). various studies mention that there is a relationship between knowledge and the stigma that community expressed to people living with hiv/aids. respondents with a higher level of education should have a better level of knowledge compared to respondents who have a low level of education. community stigma labelling on the healthcare workers during the covid19 pandemic the current study found that majority of the community labelling to the healthcare workers was un-stigmatized (82.6%). it is in line with earlier study described that most respondents did not stigmatize covid-19 patients and health workers.20 this current finding also illustrated that lower levels of education tend to stigmatize labelling compared to higher levels of education. it is in line with previous study highlighted that people who has lower education levels (elementary and senior high school) have a 2.23 times greater chance of stigmatizing people (healthcare workers as the subjects of this study).22 however, this current study finding is opposite with prior study finding that described no relationship of knowledge level with the community stigma.23 knowledge is very closely related to the participants’ education. lack of knowledge is one of the major factors causing stigma.24 education is a process that purposed to change the people attitudes and behaviors through teaching and training. education south east asia nursing research, vol 3 no 2, june 2021/ page 66-72 70 arief yanto / community stigma on the health care providers during covid-19 pandemic affects the learning process, the higher an education level, the easier receives information. with higher education, a person tends to get information, both from other persons and mass media. the more information that comes in, the more knowledge gained.25 the community stereotype stigma on the healthcare workers during the covid-19 pandemic the current study found majority community expressed un-stigmatized among healthcare workers (81.9%). this is not in line with earlier study that explained majority respondents believed that health workers should have strict restrictions on their freedoms such as being isolated from their communities and families, and conversely only few respondents avoid healthcare workers and fear of being infected with covid-19.26 stereotypes can be formed as positive or negative views. psychologically the development of stereotypes occurs over various human psychiatric processes in this way one chooses attention, views, compresses and categorizes other individuals is very instrumental in building stereotypes against other groups.27 community stigma on the healthcare workers during the covid-19 pandemic among gemah village was classified as a good category. it could be affected by several factors included: the individual factor that is influenced by the level of knowledge of the community itself. moreover, this study showed that there is a significant link between knowledge of covid-19 and stigma against health workers..20 the proportion of people who have enough knowledge is stigmatized than people with less knowledge. previous study suggested that stigma has a high impact on workers' performance.6 stigmatization can affect the healthcare workers’ emotional caring. stigma to healthcare workers is psychologically stressed because of discrimination and exclusion from the community. psychological distress and depression can decrease the immune system of healthcare workers.16 in addition, stigma and also negative stereotypes given by individuals or community to the healthcare workers or covid-19 patients contribute to the high mortality rate due to the coronavirus infection.14 the community separation stigma on the healthcare workers during the covid-19 pandemic the study finding showed that most of participants responded un-stigmatized for the community separation sigma on the healthcare workers (89.9%) to health workers. this is supported by the results of the distribution of respondents' answers that the majority of respondents disagree with the statement prohibiting their families from contacting with the healthcare workers during the covid-19 pandemic. separation can be defined as disassociation between individuals and groups because they have different social characteristics living in the same environment.28 this is opposite with prior study that explained 135 healthcare workers were expelled because of negative stigma, while 160 nurses also claimed to be shunned by surrounding people and 71 nurses felt shunned by family.8 the labelling and stereotype research found a low level of stigmatize (18.1%). this can happen if people are still afraid of contracting the corona virus. fear is a common cause where humans tend to fear with the unknown thing and easier to connect fear to different groups or for that matter healthcare workers. however, over time, the fear of covid-19 decreased due to economic considerations and community boredom.29 gemah village community has a relatively good level of stigma with regard to ease of access to information. it contributes that there is no longer a community that is not informed about covid-19 including south east asia nursing research, vol 3 no 2, june 2021/ page 66-72 71 arief yanto / community stigma on the health care providers during covid-19 pandemic transmission and efforts to prevent covid19. with social media, people can access and get information easily. news related to covid-19 becomes information that turns trending every day at the beginning of the pandemic situation. the onslaught of news and information provided by the government through mass media makes the public accustomed to the covid-19 pandemic. however, the lack of ability to process and filter information about covid19 makes the establishment of negative stigma among community on the healthcare workers.30 the community discrimination stigma on the healthcare workers during the covid-19 pandemic the study found, majority the participants were not expressed their stigmatize to the healthcare workers (77.5%). the current study result result is supported by the respondents’ answer who the majority of respondents answered disagree with the statement of “prohibited to eat together with health workers in the pandemic period”. this is in contrast to the prior finding that described healthcare workers who work in hospitals are discriminated against by hotel staff, they have difficulty getting food and shelter..5 several factors can influence the occurrence of community discrimination to the healthcare workers included: the level of knowledge about covid-19, perceptions about health workers during the covid-19 pandemic, education level, length of work and age.31 furthermore, this study finding also found low percentage stigmatize rated by participants (22.5%). female participants were more practicing stigma than male participants, as the sam result of stigma labelling respectively. likewise, with the respondents’ education level, higher educated respondents also practicing stigma. prior studies have been conducted showing that there is no significant relationship between knowledge and stigmatization attitudes. people tend to have various level of knowledge and different perception of an infected people by some certain diseases. conclusion community stigma on the healthcare workers during the covid-19 pandemic is classified in the mild category. majority of the participants did not practicing stigmatize to the health care workers. it is evidenced by the study findings that the indicator of stigma including labelling, stereotype, separation dan discrimination showed a good result. acknowledgement the researcher would like to say thank you to all the students who participated as research respondents. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. chopra kk, arora vk. covid-19 and social stigma: role of scientific community. indian j tuberc. 2020;67:284–5. 2. satuan tugas penanganan covid-19. tanya jawab | satgas penanganan covid-19. satuan tugas penanganan covid-19. 2020. 3. who. coronavirus disease data report. 2020. 4. gugus tugas percepatan penanganan covid-19 pemkot semarang. dashboard data covid kota semarang. pemerintah kota semarang. 2021. 5. singh r, subedi m. covid-19 and stigma: social discrimination towards frontline healthcare providers and covid-19 recovered patients in nepal. asian j psychiatr. 2020;53:102222. 6. ramaci t, barattucci m, ledda c, rapisarda v. social stigma during covid-19 and its impact on hcws outcomes. sustain. 2020;12:1–13. 7. poudel a. stigma against health workers, patients and area locals continues in covid-19 hotspots. 2020; 8. ihsanuddin. pemerintah sebut 135 tenaga medis diusir karena stigma negatif. 2020; south east asia nursing research, vol 3 no 2, june 2021/ page 66-72 72 arief yanto / community stigma on the health care providers during covid-19 pandemic 9. humasfik. stop stigma pada tenaga medis dan pasien covid-19. 2020. 10. sugiharti, handayani rs, lestary h, mujiati, susyanti al. stigma dan diskriminasi pada anak dengan hiv aids (adha) di sepuluh kabupaten/kota di indonesia. j kesehat reproduksi. 2019;10:153–61. 11. dai nf. stigma masyarakat terhadap pandemi covid-19. stigma masy terhadap pandemi covid-19. 2020;66–73. 12. bagcchi s. stigma during the covid-19 pandemic. lancet infect dis. 2020;20:782. 13. setiawati l, sariti i, tinggi s, kesehatan i, tengah j. stigma dan perilaku masyarakat pada pasien positif covid-19. j gawat darurat. 2020;2:95–100. 14. kemenkes ri. stigma berkontribusi terhadap tingginya angka kematian covid-19. 2020. 15. dinkes bali. mari hentikan stigma negatif terkait covid-19 dinas kesehatan provinsi bali. 2020. 16. rosyanti l, usman rd, hadi i, syahrianti s. kajian teoritis hubungan antara depresi dengan sistem neuroimun. heal inf j penelit. 2017;9:78–97. 17. abudi r, mokodompis y, nurfadias a. stigma terhadap orang positif covid-19. jambura j heal sci res. 2020;2:77–84. 18. who. panduan untuk mencegah dan mengatasi stigma sosial 1 terkait covid-19. who. 2020. p. 1–5. 19. pranita e. pekerja di rumah sakit rentan terinfeksi corona, ahli sarankan ini halaman all kompas.com. kompas. jakarta: kompas.com; 2020. 20. oktaviannoor h, herawati a, hidayah n, martina m, hanafi as. pengetahuan dan stigma masyarakat terhadap pasien covid-19 dan tenaga kesehatan di kota banjarmasin. din kesehat j kebidanan dan keperawatan. 2020;11:98–109. 21. hati k, shaluhiyah z, suryoputro a. stigma masyarakat terhadap odha di kota kupang provinsi ntt. vol. 12, universitas diponegoro semarang. diponegoro; 2017. 22. berek pal, bubu w. hubungan antara umur, jenis kelamin, pendidikan dan pekerjaan dengan stigmatisasi terhadap orang dengan hiv/aids di rsud mgr. gabrielmanek,svd atambua. j sahabat keperawatan. 2019;1:36– 43. 23. garamina hj. hubungan pengetahuan dan sikap masyarakat terhadap stigma penyakit. j aromed unila. 2015;2:326–32. 24. adhikari b, kaehler n, chapman rs, raut s, roche p. factors affecting perceived stigma in leprosy affected persons in western nepal. plos negl trop dis. 2014;8:2–9. 25. budiman, riyanto a. kapita selekta kuesioner : pengetahuan dan sikap dalam penelitian kesehatan. jakarta: salemba medika; 2014. 202 p. 26. taylor s, landry ca, rachor gs, paluszek mm, asmundson gjg. fear and avoidance of healthcare workers: an important, underrecognized form of stigmatization during the covid-19 pandemic sciencedirect. j anxiety disord. 2020;75. 27. murdianto. stereotipe , prasangka dan resistensinya ( studi kasus pada etnis madura dan tionghoa di indonesia ). qalamuna. 2018;10:137–60. 28. kbbi. arti kata pencegahankamus besar bahasa indonesia. kbbi online. 2012. p. 1. 29. aritonang d. ketakutan masyarakat makin menurun di tengah lonjakan kasus covid-19 kompas.id. kompas. 2020. 30. rahman ne, tyas aw, nadhilah a. hubungan pengetahuan tentang covid-19 terhadap sikap stigma masyarakat pada orang yang bersinggungan dengan covid-19. share soc work j. 2021;10:209. 31. paryati t, raksanagara as, afriandi i, kunci k. faktor-faktor yang mempengaruhi stigma dan diskriminasi kepada odha(orang dengan hiv/aids) oleh petugas kesehatan : kajian literatur. pustaka unpad. 2013;1–11. relationship between knowledge and attitude about prevention of diabetes mellitus complications in diabetes mellitus patients corresponding author: henrianto karolus siregar henriantokarolus9219@gmail.com south east asia nursing research, vol 3 no 4, december 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.4.2021.153-159 original research relationship between knowledge and attitude about prevention of diabetes mellitus complications in diabetes mellitus patients henrianto karolus siregar1, khairunnisa batubara2, hanna ester empraninta3, fatima ura pabanne4 1 stikes rs husada jakarta, indonesia 2 akademi keperawatan, kesdam i/bb medan, indonesia 3 akademi keperawatan, kesdam i/bb binjai, indonesia 4 politeknik kaltara, indonesia article info abstract article history: submitted: nov 6th 2021 accepted: dec 14th 2021 published: dec 24th 2021 keywords: knowledge and attitude; complications of diabetes mellitus diabetes mellitus is a chronic disorder characterized by hyperglycemia characterized by defects in insulin secretion, insulin action or both. attitudes of patients regarding complications of diabetes mellitus need to be approached to patients who have diabetes mellitus. the number of people with diabetes mellitus in the world from year to year has increased, this is related to the increasing population, increasing life expectancy, urbanization which changes traditional lifestyles to modern lifestyles, obesity increases and physical activity decreases. knowledge of patients with diabetes mellitus can be interpreted as the result of knowing from patients about their disease, understanding the disease, and understanding prevention, treatment and complications. this study aims to identify the relationship between knowledge and attitudes of patients with diabetes mellitus about complications of diabetes mellitus. this study is descriptive with 105 samples and data collection techniques using convinience sampling. collecting data using a questionnaire that has been validated and reliability using the cronbach alpha test. the results showed that the knowledge of diabetes mellitus patients about complications of diabetes mellitus was categorized as good as many as 83 respondents (79.0%). it can be used as a guideline for carrying out nursing care for patients with diabetes mellitus in order to realize the desired nursing goals and evaluations such as health workers are expected to further increase their role in providing health education about the prevention of complications of diabetes mellitus. introduction diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia that occurs due to abnormalities in insulin secretion, insulin action or both, characterized by carbohydrate and fat metabolism that is relatively insulin deficient.1 according to the world health organization (who), indonesia ranks fourth largest in the number of people with diabetes mellitus with a prevalence of 8.6% of the total population, while the positions above are india, china and the united states and who https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.4.2021.153-159&domain=pdf&date_stamp=2021-12-24 south east asia nursing research, vol 3 no 4, december 2021/ page 153-159 154 henrianto karolus siregar / relationship between knowledge and attitude about prevention of diabetes mellitus complications in diabetes mellitus patients predicts an increase in the number of people with diabetes mellitus in indonesia from 8.4 million in 2000 to around 21.3 million in 2030. it is estimated that the number of people with diabetes mellitus will increase in 2030, namely india (79.4 million), china, united states (30.3 million) and indonesia (21 ,3 million), in 2020 it will be 300 million people and in 2030 it will be 366 million people.2 in indonesia, based on epidemiological research, the prevalence of diabetes mellitus is 1.5-2.3% in the population over 15 years of age, even in urban areas the prevalence of diabetes mellitus is 14.7% and in rural areas is 7.2%. the prevalence increases 2-3 times compared to developed countries, so diabetes mellitus is a serious public health problem, and can occur in the elderly.3 according to the international diabetes foundation (idf) there are 1785 diabetics with complications of neuropathy (63.5%), retinopathy (42%), nephropathy (7.3%), macrovascular (16%), microvascular (6%), wounds. diabetic foot (15%). the number of complications caused, the preventive measures that can be taken by people with diabetes mellitus to prevent complications, namely by controlling blood sugar levels, physical exercise, consumption of antidiabetic drugs, and diabetic foot care are important for people with diabetes mellitus.3 in north sumatra, according to the profile of rsud dr. pirngadi diabetes mellitus is the most common type of disease suffered by patients who make visits to rsud dr. pirngadi medan during january-december 2021 diabetes mellitus was ranked first among the top 10 diseases throughout 2014 at dr. pirngadi medan as many as 1050 patients from 11779 visits. complications of long-term diabetes mellitus include cardiovascular disease (multiple risk), chronic kidney failure (the main cause of dialysis), retinal damage that can cause blindness, and nerve damage that can cause impotence and gangrene with the risk of amputation. more serious complications are more common when blood sugar control is poor.4 diabetes mellitus is mostly a hereditary disease but not an infectious disease. however, this does not mean that the disease must be passed on to children. even though both parents suffer from diabetes mellitus, sometimes none of their children suffer from the disease.5 the morbidity and mortality rate in diabetes mellitus is increasing in various countries, this is associated with a very fast increasing incidence and progression of the disease due to the ignorance of the patient himself, or the patient generally comes with advanced and severe complications. if we look more deeply, it turns out that hyperglycemia is the beginning of a disaster for diabetics, this is proven and also occurs in patients with impaired glucose tolerance who have vascular complications disorders.5 based on the results of these studies, it can be concluded that prevention efforts must begin early, namely when glucose tolerance is disturbed (tgt) or since the discovery of risk factors for diabetes mellitus that can be corrected. efforts to change lifestyles, which include weight loss by reducing calorie intake and increasing physical activity, must always be emphasized given the fairly good success rate, low cost and almost no risk.6 knowledge can be interpreted as the result of knowing that occurs after someone senses a certain object. knowledge of diabetes mellitus patients can be interpreted as the result of knowing from patients about their disease, understanding their disease, and understanding prevention, treatment and complications.7 knowledge itself is influenced by formal education factors. knowledge is very closely south east asia nursing research, vol 3 no 4, december 2021/ page 153-159 155 henrianto karolus siregar / relationship between knowledge and attitude about prevention of diabetes mellitus complications in diabetes mellitus patients related to education, where it is hoped that with higher education, the person will have wider knowledge. a person's knowledge of an object contains two aspects, namely positive aspects and negative aspects.7 the attitude of respondents who are not good is shown by the attitude of respondents who do not support the complications of diabetes mellitus. attitude is a reaction or response that is still closed from a person to a stimulus or object. an attitude will not necessarily be manifested in the form of an action. for the realization of the attitude to become a real action, a supporting factor or a possible condition is needed, including facilities.8 a person with diabetes mellitus who has intended to eat according to the meal plan that he has made himself, sometimes gets out of line because the situation at home or work is not supportive. if all positive behaviors have been implemented, of course, the diabetes mellitus sufferer can be included in the group of diabetes mellitus sufferers with high compliance.9 as a result of compliance is controlled diabetes. this study aims to examine the knowledge of diabetes mellitus patients about complications of diabetes mellitus at dr. pirngadi hospital medan methods this type of research is descriptive research which aims to identify the relationship between knowledge and attitudes of patients with diabetes mellitus about complications of diabetes mellitus in rsud dr. pirngadi medan. this research was conducted in rsud dr. pirngadi medan in 2021. the number of samples in this study was 105 people. the sampling technique used is convinience sampling. this method is a way of determining the sample by looking for subjects on the basis of things that please or please the researcher. the inclusion criteria for the sample in this study were patients with diabetes mellitus who were treated as outpatients and inpatients, were willing to be respondents who could read and write indonesian. the validity test in this study was carried out with content validity. this validity has been consulted with 3 expert lecturers who are competent at the faculty of nursing, university of north sumatra. the instrument is declared valid if the content validity index is 0.8 or more. the instrument validity value is 0.88. the results of the reliability of this research instrument using cronbach alpha is 0.911. prior to data collection, the ethical permit was approved by the ethics commission of the faculty of nursing, university of north sumatra. researchers gave informed consent to respondents before being studied. researchers require participants to sign an informed consent and explain the purpose of the study and the benefits of the research for respondents. results from the research that has been done, the results obtained about the characteristics of the respondents consist of: age, duration of suffering from diabetes mellitus, gender, education level, occupation. in table 5.1 it can be seen that the majority of respondents aged 56-65 years were 59 people (56.2%), respondents had long suffered from diabetes mellitus 0-6 years were 41 people (39.0%), respondents were male as many as 60 people (57.1%), respondents with high school education as many as 47 people (44.8%), respondents having jobs as retired civil servants as many as 43 people (41.0%). the table above shows that of 105 respondents who have good knowledge of complications of diabetes mellitus as many as 83 people (79.0%). the table above shows that out of 105 respondents who had a positive attitude towards complications of diabetes mellitus, 83 people (79.0%). south east asia nursing research, vol 3 no 4, december 2021/ page 153-159 156 henrianto karolus siregar / relationship between knowledge and attitude about prevention of diabetes mellitus complications in diabetes mellitus patients table 1 distribution and frequency of respondent characteristics, knowledge and attitude of diabetes mellitus patients about complications of diabetes mellitus (n=105) indicators f % age 36-45 46-55 56-65 66-86 7 11 59 28 6.7 10.5 56.2 26.7 long suffering from diabetes mellitus 6 age 7-12 age 41 32 39.0 30.5 13-18 age 19-24 age 25-30 age 31-36 age 14 9 8 1 13.3 8.6 7.6 1.0 gender man woman 60 45 57.1 42.9 level of education primary school junior high school senior high school college 4 17 47 37 3.8 16.2 44.8 35.2 work government employees entrepreneur retired civil servants housewife 14 25 43 23 13.3 23.8 41.0 21.9 knowledge good enough not enough 83 19 3 79.0 18.1 2.9 attitude good not enough 83 19 79.0 18.1 discussion knowledge of diabetes mellitus patient based on the results of research conducted at rsud dr. pirngadi medan has good knowledge. these results indicate that the majority of patients with diabetes mellitus have diabetes mellitus complications in rsud dr. pirngadi medan already has good knowledge with respondents aged 56-65 years so that the older they are, the level of maturity and strength of a person will be more mature in thinking and working.7 the results of masniari research say that age is one of the most important characteristics of people. age has a relationship with the level of exposure, the magnitude of the risk and the nature of resistance. differences in experience with health problems/diseases and decision making are influenced by the age of the individual. the older a person is, the more mature his mental development will be and it will also affect the knowledge he gains.8 based on the respondent's education is high school and college so that education can affect a person, including a person's behavior will pattern of life, especially in motivating to participate in development, in general, the higher a person's education, the easier it is to receive information. knowledge is very closely related to south east asia nursing research, vol 3 no 4, december 2021/ page 153-159 157 henrianto karolus siregar / relationship between knowledge and attitude about prevention of diabetes mellitus complications in diabetes mellitus patients education, where it is hoped that with higher education, the person will have wider knowledge.7 the level of knowledge can be influenced by two factors, namely internal factors and external factors. internal factors are education, occupation, and age. external factors are the environment, and sociocultural.10 based on the occupation of the respondent is a retired civil servant so that the ability and understanding of diabetes mellitus knowledge about complications of diabetes mellitus is good. according to respondent 1 that statements about complications of diabetes mellitus do not know, namely diabetes can cause blood to become thick if blood sugar levels are high, diabetes can cause damage to blood vessels, diabetes can cause skin conditions to become dry and easy to blister, diabetes can cause skin problems. cause stress, diabetes can cause depression.11 based on this statement, the respondent did not know that the above statement was a complication of diabetes mellitus because the respondent did not experience this complication. these results indicate that the respondent's education is high school, the age of the respondent is 74 years old and has suffered from diabetes mellitus for 17 years.9 according to respondent 2 that the statement about complications of diabetes mellitus did not know to answer all the statements because the respondent's length of suffering from diabetes mellitus was still 1 month. according to respondent 7 that the statement about complications of diabetes mellitus did not know the answer to all the statements because the respondent's length of suffering from diabetes mellitus was still 1 month, the respondent's education was junior high school, the respondent's job was as a housemaid.3 these results indicate that the respondent does not know the statement regarding complications of diabetes mellitus and the level of knowledge is very closely related to education, where it is expected that with higher education, the person will have wider knowledge.11 according to respondent 42 that the statement about complications of diabetes mellitus did not know the answer to all the statements because the duration of suffering from diabetes was still 2 months, the respondent's education was high school, and the respondent's occupation was selfemployed. this shows that the respondents did not know that the statement was about complications of diabetes mellitus and had never experienced these complications.8 according to respondent 45 that the statement about complications of diabetes mellitus did not know the answer to all the statements because the respondent's length of suffering was still 6 months, the respondent's education was junior high school, and the respondent's occupation was self-employed. this is influenced by the education level of the respondent is junior high school so that the level of knowledge about complications of diabetes mellitus still has less knowledge. where education can affect a person, including a person's behavior regarding lifestyle, especially in motivating to participate in maintaining health.9 according to respondents 53 that statements about complications of diabetes mellitus do not know the answer to statements about diabetes can result in a decrease in blood sugar levels at a dangerous level, diabetes can cause falls/injury if blood sugar levels are very high.3 diabetes can cause blood to become thick if blood sugar levels are high, diabetes can cause blockage of the heart arteries, diabetes can cause heart pumping failure (heart failure), diabetes can cause foot south east asia nursing research, vol 3 no 4, december 2021/ page 153-159 158 henrianto karolus siregar / relationship between knowledge and attitude about prevention of diabetes mellitus complications in diabetes mellitus patients infections, diabetes can cause sores or abrasions on the hands and feet, diabetes can cause skin conditions to become dry and blister easily.5 these results indicate that the respondent has never experienced these complications, the duration of suffering from diabetes mellitus is still 2 months, education is high school, and the respondent's occupation is self-employed. differences in experience with health problems/diseases and decision making are influenced by age and duration of suffering from diabetes mellitus.6 according to respondent 54 that the statement about complications of diabetes mellitus did not know the answer to all the statements because the duration of suffering from diabetes mellitus was still 1 year, the age of the respondent was 45 years, the respondent's education was junior high school, and the respondent's occupation was self-employed. increased knowledge can be influenced by age, education level, and duration of suffering from diabetes mellitus.11 age has a relationship with the level of exposure, the magnitude of the risk and the nature of resistance. the older a person is, the more mature his mental development will be and it will also affect the knowledge he gains. knowledge is very closely related to education, where it is hoped that with higher education, the person will have wider knowledge.8 according to respondents 63 that statements about complications of diabetes mellitus do not know the answer to statements about diabetes can result in falls/injury if blood sugar levels are very high, diabetes can cause blood to become thick if blood sugar levels are high, diabetes can cause fluid deficiency.5 diabetes can cause blockage of the heart arteries, diabetes can cause heart pumping failure (heart failure), diabetes can damage blood vessels, diabetes can damage the kidneys and cause kidney failure, diabetes can cause tingling in the legs, diabetes can cause numbness in the feet and hands, diabetes can cause infections in the feet, diabetes can cause skin conditions to become dry and easy to blister, diabetes can cause stress and depression.3 these results indicate that the respondent has never experienced these complications, the duration of suffering from diabetes mellitus is 11 years, the respondent's education is junior high school, and the respondent's occupation is self-employed. so that education greatly affects a person, including a person's behavior towards a healthy lifestyle. according to respondent 80 that the statement about complications of diabetes mellitus did not know the answer to all the statements because the respondent's length of suffering was 20 years, the respondent's education was junior high school, and the respondent's occupation was a housewife.9 these results indicate that it is not necessarily long-standing experience of suffering from diabetes mellitus respondents know about the knowledge of complications of diabetes mellitus. so that education greatly affects the level of knowledge of respondents about complications of diabetes mellitus. knowledge is very closely related to education, where it is hoped that with higher education, the person will have wider knowledge.3 patient attitude towards complications of diabetes mellitus an attitude will not necessarily be manifested in the form of an action. for the realization of an attitude to become a real action, a supporting factor or an enabling condition is needed, including facilities. a person with diabetes mellitus who has intended to eat according to the meal plan that he has made himself, sometimes gets out of line because the situation at home or work is not supportive. if all positive south east asia nursing research, vol 3 no 4, december 2021/ page 153-159 159 henrianto karolus siregar / relationship between knowledge and attitude about prevention of diabetes mellitus complications in diabetes mellitus patients behaviors have been implemented, of course, the diabetes mellitus sufferer can be included in the group of diabetes mellitus sufferers with high compliance. as a result of compliance is controlled diabetes. if the patient does not have a positive attitude towards diabetes mellitus, complications will occur and will eventually lead to death. in order to maintain the quality of life and avoid complications from diabetes mellitus, each patient must live a healthy lifestyle, namely living a healthy lifestyle with diabetes mellitus and regular exercise. conclusion based on the results of this study, the knowledge of diabetes mellitus patients about complications of diabetes mellitus already has good knowledge because knowledge is closely related to education, where it is expected that with higher education, the person will have more extensive knowledge. age is one of the most important characteristics of people. age has a relationship with the level of exposure, the magnitude of the risk and the nature of resistance. the older a person is, the more mature his mental development will be and it will also affect the knowledge he gains. so that the education and attitudes of patients with diabetes mellitus can influence a person, including a person's behavior regarding lifestyle, especially in motivating to participate in development, in general, the higher a person's education, the easier it is to receive information. prevention that can be done by people with diabetes mellitus to prevent complications, namely by controlling blood sugar levels, physical exercise, consumption of anti-diabetic drugs, and diabetic foot care are important for people with diabetes mellitus. acknowledgment special thanks to patients, nurse and doctor at rsud dr pirngadi medan. references 1. hinkle jl, cheever kh. brunner and suddarth’s textbook of medical surgical nursing. 14th ed. squazzo k, editor. vol. 1. philadelphia: wolters kluwer; 2018. p. 6112. 2. restada ej. hubungan lama menderita dan komplikasi diabetes melitus dengan kualitas hidup pada penderita diabetes melitus di wilayah puskesmas. j keperawatan. 2016;3(1):5–20. 3. purwanti os. analisis faktor-faktor risiko terjadi ulkus kaki pada pasien diabetes mellitus di rsud dr. moewardi [thesis]. depok: univeritas indonesia. 2013;68. 4. melinda sari t. hubungan tingkat pengetahuan pasien diabetes mellitus dengan tingkat kepatuhan kontrol penyakit diabetes mellitus pada pasien diabetes mellitus di poliklinik rumah sakit islam samarinda. stikes muhammadiyah samarinda. 2016;7. 5. hikmat p. komplikasi kronik dan penyakit penyerita pada diabetes. med care. 2017;1–5. 6. irawan d. prevalensi dan faktor risiko kejadian diabetes melitus tipe 2 di daerah urban indonesia. univ indones. 2010;1–121. 7. notoatmodjo s. promosi kesehatan & perilaku. vol. 1, jakarta: rineka cipta. 2007. 8. masniari c. tingkat pengetahuan dan sikap pasien diabetes melitus terhadap resiko ulkus kaki di poliklinik penyakit dalam rumah sakit umum pusat haji adam malik medan. skripsi univ sumatera utara. 2018; 9. roifah i. analisis hubungan lama menderita diabetes mellitus dengan kualitas hidup penderita diabetes mellitus. j ilmu kesehat. 2017;4(2):7. 10. polit, d.f.,& beck ct. nursing research: generating and assessing evidence for nursing practice 10th edition. wolters kluwer health. 2015. 11. hariani, abd. hady, nuraeni jalil, surya arya putra. hubungan lama menderita dan komplikasi dm terhadap kualitas hidup pasien dm tipe 2 di wilayah puskesmas batua kota makassar. j ilm kesehat diagnosis. 2020;15(1):56–63. thesis camp as an effort to complete the student's final project (tesis) of the unimus nursing master’s degree program during the covid-19 pandemic corresponding author: vivi yosafianti pohan vyp@unimus.ac.id south east asia nursing research, vol 4 no 1, march 2022 issn:2685-032x doi: https://doi.org/10.26714/seanr.4.1.2022.1-6 original research thesis camp as an effort to complete the student's final project (tesis) of the unimus nursing master’s degree program during the covid-19 pandemic vivi yosafianti pohan1 , dera alfiyanti1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: submitted: dec 26th 2021 accepted: march 1st 2022 published: march 29th 2022 keywords: thesis camp; thesis; covid19 pandemic this research is a research and development that aims to develop technical thesis learning by using thesis camp as one of the learning techniques in preparing a thesis proposal for unimus nursing masters students. the technical development of this learning is based on the length of time it takes to complete a thesis proposal experienced by most of the unimus master's nursing students who are preparing a thesis proposal. the results of the survey on students showed that 85% had difficulty in compiling a thesis proposal for various reasons, including difficulty finding the research title, difficulty finding problems, and difficulty managing time because most of the students were already working. this has an impact on the length of the student's study period which affects the discrepancy with the educational calendar. this study was designed to: 1) examine students' understanding in the preparation of a thesis proposal, 2) create a technical prototype for thesis camp learning, 3) test the effectiveness of the thesis camp, and 4) compile a thesis camp guidebook. this research generally uses a research and development approach. the research stages used descriptive qualitative methods in exploratory studies, and development through workshop activities in the context of preparing a camp thesis guide book. during the covid-19 pandemic, it was not possible for students to consult directly with the thesis supervisor, so this thesis camp was carried out with blended learning (70% online learning and 30% learning offline) and while offline still using the covid-19 prevention protocol, consist of here are wearing masks, washing hands, and keeping a distance. thesis camp is proven to be effective in increasing the timeliness of completing thesis writing for nursing master students of unimus. introduction the proposed institutional research is highly relevant based on the university's higher education research roadmap through the institute for research and community service which is developing institutional research, namely research at the study program and faculty level. the research output is in the form of a thesis camp manual which provides a real picture of the steps for completing a thesis and can increase the motivation of master of nursing students in completing their final study project, namely the thesis. this can have an impact on timely graduation which https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.4.1.2022.1-6&domain=pdf&date_stamp=2022-03-29 south east asia nursing research, vol 4 no 1, march 2022/ page 1-6 2 vivi yosafianti pohan / thesis camp as an effort to complete the student's final project (tesis) of the unimus nursing master’s degree program during the covid-19 pandemic affects the accreditation value of study programs, faculties, and universities, and is a form of contribution to the university of muhammadiyah semarang, especially for the nursing masters study program. the covid-19 pandemic has had a significant impact on the world of education. conventional and routine learning that emphasizes the interaction of lecturers and students in the classroom shifts to distance learning. 1 therefore, a strategy is needed so that students can complete the final project on time. methods the research uses a research and development approach. the r&d model in the field of education and learning is a process used to develop and validate educational products, one of which is the thesis learning method through thesis camp activities. the design chosen is an r&d design with modifications. this study uses a research and development method (research and development) theoretical model, namely a model based on theoretical studies and supported by empirical data about learners' language misconceptions. this research was completed by using descriptive methods in an exploratory study in order to obtain initial data that becomes a preliminary study (base line study). the fgd model was used in the framework of compiling a prototype model for the thesis camp guide. the research flow with the research design arranged as follows (scheme 1). the subjects of this research are the supervisors and thesis examiners in the unimus master of nursing study program and students who are preparing a thesis proposal. in this research, several respondents will be selected to represent as research subjects. the selection of supervisors and students as the subject of this research will be carried out purposively. the fgd process will select research subjects who are experts in research and supervisors. the object of this research is a thesis proposal based on thesis camp. the data analysis technique used in this research is descriptive qualitative analysis. the validity of the data achieved was carried out by several methods, namely (1) multiple data collection methods, including methods of observation, interviews, questionnaires, tests, and documentation; (2) multiple data sources, including oral, written, and audiovisual data; (3) diligence and careful observation; and (4) discussion between researchers. 2 scheme 1 research flow identification of problems studies introduction focus grup discussion (fgd) composing of thesis camp guide dissemination of implementation evaluation of thesis proposal construction thesis proposal south east asia nursing research, vol 4 no 1, march 2022/ page 1-6 3 vivi yosafianti pohan / thesis camp as an effort to complete the student's final project (tesis) of the unimus nursing master’s degree program during the covid-19 pandemic result the participants of this research were 8 nursing master students who were preparing a thesis proposal. the age of the participants is in the range of 25 years 48 years, sex is 7 women and 1 man, and 6 participants have worked, and participants are willing to carry out interviews, questionnaires, and forum discussion groups (fgd). interviews lasted for 10-15 minutes, filling out the questionnaire for 15 minutes, and fgd for 30-40 minutes at different times. the data analysis process begins with reading the transcript repeatedly, identifying meaningful participant statements, determining keywords, sub-theme categories, then identifying the sub-themes as the main themes. the themes obtained are described as follows: theme 1: thesis camp activity statement based on the results of interviews and fgd with 8 participants, it was found that the thesis camp activities were very helpful in completing student thesis proposals with various rational opinions, namely: the progress of thesis proposal writing was monitored, there was a clear picture of the steps in making a thesis proposal, the practice was difficult to implement, very helpful students in making a thesis, the progress of thesis work can be controlled and in accordance with the specified target date and can ask directly to the supervisor, time management is more structured and more enthusiastic, and is very helpful in directing the preparation of the thesis.the nursing master's student participants revealed that the thesis camp activities that had been carried out were not optimal or difficult to carry out due to various reasons such as the short duration of the activity so that it was difficult to time management, the response of the supervisor was long, and the difficulty in finding the right reference. writing a master's thesis proposal for nursing students requires collaboration between students and their supervisors, in this case the supervisor sees the progress of students in preparing proposals and reports to the study program about the progress of student proposals. writing a master's thesis proposal for nursing students can be completed if they have good and structured time management as well as high motivation and consistency in writing proposals. 11 theme 2: thesis camp learning techniques the following schematic 3 describes the learning techniques in thesis camp. thesis camp is a learning technique strategy for thesis proposal preparation that has structured guidelines both in terms of time and stages of proposal preparation. the preparation of a thesis proposal through the thesis camp learning method is a learning method that has a target achievement. the preparation of thesis proposals by nursing master students can be realized according to the learning targets, of course, they must have high motivation from nursing master students. scheme 2 thesis camp activity statement category theme sub theme the practice is difficult monitored proposal writing structured time management thesis camp activity theme 1: negative and positive impacts in the preparation of thesis proposals south east asia nursing research, vol 4 no 1, march 2022/ page 1-6 4 vivi yosafianti pohan / thesis camp as an effort to complete the student's final project (tesis) of the unimus nursing master’s degree program during the covid-19 pandemic scheme 3 thesis camp pembelajaran learning techniques discussion the phenomenon that occurs in the preparation of thesis proposals shows that master's students are not optimal in writing thesis proposals as a condition for graduating from master's education. research is an activity of stringing letters into words and words into sentences.5 the writing process is an effort to string ideas, ideas and or thoughts into sentences permanently, can be understood/understood by other parties, can be used to influence the ideas, ideas and or thoughts of others. writing is a creative process, namely an activity that relies on one's (intellectual) thinking ability.10 good writing goes through the process of organizing ideas or ideas as well as existing facts, so that writing can be understood clearly, systematically, and fulfills the stated goals. a written thesis proposal requires skills in processing various reference data that can support and give weight to the proposal design. this study showed that master of nursing students are not ready to draft a thesis proposal which is one indicator of the cause of master students graduating not on time.8 thesis is an academic work compiled as one of the requirements to achieve a master's degree originating from a study under the guidance of one or more lecturers who are responsible for a particular field.3 thesis is a postgraduate student's scientific writing used as a requirement for obtaining a master's degree. researchers (master students) in preparing a thesis need a reference as a source of quality data. one source of information that can be used as reference material in research is scientific magazines or journals. thesis is a scientific paper that is used as a requirement by postgraduate students to obtain a master's degree. the results of the thesis research are expected to find a method or method that is more effective so that its benefits are useful for the public. 9 the development and completion of a thesis is influenced by several factors, such as the quality of supervision by lecturers, time management, and cognitive competence.4 master's degree students must forge scientific thinking skills and the ability to conduct research, and be able to demonstrate the development of their knowledge.6 scientific works that deserve to be published are scientific works that contain novelty, novelty and also scientific contributions. the idea of a scientific research paper in the form of a thesis is obtained through a literature search that becomes a reference. references must come from competent sources, contain an element of novelty, then the themes found can be directly consulted with lecturers in accordance with their fields of knowledge and research questions must be clear and focused. the correct flow of thesis research is to identify problems in general, then conduct a literature search on solutions that have been previously proposed by previous category theme sub theme structured learning techniques learning achievement targets motivation for writing a thesis theme 2: learning techniques for writing a thesis proposal thesis camp south east asia nursing research, vol 4 no 1, march 2022/ page 1-6 5 vivi yosafianti pohan / thesis camp as an effort to complete the student's final project (tesis) of the unimus nursing master’s degree program during the covid-19 pandemic researchers.8 the next step is to identify problem gaps that still require solutions or that have not been resolved or do need to be completed. identification of innovative solutions to problems and scientific explanations is the next step. in formulating the hypothesis, experiments need to be carried out to test the hypothesis, if the hypothesis is proven with positive results, it can be continued with writing a thesis and publication. master's students must also prepare their experimental tools. literature review techniques, experimental tools, research methods designed, and factors that influence the results and how they relate must be well understood and mastered by students of the nursing master's program. the research proposal contains the main problem of a research as well as the steps in solving the problem. the components of the research proposal include background, problem-solving ideas, provisional analysis, and research objectives. the purpose of a master's student research proposal is to get approval from other parties (supervising lecturers and examiners) as experts who are competent to conduct research. the research proposal gives other parties an understanding of the importance of the research and what needs must be met in carrying out the research. the research proposal aims to be able to meet all kinds of needs that support research. these needs can be in the form of permits, places, tools, materials, literature, to financial support. the study program is a unified study plan that is used as a guide for the course of academic education whose implementation is based on a curriculum. the nursing master's program aims for students to master knowledge, skills, and attitudes in accordance with the educational curriculum targets that have been designed, including the study of thesis subjects.7 the study program's efforts in carrying out teaching and learning activities vary greatly in learning methods, one of which is the thesis camp learning method. thesis camp activity is an excellence camp activity to strengthen the knowledge base related to research and understanding to solve problems during thesis preparation.12 thesis camp is a training pattern conducted for unimus nursing masters students to assist the process of writing a thesis proposal. the results of writing a thesis proposal will be continued for writing a final scientific paper for a master of nursing student called a thesis. the training carried out is continuous guidance and mentoring for 2 weeks (12 days), with a duration of 46 hours a day. the output of the thesis camp activity is in the form of a thesis proposal document from chapters i-iii which is ready for a thesis proposal exam. the expected outcome is an increase in students' abilities in writing and compiling thesis proposals and the next step is to carry out research, report and be accounted for by students through thesis exams and be published. this activity is very useful for master students because it equips students to be able to prepare thesis proposals and prepare to conduct research as the final project of studying in the master of nursing study program. this study also found that there was an increase in the percentage of thesis proposal preparation, namely chapters 1 to chapter 2 of 16 students (51%) and chapters 1 to chapter 3 of 15 students (49%) based on the survey conducted. this shows that the thesis camp activities that have been carried out for 2 weeks (12 days) have proven to be effective in the preparation of thesis proposals. thesis camp activity guidebook is a very meaningful activity guide for the implementation of thesis camp activities and has been registered nationally (isbn). conclusion thesis camp is proven to be effective in increasing the timeliness of completing student thesis writing. the acceleration (acceleration) of the progress of writing a south east asia nursing research, vol 4 no 1, march 2022/ page 1-6 6 vivi yosafianti pohan / thesis camp as an effort to complete the student's final project (tesis) of the unimus nursing master’s degree program during the covid-19 pandemic thesis proposal has been realized in semester 1 of the unimus master of nursing study program. acknowledgment the author would like to thank lp2m universitas muhammadiyah semarang which has financed this research as well as to the respondents and all parties who have helped and supported the research process and writing of this research article. references 1. abidah, a., hidayatullah, h.n., simamora, r.m., fehabutar, d., & mutakinati, l. the impact of covid-19 to indonesian education and its relation to the philosophy of merdeka belajar. studies in philosophy of science and education (sipose) vol.1, no.1, april 2020, pp.38-49. 2. barosso, j. introduction to qualitative research, dalam lobiondo-wood.,& haber, j., nursing research: methods and critical appraisal for evidence base practice 2010 (hlm.86-99). st. louis: mosby elsevier. 3. lasa. kamus kepustakawanan indonesia 2009. yogyakarta: book publisher. 4. ore, l.s.b., navaro, c.e.b. why students find it difficult to finish their theses?. journal of turkish science education 2020, 17(4): 591602, doi: 10.36681/tused.2020.47 5. pranowo. guided writing sebagai model bimbingan tugas akhir skripsi mahasiswa jurusan pendidikan bahasa prancis fbs uny r&d 2013. bandung: alfabeta 6. rahma, a.a. pemanfaatan jurnal psikologi dalam penyusunan tesis mahasiswa psikologi ugm tahun 2012 kajian analisis sitiran. berkala ilmu perpustakaan dan informasi 2012, vol. 13 no. 1, juni 2017 issn 2477-0361 7. siallagan, df. fungsi dan peranan mahasiswa 2011, www.academia.edu, diakses pada 20 maret 2021 8. spica, b. perilaku prososial mahasiswa ditinjau dari empati dan dukungan sosial budaya skripsi 2008. fakultas psikologi universitas katolik soegijapranata semarang. 9. sujadi. tracer study fakultas ilmu keolahragaan universitas negeri surakarta 2013: universitas muhammadiah surakarta. 10. suwono. definisi mahasiswa 1978. available online at http://definisipengertian.com/2015/pengerti an-mahasiswa/ (diakses tanggal 5 mei 2021) 11. ulfah, s.h. evikasi diri mahasiswa yang bekerja pada saat penyusunan skripsi 2010. yogyakarta. 12. yusop, h., et.al. the effectiveness of excellent camp: a study on paired sample. procedia economics and finance 31 (2015) 453-461. doi: 10.1016/s2212-5671(15)01174-0 http://www.academia.edu/ http://definisipengertian.com/2015/pengertian-mahasiswa/ http://definisipengertian.com/2015/pengertian-mahasiswa/ http://definisipengertian.com/2015/pengertian-mahasiswa/ covid-19 patient transport: a literature review corresponding author: siti aisah aisah@unimus.ac.id south east asia nursing research, vol 4 no 1, march 2022 issn:2685-032x doi: https://doi.org/10.26714/seanr.4.1.2022.28-34 review article covid-19 patient transport: a literature review siti aisah1, tri nurhidayati1, dewi setyawati1, mohammad gita muntoha1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: submitted: sept 25th 2021 accepted: march 5th 2022 published: march 29th 2022 keywords: covid-19 transportation; covid-19 ambulances the pandemic caused by the severe acute respiratory syndrome coronavirus-2 (covid-19) is tremendously affecting health care services worldwide due to the nature of this virus which is highly infectious with a high rate of transmission. transmission of the covid-19 virus quickly occurs through close contact, droplet, airborne, and faecal-oral. during the prevention and containment of the pandemic, ambulances play an important role in transporting infectious patients. health workers working in ambulances are at high risk of contracting the covid-19 virus considering an ambulance is a small, confined and enclosed compartment. it is necessary to find a safe way of transporting covid-19 patients by ambulance. methods this thesis uses a literature review method. by following the prisma flow diagram, research journals are gathered from the electronic database sciencedirect and pubmed by performing keyword searches. the results are then sorted based on predefined inclusion criteria. nine original research journals are obtained and reviewed. results we found a variety of control measures that can be applied in transporting covid-19 patients safely. these control measures can be categorised using the control hierarchy approach which includes elimination, engineering control, administrative control and usage of personal protective equipment (ppe). conclusion transportation of covid-19 patients by ambulance can be carried out safely by strictly adhering to the control measures and certain protocols found in this literature review these control measures can be categorised using the control hierarchy approach which includes elimination, engineering control, administrative control and usage of personal protective equipment (ppe). conclusion transportation of covid-19 patients by ambulance can be carried out safely by strictly adhering to the control measures and certain protocols found in this literature review these control measures can be categorized using the control hierarchy approach which includes elimination, engineering control, administrative control and usage of personal protective equipment (ppe). conclusion transportation of covid19 patients by ambulance can be carried out safely by strictly adhering to the control measures and certain protocols found in this literature review. introduction the covid-19 pandemic is still ongoing. the extraordinary event (klb) of viral pneumonia that began in early december 2019 occurred in wuhan city, hubei https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.4.1.2022.28-34&domain=pdf&date_stamp=2022-03-29 south east asia nursing research, vol 4 no 1, march 2022/ page 28-34 29 siti aisah / covid-19 patient transport: a literature review province, china and was caused by the new severe acute respiratory syndrome coronavirus 2 (sars-cov-2). on january 30, 2020, the world health organization (who) declared this outbreak a public health emergency of international concern (pheic) which is the highest warning issued by who.1 in its press conference on 11 february 2020, who named this disease as corona virus disease 2019 (covid-19).2 and a month later on march 11, 2020, who declared this covid-19 outbreak a pandemic.3 the ease of transmission and the high death rate from covid-19 has caused a worldwide health crisis. as of january 26, 2020, there were 2,794 confirmed cases of covid-19 of which 80 died.4 furthermore, as of april 13, 2020, more than 1,770,000 cases have been diagnosed in 213 countries, territories or territories.5 in a year later, the number of confirmed cases of covid-19 globally has reached 130,422,190 people as of april 5, 2021.6 meanwhile, new confirmed cases showed an upward trend again where at its peak on december 20, 2020 there were 851,249 new cases and then on february 16, 2021 it fell to 228,734 new cases, now there is an increase again because there are 685,576 new cases as of april 3, 2021.7 one of the complications of covid-19 is pneumonia where the patient will feel short of breath and there is a drastic decrease in oxygen saturation in the blood. people who are hospitalized with covid-19, 15-30% will experience covid-19 associated acute respiratory distress syndrome (cards).8 where if it is not handled properly, the patient will require respiratory assistance with a ventilator later. this is a new problem because some small hospitals do not yet have icu rooms, or the limited capacity of icu rooms equipped with ventilators. for this reason, patients need to be referred to a larger hospital and/or a hospital that still has an icu room with a ventilator available. covid-19 patients who are self-isolating at home may also require transportation to the hospital in the event of a decline in health conditions. referring to the events above, it is necessary to transport covid-19 patients. ambulance vehicles are a common means of transportation used for patients who are in critical condition such as the above incident. ambulance originated in france in the 15th century. there are two types of ambulance, namely 'the ward type' and 'the transfer type'. 'the ward type' ambulance has resuscitation equipment and essential medicines. 'the transfer type' is used to transfer patients whose condition is stable to the hospital. various types of ambulances appear based on variations in the patient's condition9. ambulances play an important role during a pandemic. covid-19 patients who show an increase in symptoms such as shortness of breath will be transferred to a special covid-19 health facility by ambulance so that their condition can be monitored closely. who states that covid-19 can be transmitted through close contact, droplet particles and small particles in the air (airborne). methods of transmission through droplets and airborne mainly occur in close contact and in rooms with poor ventilation levels.10 the above conditions strongly describe the situation when transporting covid-19 patients in the ambulance. this is a challenge for health workers who carry out patient transfers because it includes a high risk of infection in a limited space for several hours.11 based on this, the authors are interested in raising the research topic "literature review: transport of covid-19 patients". the general purpose of this study is to review the literature review on how to safely transport covid-19 patients using ambulances. methods the method used to compile this literature review is done using an electronic database. journal search method using sciencedirect south east asia nursing research, vol 4 no 1, march 2022/ page 28-34 30 siti aisah / covid-19 patient transport: a literature review and pubmed. the keywords used are covid-19 transportation and covid-19 ambulance. the journal year is limited to 2020-2021. after the journals found were sorted according to the inclusion criteria, the authors obtained nine journals that would be used in this literature review. result from the results of the sorting of journal articles using the prisma method, nine research articles related to the transportation of covid-19 patients were obtained with the characteristics of the journal as presented in table 1. table 1 journal characteristics and recommendations no author title research methods recommendation 1 chen et al. (2021)9 analysis and influence of ambulances on containment of the spread of covid-19 in china cross-sectional the need for an ambulance equipped with a negative pressure system to contain the spread of covid-19 2 schwabe et al. (2020)12 long-distance aeromedical transportation for covid patients 19 in an ambulance plane using a portable isolation unit: opportunities, limitations and mitigation strategies retrospective review the use of patient isolation capsules in the transportation of covid-19 patients by airplane 3 yang et al. (2020)13 clinical characteristics of patients with coronavirus disease 2019 (covid-19) receiving emergency medical services by ambulance in king county, washington retrospective group study screening of ambulance patients based on clinical symptoms, especially fever and respiratory problems as an initial diagnosis of suspected covid-19 in prehospital situations 4 ghazali et al. (2020)14 feedback for preparing an ambulance team to manage patients who contracted covid-19: case study case study the need for screening patients, especially those who show symptoms of respiratory, hemodynamic and neurological problems, needs to be considered as covid-19 suspects in the context of this pandemic associated with the use of ppe. 5 murphy et al. (2020)15 occupational exposure and programmed response to the covid-19 pandemic: emergency medical ambulance service experience retrospective group study the change in working methods starts from the central operator who applies covid-19 risk scoring to patients and the results are conveyed to the ambulance staff regarding whether or not the use of ppe is necessary to reduce the risk of exposure and achieve a measurable level of ppe use. 6 spooler et al. (2021)16 helicopter transport for covid-19 critical care patients in the netherlands: protection against covid-19 exposure a challenge for critical care personnel in new operations retrospective observational study the use and removal of ppe and post-transport helicopter disinfection need to be carried out properly 7 tsukahara et al. (2020)17 feasibility study of a portable and transparent hood made of vinyl chloride for use in ambulances during the covid-19 pandemic experimental research the use of a transparent hood over the patient's head area connected to the suction machine continuously creates south east asia nursing research, vol 4 no 1, march 2022/ page 28-34 31 siti aisah / covid-19 patient transport: a literature review no author title research methods recommendation negative pressure within the hood 8 spangler et al. (2021)18 prehospital covid-19 identification: an observational study retrospective observational study use of the covid-19 suspect screening protocol based on the patient's clinical condition for the central operator and ambulance staff 9 tang et al. (2021)19 earlier and more extensive screening of sars-cov-2 is needed for first responders cross-sectional an earlier covid-19 screening was carried out on front-line health workers with symptoms of illness after direct contact with covid-19 patients discussion in connection with the high risk of transmission during the transportation of covid-19 patients, there are steps that need to be taken to mitigate risk and prevent exposure. according to koehler & rule (2020), efforts to mitigate risk and prevent exposure to covid-19 can be carried out through the hierarchical risk control framework approach created by niosh.20 depicted in the inverted pyramid in figure 1 below, the more effective controls are at the top of the pyramid, while the less effective controls are at the bottom. 00 this risk control control hierarchy consists of five levels of control efforts, namely elimination, substitution, engineering control, administrative controls, and personal protective equipment (ppe).20 in the context of transporting covid-19 patients by ambulance, exposure risk control can be structured based on the following framework: elimination can be done by avoiding transportation of covid-19 patients. patients with covid-19 with stable conditions and without complaints means it is possible to self-isolate at home21,22 and there is no need to send the patient to a quarantine facility as was done by the indonesian government at the beginning of the pandemic. substitution cannot be applied in the context of transporting covid-19 patients. engineering controls aim to separate ambulance personnel from danger. one of the safest methods for transporting covid19 patients is the use of negative pressure isolation capsules as exemplified in the second research journal above using the epishuttle pmiu.12 or by using rega piu.11 ambulances with a negative pressure system as mentioned in the first journal or the use of a hood on the patient's head with negative pressure as mentioned in the seventh journal are also highly recommended for use in the transportation of covid-19 patients because they have been shown to reduce exposure by reducing the number of virus droplets or aerosols. covid-19 in the air.9,17 if there is no separation wall between the front of the ambulance (where the driver and front passenger) and the rear compartment (where the patient is treated during the trip in the ambulance) then it is necessary to make a dividing wall to reduce exposure to the officers in front, as well as to the aircraft. the separator between the cockpit and the cabin.23 air recirculation in the ambulance must also be avoided by turning off the recirculation button on the ambulance air conditioning system. try to get fresh air into the ambulance.24 one literature recommends opening the ambulance windows in the driver's area whenever possible25 and a guide issued by the malaysian ministry of health (kkm) states that the windows in the driver's area should be lowered by 3 cm.26 south east asia nursing research, vol 4 no 1, march 2022/ page 28-34 32 siti aisah / covid-19 patient transport: a literature review administrative control for infection risk control in the transportation of covid-19 patients is carried out from before transportation, during transportation to after transportation by implementing certain protocols. starting from the central operator who screens the level of risk of covid-19 using a kind of scoring system, for people who need an ambulance to determine the criteria for suspects where the results are submitted to the ambulance staff as a suggestion for determining the proper use of ppe before the ambulance comes to the patient. this is very helpful in reducing the risk of exposure to health workers as mentioned in the third, fourth and fifth journals above.13–15 the central operator in collaboration with ambulance staff is also responsible for contacting the health facility or hospital where the patient will be taken to ensure the availability of beds in the er or isolation room or icu room according to the patient's needs before transportation is carried out, to avoid prolonged contact between the patient and the staff. health in the ambulance which increases the risk of exposure.27 patients should also be advised to wear a surgical mask before contact with ambulance staff.14 patients who need the help of an oxygen mask are still wearing a surgical mask over the oxygen mask.24,25 during transportation, try as much as possible not to take medical actions that produce aerosols and if you do, high caution and strict mitigation are needed, for example by using a hepa filter on an ambu bag or using a video intubation device to facilitate intubation or by using a supraglottic airway device. such as laryngeal mask instead of endo tracheal tube (ett).28 protocols for the use of ppe and routine hand washing before and after transportation also need to be regulated in administrative controls.23 as mentioned in the first and sixth journals above, after the covid-19 patient has been transported and has been handed over to the designated health facility, disinfection and cleaning of the ambulance must be carried out. disinfection of ambulances and medical equipment after transportation is important to prevent exposure to both health workers and patients who will use the ambulance afterwards.9,16 ppe and used medical materials must be disposed of in the medical waste bin to prevent exposure. as discussed in the ninth journal above, routine pcr examinations for health workers working in high-risk areas such as ambulances and for staff with symptoms of illness must be carried out to prevent the spread of covid-19 in the workplace.19,29 every ambulance officer needs to be vaccinated against covid-19 if there are no contraindications because research shows that health workers who receive covid-19 vaccination have a very low risk of contracting it.30,31 personal protective equipment (ppe). although ppe is the lowest level in the risk control hierarchy, its presence is necessary and must be worn when health workers will carry out treatment or direct contact with covid-19 patients as described in the fourth, fifth and sixth journals above. in general, the required ppe for ambulance staff in handling covid-19 patients is at least level 2 ppe including surgical masks, non-sterile gloves, isolation gowns and eye protection (protective glasses or face shield). however, the use of level 2 ppe equipped with n95 masks is preferred. when health workers are about to take medical actions that have the potential to cause aerosols, surgical masks must be replaced with n95 masks.32,33 what is no less important is that training on the use of ppe and the removal of ppe must be given to health workers beforehand so that ppe can be used properly.14,15 the application of the buddy check system method where coworkers participate in ensuring that the ppe we wear is installed correctly and also ensuring that the sequence when removing ppe is followed correctly has proven to be very useful for preventing exposure.16 south east asia nursing research, vol 4 no 1, march 2022/ page 28-34 33 siti aisah / covid-19 patient transport: a literature review conclusion the transfer of covid-19 patients using land, water or air ambulances (heli or plane) can be carried out safely as long as it is carried out in accordance with strict procedures, namely the use of negative pressure ambulances, use of personal isolation capsules, use of negative pressure hoods, use of level 2 ppe with the use of n95 masks, disinfection of ambulances after use, screening of suspected covid-19 patients by the central operator and ambulance officers, and routine covid-19 checks on ambulance officers. further studies are needed as a basis for making protocols for use in the transportation of covid-19 patients. acknowledgments the author would like to thank all those who have helped and supported the research process and writing this research article. conflicts of interest ambulances play an important role during a pandemic. covid-19 patients who show an increase in symptoms such as shortness of breath will be transferred to a special covid-19 health facility by ambulance so that their condition can be monitored closely. references 1. harapan h, itoh n, yufika a, winardi w, keam s, te h, et al. coronavirus disease 2019 (covid19): a literature review. vol. 13, journal of infection and public health. elsevier ltd; 2020. p. 667–73. 2. who. who director-general’s remarks at the media briefing on 2019-ncov on 11 february 2020. 2020. 3. who. who director-general’s opening remarks at the media briefing on covid-19 11 march 2020. 2020. 4. zhou p, yang x lou, wang xg, hu b, zhang l, zhang w, et al. a pneumonia outbreak associated with a new coronavirus of probable bat origin. nature. 2020 mar;579(7798):270–3. 5. lv m, luo x, estill j, liu y, ren m, wang j, et al. coronavirus disease (covid-19): a scoping review. vol. 25, eurosurveillance. european centre for disease prevention and control (ecdc); 2020. 6. who. weekly operational update on covid-19 5 april 2021. 2021. p. 1. 7. who. who coronavirus (covid-19) dashboard | who coronavirus (covid-19) dashboard with vaccination data. 2021. 8. attaway ah, scheraga rg, bhimraj a, biehl m, hatipoğ lu u. severe covid-19 pneumonia: pathogenesis and clinical management. vol. 372, the bmj. bmj publishing group; 2021. 9. chen y, yang y, peng w, wang h. influence and analysis of ambulance on the containment of covid-19 in china. saf sci. 2021 jul;139:105160. 10. who. transmission of sars-cov-2: implications for infection prevention precautions. 2020. 11. albrecht r, knapp j, theiler l, eder m, pietsch u. transport of covid-19 and other highly contagious patients by helicopter and fixedwing air ambulance: a narrative review and experience of the swiss air rescue rega. vol. 28, scandinavian journal of trauma, resuscitation and emergency medicine. biomed central ltd.; 2020. p. 40. 12. schwabe d, kellner b, henkel d, pilligrath hj, krummer s, zach s, et al. long−distance aeromedical transport of patients with covid−19 in fixed−wing air ambulance using a portable isolation unit: opportunities, limitations and mitigation strategies. open access emerg med. 2020;12:411–9. 13. yang by, barnard lm, emert jm, drucker c, schwarcz l, counts cr, et al. clinical characteristics of patients with coronavirus disease 2019 (covid-19) receiving emergency medical services in king county, washington. jama netw open. 2020 jul;3(7):e2014549. 14. ghazali da, ouersighni a, gay m, audebault v, pavlovsky t, casalino e. feedback to prepare ems teams to manage infected patients with covid-19: a case series. prehosp disaster med. 2020 aug;35(4):451–3. 15. murphy dl, barnard lm, drucker cj, yang by, emert jm, schwarcz l, et al. occupational exposures and programmatic response to covid-19 pandemic: an emergency medical services experience. emerg med j. 2020 nov;37(11):707–13. 16. spoelder ej, tacken mct, van geffen gj, slagt c. south east asia nursing research, vol 4 no 1, march 2022/ page 28-34 34 siti aisah / covid-19 patient transport: a literature review helicopter transport of critical care covid-19 patients in the netherlands: protection against covid-19 exposure-a challenge to critical care retrieval personnel in a novel operation. scand j trauma resusc emerg med. 2021 dec;29(1):1–7. 17. tsukahara k, naito h, nojima t, yorifuji t, nakao a. feasibility study of a portable transparent vinyl chloride shield for use in an ambulance during the covid-19 pandemic. crit care. 2020 dec;24(1):1–3. 18. spangler d, blomberg h, smekal d. prehospital identification of covid-19: an observational study. scand j trauma resusc emerg med. 2021 dec;29(1):1–10. 19. tang o, bigelow bf, katz mj. earlier and widespread screening for sars-cov-2 is needed for first responders. vol. 40, american journal of emergency medicine. w.b. saunders; 2021. p. 215–6. 20. cdc. hierarchy of controls | niosh | cdc. u.s. department of health & human services. 2015. 21. ju y, chen w, liu j, yang a, shu k, zhou y, et al. effects of centralized isolation vs. home isolation on psychological distress in patients with covid-19. j psychosom res. 2021 apr;143:110365. 22. buick je, cheskes s, feldman m, verbeek pr, hillier m, leong yc, et al. covid-19: what paramedics need to know! can j emerg med. 2020 jul;22(4):426–30. 23. peddle mb, smith ja. hazard control for communicable disease transport at ornge. can j emerg med. 2020;s79–83. 24. jalili m. view of how should emergency medical services personnel protect themselves and the patients during covid-19 pandemic? advanced journal of emergency medicine. 2020. p. 4. 25. liew mf, siow wt, yau yw, see kc. safe patient transport for covid-19. vol. 24, critical care. biomed central ltd.; 2020. p. 1–3. 26. kkm. annex 11 : protocol for ambulance transfer for patient under investigation (pui) or confirmed covid-19 preparation of the ambulance. 2020. 27. yousuf b, sujatha ks, alfoudri h, mansurov v. transport of critically ill covid-19 patients. vol. 46, intensive care medicine. springer; 2020. p. 1663–4. 28. hart j, tracy r, johnston m, brown s, stephenson c, kegg j, et al. recommendations for prehospital airway management in patients with suspected covid-19 infection. west j emerg med. 2020;21(4):809–12. 29. chin et, huynh bq, chapman lac, murrill m, basu s, lo nc. frequency of routine testing for coronavirus disease 2019 (covid-19) in highrisk healthcare environments to reduce outbreaks. clin infect dis. 2020 oct; 30. amit s, regev-yochay g, afek a, kreiss y, leshem e. early rate reductions of sars-cov-2 infection and covid-19 in bnt162b2 vaccine recipients. vol. 397, the lancet. elsevier b.v.; 2021. p. 875–7. 31. beusekom m van. risk of covid very low in vaccinated medical workers: study | cidrap. center for infectious disease research and policy. 2021. 32. who. covid-19: occupational health and safety for health workers. 2021. 33. cdc. using personal protective equipment (ppe) | cdc. 2020. pregnant mother's anxiety level on stunting risk corresponding author: eni hidayati eni.hidayati@unimus.ac.id south east asia nursing research, vol 4 no 1, march 2022 issn:2685-032x doi: https://doi.org/10.26714/seanr.4.1.2022.14-20 original research pregnant mother's anxiety level on stunting risk eni hidayati1, sifana ayu damayanti1, desi aryana rahayu1, muhammad fatkul mubin1, tri nurhidayati1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: submitted: dec 26th 2021 accepted: march 1st 2022 published: march 29th 2022 keywords: level of anxiety; pregnant women; risk of stunting pregnancy at a young age and over the age of 35 is vulnerable to causing pregnant women to experience various risks of pregnancy because pregnant women at a young age do not know much about how to maintain their pregnancy conditions and pregnant women over the age of 35 experience a decrease in nutrient absorption so they are easy to experience various kinds of problems. one of the risks of pregnancy is stunting. pregnant women usually experience a psychological decline that causes anxiety in themselves. so that it also has an impact on the growth and development of the prospective baby. the type of research used is an analytical approach. the design of this study used a cross-sectional approach. the population in this study were pregnant women in the sembungharjo village area with a total of 27 pregnant women using a total sampling of data analysis using the chisquare test. the results of the study from 27 respondents were obtained that pregnant women with mild anxiety among as many as 16 respondents (59.3%), moderate anxiety among as many as 5 respondents (18.5%), and no anxiety among as many as 6 respondents (22.2%). respondents with severe anxiety were 0 (0%). a total of 27 pregnant women respondents found that as many as 5 respondents (18.5%) had low risk while 22 respondents (81.5%) were not at risk, and pregnant women with high risk were 0 (0%). the conclusion is that there is no relationship between the anxiety level of pregnant women and the risk of stunting in sembung harjo sub-district, genuk sub-district with a p-value of 0.366 (a> 0.05). introduction pregnancy is a period of mental, psychological and emotional changes, although many women say that pregnancy is something that adds to the perfection of the family, especially the first pregnancy for women.1 pregnancy is divided into 3 trimesters, namely the first trimester (1-3 months), the second trimester (4-6 months) and the third trimester (7-9 months) for primigravida mothers (pregnant for the first time). % of pregnant women experience anxiety in the third trimester, namely the final trimester to face the first delivery.2 who estimates that every year there are 210 million pregnancies worldwide, the prevalence of anxiety in pregnant women in portugal is 18.2%, in bangladesh 29%, in hong kong 54%. in indonesia, the number of pregnant women is 5,263,057. the incidence of pregnancy anxiety is 18-70%. for pregnant women for the first time, there are many pressures and https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.4.1.2022.14-20&domain=pdf&date_stamp=2022-03-29 south east asia nursing research, vol 4 no 1, march 2022/ page 14-20 15 eni hidayati / pregnant mother's anxiety level on stunting risk thoughts that arise, one of which is biological pressure that arises due to various physical changes. for example, this change in body shape can cause fear and anxiety when facing childbirth for the first time.3 the relationship between the anxiety level of pregnant women and the risk of giving birth to a low birth weight baby in indonesiapublic health centerrappang. based on this research, it was found that the majority of pregnant women had mild anxiety as many as 22 people (73.0%), moderate anxiety as many as 4 people (13.0%) and as many as 3 people did not experience anxiety (3.0%) which means that most most pregnant women have mild anxiety during their pregnancy.pregnancy anxiety refers to worries and fears about pregnancy and the health of the baby. anxiety in pregnancy can be associated with low knowledge of pregnant women about pregnancy, especially how to deal with anxiety. preventive action by providing health education to pregnant women in order to increase the knowledge of pregnant women in overcoming their anxiety about the risk of pregnancy. there are still many pregnancies in indonesia that are at risk of pregnancy which causes dangers and complications that will occur to the mother and fetuswhichwill cause death, disability and abnormalities in the fetus. screening for abnormalities in the fetus can be carried out routine anc examinations so that they can be detected at gestational age. abnormalities of physical disabilities in infants that are often encountered are congenital heart disease, cleft lip and one of the most common ones is stunting.4 the incidence of stunting is currently one of the problems that occurs in the world, including in indonesia, stunting occurs mostly in infants under five, based on 2019 data it was recorded at 27.67% or. according to data from the province of central java, until february 2020 there were 156,549 children under five who were stunted. in the province of south sulawesi in 2019, children under five who experienced stunting were 35.6%.5 education on nutritional needs during pregnancy is very important to prevent various risk factors for pregnancy, lack of awareness about the importance of maternal nutrition will have an impact on efforts made to prevent stunting. stunting is a failure of child growth and development due to non-fulfillment of nutritional needs that lasts for a long time starting from pregnancy until the age of 24 months. one way to overcome stunting and must be carried out is fulfilling nutrition for pregnant women and controlling food. to increase maternal knowledge in the first 1000 days of life by providing counseling to pregnant women about the risks that may occur with their pregnancy, one of which is the risk of stunting.6 many factors underlie the high incidence of stunting in toddlers, the cause is lack of food intake or even the presence of infectious diseases, other factors are lack of mother's knowledge, wrong parenting, parenting has an important role in realizing optimal child growth, or poor hygiene patterns. . not many people know that short children are a problem because all short children around the community look like children with normal activities.7 many children under five years of age also experience stunting, one of the risk factors for stunting in children under five years old, they are not given exclusive breastfeeding. years needed, so that the child's nutrition is not met and the possibility of infection can occur in the first 1000 days of life so that it becomes an obstacle for children in development.8 from a preliminary study of data from the sembungharjo sub-district, genuk subdistrict. the results of a survey and short interviews conducted with 6 pregnant women about the level of anxiety of pregnant women about the risk of stunting, it was found that 2 out of 6 pregnant women could not answer correctly about the definition of stunting, 92.6% of pregnant south east asia nursing research, vol 4 no 1, march 2022/ page 14-20 16 eni hidayati / pregnant mother's anxiety level on stunting risk women knew what caused stunting. 85.2% of pregnant women do not have anxiety about stunting in their pregnancy. and 100% of pregnant women answered that they had routinely checked their pregnancy at health services. 81.5% of pregnant women answered that they were worried about the baby they were going to give birth to. methods design this study uses a correlation research design with the type of research used is an analytical approach. the design of this study used a cross sectional approach.the purpose of this study was to determine whether there is a relationship between the anxiety level of pregnant women and the risk of stunting sample the population in this study were all pregnant women in sembungharjo village as many as 27 people. the research sample was 27 respondents using a total sampling of data analysis using the chi square test. results characteristics of respondents are the average age of 20-29 years (74.1%), the average education of high school respondents is 23 respondents (85.2%), the average gestational age is 13 respondents aged 0-4 months (48.1 %). table 1 the category of anxiety level and stunting risk of pregnant women indicators f % anxiety level light 16 59.3 currently 5 18.5 there is not any 6 22.2 heavy 0 0 anxiety level low risk 5 18.5 no risk 22 81.5 high risk 0 0 table 2 analysis of the relationship between the anxiety level of pregnant women and the risk of stunting anxiety level risk level p no risk low risk there is not any 4 2 light 13 3 currently 5 0 0.366 heavy 0 0 total 22 5 based on the results of calculations using the chi-square test with 27 pregnant women respondents, p 0.366 means that there is no relationship between the anxiety level of pregnant women and the risk of stunting. because p value > 0.05. so ho is accepted and ha is rejected, which means that there is no relationship between the anxiety level of pregnant women and the risk of stunting in sembungharjo village, genuk district, semarang city. discussion general description of respondent characteristics. based on the results of the frequency distribution of respondents' characteristics by age, the respondents' ages ranged from 20 years to 49 years, most of the respondents aged (20-29 years) were (74.1%) respondents. age (30-39 years) as many as (22.2%) respondents. age (40-49 years) that is (3.7%). based on the frequency distribution based on the last education, 23 respondents (85.2%) obtained high school education and 4 respondents (14.8%). based on the frequency distribution based on gestational age, there were 13 respondents (48.1%). 56 months as many as 10 respondents (37.0%). 7-9 months as many as 4 respondents (14.8%). an illustration of the level of anxiety of pregnant women on the risk of stunting. based on the results of the study, the description of the anxiety level of pregnant women was found that most of the motherspregnant with mild anxiety as many as 16 respondents (59.3%), moderate south east asia nursing research, vol 4 no 1, march 2022/ page 14-20 17 eni hidayati / pregnant mother's anxiety level on stunting risk anxiety as many as 5 respondents (18.5%), and no anxiety as many as 6 respondents (22.2%). in this study, it was found that most of the respondents had mild anxiety about their pregnancy. pregnant women already understand the factors that will be experienced during pregnancy and respondents already know how to overcome their anxiety. based on these studies, it can be concluded that the majority of pregnant women experience mild anxiety during their pregnancy.9 the relationship between the anxiety level of pregnant women and the risk of giving birth to a low birth weight baby at the rappang public health center. based on this study, it was found that the majority of pregnant women had mild anxiety as many as 22 people (73.0%), moderate anxiety as many as 4 people (13.0%) and as many as 3 people did not experience anxiety (3.0%) which means that most most pregnant women have mild anxiety during their pregnancy.10 about 23 respondents who did not experience anxiety (60.5%) and about 15 respondents experienced anxiety (39.5%) based on the results obtained from the study, pregnant women who experienced anxiety were caused by several reasons. factors namely age, level of knowledge and parity.11 it was found that of the 23 respondents who had the last education of high school with a total of 23 people (71%) the majority of pregnant women with moderate anxiety levels were 10 people (31.3%) and 5 people with severe anxiety (15.6%). concluded that the lack of education status in pregnant women will cause pregnant women to experience stress more easily compared to pregnant women with higher education.12 entitled the level of anxiety of pregnant women in facing childbirth based on health status in the work area of the jombang public health center, it was found that from 123 respondents, as many as 107 respondents (87%) experienced mild anxiety and 16 respondents moderate anxiety ( 13%) based on this study, pregnant women have more mild and moderate levels of anxiety in the work area of the jombang public health center.13 in accordance with research from nurul rahmitha entitled the anxiety level of third trimester primigravida pregnant women at the tamanlanrea district health center, with the number of respondents as many as 37 people with the result that more pregnant women have mild and moderate levels of anxiety, namely 11 people each ( 29.7%) while pregnant women who do not have anxiety are 10 people (27%) and pregnant women who have severe anxiety levels are 5 people (13.5%).14 an overview of the stunting risk of pregnant women. based on the results of the research on the risk of stunting in pregnant women, it was found that the majority of pregnant women who did not have the risk of stunting were 22 respondents (81.5%). whereas5 respondents (18.5%) had a low risk, in this study it was found that the average respondent did not have a stunting risk because most of the respondents had fulfilled their nutritional needs during pregnancy, this can be seen in the stunting risk questionnaire given by researchers to respondents, about knowledge and fulfillment of nutrition during pregnancy for the prevention of stunting in the baby in the womb. most pregnant women already know stunting and its causes so that the average respondent has fulfilled their nutritional needs to prevent stunting in their pregnancy. prevention of stunting from an early age with nutritious food for pregnant women in the wonocolo sub-district, surabaya, it was found that from 40 respondents, most of the pregnant women had fulfilled their nutritional and nutritional needs for stunting prevention during pregnancy.15 malnutrition in pregnant women can cause poor conditions for babies in the womb, pregnant women who have not met balanced nutrition since the beginning of pregnancy have a risk of giving birth to south east asia nursing research, vol 4 no 1, march 2022/ page 14-20 18 eni hidayati / pregnant mother's anxiety level on stunting risk stunting babies or other disease disorders based on the research entitled balanced nutrition education for pregnant women in stunting prevention in the village. karang bayan, west lombok regency, it can be concluded that the more pregnant women who have fulfilled nutrition and nutrition since the beginning of pregnancy can prevent stunting and other baby abnormalities.16 pregnant women who routinely check their pregnancies to health services also prevent the risk of stunting in pregnancy. titled antenatal care visits related to the incidence of stunting in this study, it was found that most of the respondents routinely checked their pregnancies in health services so that respondents gained knowledge about how to prevent stunting.17 get that as many as 40 pregnant women respondents got respondents with good nutritional status as many as 37 people while 3 pregnant women with poor nutritional status, from the results obtained from the study most pregnant women had fulfilled their nutrition since the beginning of pregnancy. the more pregnant women who have fulfilled their nutritional status since the beginning of pregnancy, the lower the risk of stunting.18 it was found that some pregnant women already know how to prevent the risk of stunting in their pregnancy by consuming nutritious food and regularly checking their pregnancy to the nearest health service so that pregnant women get education about their health problems and nutritional status during pregnancy.19 relationship between the anxiety level of pregnant women and the risk of stunting. based on the results of the study, the relationship between the level of anxiety of pregnant women and the risk of stunting shows that there is no relationshipbetween the anxiety level of pregnant women and the risk of stunting. in the results of the analysis of the relationship between the anxiety level of pregnant women and the risk of stunting from 27 respondents, it was found that pregnant women with mild anxiety were 16 respondents (59.3%), moderate anxiety was 5 respondents (18.5%), there was no anxiety as much as 6 respondents (22.2%). and respondents with severe anxiety 0 (0%) and pregnant women who have a risk of stunting, it was found that as many as 5 respondents (18.5%) had low risk while 22 respondents (81.5%) were not at risk. from the results of the study, it was found that the p value of 0.366 (p>0.05) it can be concluded that there is no significant relationship between the level of anxiety of pregnant women and the risk of stunting, it can be concluded that the level of anxiety of pregnant women does not have a relationship with the risk of stunting. of pregnancy, this is because most pregnant women have met their nutritional needs since the beginning of pregnancy. a person's pregnancy can be a factor that causes pregnant women to experience anxiety but the level of anxiety experienced is different, local government efforts in preventing stunting in the province of the bangka belitung islands, from the results of this study stunting is caused by poor nutrition experienced by pregnant women and lack of knowledge of pregnant women about health and nutrition before and during pregnancy. from the results of this study, it was found that the majority of pregnant women had mild anxiety levels, but the anxiety of pregnant women was not about the risk of stunting that would be experienced. but what makes them anxious is when they will face childbirth, thinking about whether the baby's condition is perfect or not. the majority of respondents have not thought about the risk of stunting in their pregnancy. because the majority of respondents have fulfilled their nutrition and nutrition since the beginning of pregnancy, so they have no worries about the risk of stunting that will be experienced. south east asia nursing research, vol 4 no 1, march 2022/ page 14-20 19 eni hidayati / pregnant mother's anxiety level on stunting risk based on the results of the chi-square test which aims to determine the relationship between the anxiety level of pregnant women and the risk of stunting in the sembungharjo sub-district, the value of sig (2-tailed) or p value of 0.366 is obtained because p value > 0.05, then ho is accepted and ha is rejected. which means that there is no significant relationship between the level of anxiety of pregnant women and the risk of stunting. this study concluded that there was no relationship between the anxiety level of pregnant women and the risk of stunting in sembungharjo village. conclusion pregnant women who have mild anxiety levels are as many as 16 respondents (59.3%), who have moderate anxiety are 5 respondents (18.5%), and there are no anxiety as many as 6 respondents (22.2%). pregnant women with severe anxiety are 0 (0%). pregnant women who have no risk are 22 respondents (81.5%). while pregnant women who have a low risk are 5 respondents (18.5%) pregnant women who have a high risk are 0 respondents (0%). based on statistical tests with the chisquare test with 27 pregnant women respondents, the p value of 0.366 means that there is no relationship between the anxiety level of pregnant women and the risk of stunting. acknowledgments the author would like to thank all pregnant women who have been willing to be respondents in this study. conflicts of interest it is hoped that pregnant women can overcome their anxiety during pregnancy. to prevent stunting, pregnant women should diligently check their pregnancy at the nearest health service and meet nutritional needs from the time of pregnancy to avoid stunting from an early age. references 1. aisyah rd, suparni s, fitriyani f. the 8 th university research colloquium 2018 universitas muhammadiyah purwokerto edukasi dalam paket caring terhadap pengetahuan tentang education in caring package on knowladge about anxiety of the 8 th university research colloquium 2018 universitas muh. univercity res colloqulum. 2018;346–9. 2. wardani hw, agustina r, damayanti eaf. tingkat kecemasan dengan kualitastidur ibu hamil primigravida trimester iii. dunia keperawatan. 2018;6:1. 3. nelsi y, vitayani s, abbas hh. analisis faktor yang mempengaruhi kecemasan pada ibu hamil terhadap hubungan seksual di rsia siti khadijah i makassar. wind heal. 2019;2:128– 36. 4. wicaksono i. pencegahan stunting sejak dini di era milenial desa sukokerto kecamatan pajarakan kabupaten probolinggo. abdi panca marga. 2019;1:43–7. 5. indonesia kkr. riskesdas. jakarta; 2018. 6. ekayanthi nwd, suryani p. edukasi gizi pada ibu hamil mencegah stunting pada kelas ibu hamil. j kesehat. 2019;10:312. 7. salamung n, haryanto j, sustini f. faktorfaktor yang berhubungan dengan perilaku pencegahan stunting pada saat ibu hamil di wilayah kerja puskesmas kabupaten bondowoso. j penelit kesehat “suara forikes” (journal heal res “forikes voice”). 2019;10:264. 8. k. septi viantri & l. diah ayu. faktor-faktor yang berhubungan dengan kejadian stunting pada anak usia dibawah 5 tahun. fakt yang berhubungan dengan kejadian stunting pada anak usia dibawah 5 tahun. 2020;5:196. 9. siregar ny, kias cf, nurfatimah n, noya f, longgupa lw, entoh c, et al. tingkat kecemasan ibu hamil trimester iii dalam menghadapi persalinan. j bidan cerdas. 2021;3:18–24. 10. pratiwi wr. hubungan tingkat kecemasan ibu hamil terhadap risiko melahirkan bayi berat lahir rendah di puskesmas rappang | jiki jurnal ilmiah kesehatan iqra. j ilm kesehat iqra. 2019;07:32–7. 11. rudiyanti n, raidartiwi e. tingkat kecemasan pada ibu hamil dengan kejadian preeklampsia di sebuah rs provinsi lampung. j ilm keperawatan sai betik. 2018;13:173. 12. maki fp, pali c, opod h. gambaran tingkat south east asia nursing research, vol 4 no 1, march 2022/ page 14-20 20 eni hidayati / pregnant mother's anxiety level on stunting risk kecemasan ibu hamil primigravida trimester iii di klinik bersalin sutra minahasa selatan. j ebiomedik. 2018;6:103–10. 13. siallagan d, lestari d. tingkat kecemasan menghadapi persalinan berdasarkan status kesehatan, graviditas dan usia di wilayah kerja puskesmas jombang. indones j midwifery. 2018;1:104–10. 14. wolfe dt, hermanson dr, ii bab, diri ak, diri pk, chotimah c, et al. no title روانپزشکی خالصه . educ psychol j. 2017;2:65–72. 15. ningrum np, hidayatunnikmah n, rihardini t. cegah stunting sejak dini dengan makanan bergizi untuk ibu hamil. e-dimas j pengabdi kpd masy. 2020;11:550–5. 16. pratiwi ig. edukasi tentang gizi seimbang untuk ibu hamil dalam pencegahan dini stunting. j pengabdi masy sasambo. 2020;1:62. 17. hutasoit m, utami kd, afriyliani nf. kunjungan antenatal care berhubungan dengan kejadian stunting. kesehat samodra ilmu. 2020;11:1–10. 18. safitri a, gayatri sw, kartika id. tatalaksana gizi pada ibu hamil untuk mencegah risiko stunting pada anak di puskesmas jongaya. j pengabdi kedokt indones. 2021;2:1–8. 19. alfarisi r, nurmalasari y, nabilla s. status gizi ibu hamil dapat menyebabkan kejadian stunting pada balita. j kebidanan malahayati. 2019;5:271–8. factors contributing to intradialytic hypertension in hemodialysis patients corresponding author: yunie armiyati yunie@unimus.ac.id south east asia nursing research, vol 3 no 2, june 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.2.2021.73-80 original research factors contributing to intradialytic hypertension in hemodialysis patients yunie armiyati1,2, suharyo hadisaputro3, shofa chasani4,5, untung sujianto6 1 department of nursing, universitas muhammadiyah semarang, indonesia. 2 doctoral program, faculty of medicine, universitas diponegoro, indonesia. 3 postgraduate program of health polytechnic of semarang 4 hemodialysis center, roemani hospital, indonesia. 5 faculty of medicine, universitas muhammadiyah semarang, indonesia 6 department of nursing, faculty of medicine, universitas diponegoro, indonesia. article info abstract article history: submitted: may 26th 2021 accepted: june 21st 2021 published: june 23rd 2021 keywords: idwg; fluid adherence; ultrafiltration; intradialytic hypertension; hemodialysis intradialytic hypertension (idh) is the most common complication of hemodialysis patients in indonesia. it must be controlled, to maintain the patient's quality of life and prevent worsening conditions. some factors affecting idh include predialysis fluid overload characterized by excessive interdialytic weight gain (idwg), low adherence to fluid restriction and increased ultrafiltration during haemodialysis. the study aims to identify contributing factors of idh. a case-control design was used in this study. a purposive sampling technique was used to recruit 92 samples at two centres of dialysis in semarang, which was divided into case group (n=46) and control group (n=46). data were analyzed using the chi-square test by calculating odds ratios (or). the finding showed that excessive idwg (p=0,000, or=16.95, 95% ci:5,56-51,65), low fluid adherence (p=0,001, or=4,41, 95% ci:1,82-10,68) and excessive ultrafiltration (p=0,000, or = 29,52, 95% ci:9,23-94,46) showed significant result. however, the incidence of idh was not correlated with sex, age and length of haemodialysis. a greater increase in interdialytic weight requires lower fluid and higher ultrafiltration factors must be controlled precisely because those are considered as the risk factors for the high incidence of idh. excessive ultrafiltration is the most dominant risk factor in the high incidence of idh. introduction the prevalence number of chronic kidney disease (ckd) in indonesia around 90% to 3.8 cases in 1000 population increased significantly past decades, and 19.3% of them require hemodialysis treatment.1 ckd patients at the end stage of the kidney disease stage require renal replacement therapy to maintain body functions.2 hemodialysis is the main choice of the kidney replacement therapy which is performed routinely to replace part of kidney function in patients with end-stage kidney disease. data from the indonesian renal registry (irr) shows an increasing new patients undergoing haemodialysis in indonesia from 2017 to 2018 as much as 53.7%.3 haemodialysis is effective in removing fluids, electrolytes and metabolic waste, https://doi.org/10.26714/seanr.3.2.2021.73-80 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.2.2021.73-80&domain=pdf&date_stamp=2021-06-23 south east asia nursing research, vol 3 no 2, june 2021/ page 73-80 74 yunie armiyati / factors contributing to intradialytic hypertension in hemodialysis patients symptom relief and improving the quality of life for end stage kidney disease patients.4 moreover, haemodialysis is also effective and safe enough as routine therapy for ckd patients to reduce morbidity and improve quality of life. however, various intradialytic complications can occur during the hemodialysis procedure. one of the important complications is the increased of intradialytic blood pressure or the occurrence of intradialytic hypertension (idh). idh is a phenomenon where blood pressure increases during the hemodialysis procedure.5 the blood pressure average decreases in the first hour, and increases more in the next third and fourth hours during hemodialysis procedures.6 the prevalence incidence of idh is quite varied across the globe. it can be determined by many factors, including differences in the definition of the idh terminology.7 a retrospective cohort study of 22,955 hemodialysis treatments showed that the prevalence of idh was 21.3 per 100 procedures.8 study in korea showed that 19.2% of patients on routine hemodialysis had idh.9 a study in india concluded that idh was experienced by 81.8% of hemodialysis patients.10 several studies in indonesia showed that idh is often experienced by hemodialysis patients. the 2018 annual report of the indonesian nephrology association stated that the prevalence of idh in indonesia was 38%.3 research at one dialysis center in semarang showed the prevalence of idh was 25.9%.11 another study in bali showed that idh was the most common complication experienced by hemodialysis patients with 52.4%.12 the increasing blood pressure can be severe even to the point of a hypertensive crisis that endangers the patients. idh will affect hemodialysis adequacy, increasing the risk of heart failure and patient’s mortality. idh in routine hemodialysis patients is associated with increased morbidity and mortality.13 previous study in 151 routine hemodialysis patients showed that high interdialytic blood pressure was associated with an increased risk of stroke and death. previous study showed a total of 13.91% of patients with high interdialytic blood pressure had a stroke and 16.56% of patients were died.14 idh on maintenance hemodialysis patients is associated with the increased mortality. previous study showed that the increasing >10 mmhg blood pressure during hemodialysis increased the 3.68 times risk of patient’s mortality (14). a prior study of 73 hemodialysis patients also found that idh was associated with high mortality in hemodialysis patients. the idh group showed a mortality rate of 2,846 times higher than the group without idh.15 anticipation and control of idh can be prepared by controlling the risk factors. various factors contribute to idh including predialysis fluid overload. predialysis fluid overload can be identified by an interdialytic weight gain (idwg) assessment. the increase in fluid volume between two dialysis times, manifested by interdialytic weight gain, is the most common cause of changes in blood pressure.16 idh can occur because of the activation of the renin angiotensin aldosterone system (raas) due to hypovolemia when fluid withdrawal is carried out through ultrafiltration.17 a study showed that blood pressure increases during idh due to increased cardiac output, mediated by volume overload.18 a decrease in relative blood volume and total blood volume due to a large ultrafiltration goal decreases blood flow to the kidneys, stimulates the release of renin and causes hypertension.2 fluid regulation plays an important role in the incidence of fluid overload in hemodialysis patients. excess fluid occurs due to poor fluid intake regulation during the interdialytic period, which is characterized by a high idwg value.18 the increase in fluid volume between two dialysis times, manifested by increasing of interdialytic weight gain.19 if fluid intake is south east asia nursing research, vol 3 no 2, june 2021/ page 73-80 75 yunie armiyati / factors contributing to intradialytic hypertension in hemodialysis patients excessive, during the period between dialysis there will be a large weight gain.20 a cross sectional study on hemodialysis patients in yogyakarta showed a relationship between fluid intake and idwg.21 another study on hemodialysis patients in jakarta concluded that there was a relationship between fluid restriction selfefficacy and idwg.22 other factors related to patient characteristics can also influence the occurrence of intradialytic hypertension. these factors include age, gender, duration of hemodialysis. this study was purposed to analyze the various factors that contribute to the incidence of idh such us sex, age, length of undergoing hemodialysis, idwg, compliance with fluid regulations and ultrafiltation during hemodialysis. this research is useful to anticipate and prevent idh by controlling these factors. methods this was a descriptive quantitative study with a case control study design. the study starting by identifying subjects who had idh and did not experience idh. then the risk factors were investigated retrospectively. the study was conducted in january 2019 at two hemodialysis units in semarang indonesia. a total of 92 participants from 188 patients population were recruited in this study by using purposive sampling method and it was divided into both case (n=46) and control (n=46) groups. the inclusion criteria of this study were: patients with regular hemodialysis for more than three months, scheduled hemodialysis with a frequency of 2 times a week with a duration of hemodialysis 4-5 hours, awareness of compos mentis, can communicate verbally, aged ranged from 18 to 60 years and they were not using erythropoetin. the case group patient characteristic was the patients experienced increase in mean arterial blood pressure > 15 mmhg on dialysis sessions. a standard calibrated digital spygmomanometer as used to measure the patients’ blood pressure (bp). bp measurements were taken before, every hour during hemodialysis and after hemodialysis. measurements were applied on the patients’ arm that was not attached to the vascular access. the predialysis blood pressure was measured 5 minutes before the dialysis needle was inserted and the post-analysis blood pressure was measured 5 minutes after the dialysis needle was removed. predialysis fluid overload measured based on the idwg value which is the increase in body weight between two dialysis times, representing the addition of body fluids. fluid adherence was categorized as good adherence if idwg score was <4.8% and non-compliant (bad adherence) with idwg score > 4.8%. ultrafiltration volume or ultrafiltration goal (ufg) is the amount of fluid drawn by the hemodialysis machine during a hemodialysis session in liters. excess ufg is the amount of fluid drawn by the hemodialysis machine during one hemodialysis session in excess of 4.8% dry body weight. this study had obtained approval from the research ethics committee with the approval number: 231/kepkfkm/unimus. the principles of research ethics include confidentiality, benefits, the principles of respecting human dignity and the principles of justice. univariate analysis was used to describe the characteristic of respondents’ characteristics such as sex, age, length of undergoing hemodialysis, idwg, compliance with fluid regulations and ufg. bivariate analysis was performed by using statistical data processing software on the computer. bivariate analysis to examine the relationship between sex, age, length of hemodialysis, idwg, fluid restriction compliance and ufg. the bivariate test in this study used the chisquare test. south east asia nursing research, vol 3 no 2, june 2021/ page 73-80 76 yunie armiyati / factors contributing to intradialytic hypertension in hemodialysis patients results table 1 described that most of participants’ age in this study ranged from 35 to 65 years old with the same average number of gender category. the mean length of hemodialysis showed 18,3 months. most respondents (61%) have normal of idwg, most respondents had excessive ufg values and good fluid regulatory compliance. table 2 showed various contributing factors of idh. the case group was patients with idh (n=46), while the control group was patients without idh during hemodialysis (n=46). the finding described that idh incidence were not correlated with sex, age and length of hemodialysis. this study showed, there was a trend towards excessive idwg in the idh group with 31 (86,1%) samples when compared with non idh with 5 (13,9%) samples. most of the idh group (70%) had poor fluid adherence, while most of the non idh group (65,4%) had good fluid adherence. most of the idh group (87,8%) had excessive ufg, while most of the non idh group (80,4%) had normal ufg. table 2 also showed that contributing factors of idh were excessive of idwg (p=0,000, or=16.95, 95% ci:5,5651,65), bad fluid adherence (p=0,001, or=4,41, 95% ci:1,82-10,68) and over ultrafiltration volume (p=0,000, or = 29,52, 95% ci:9,23-94,46). table 1 characteristic of responden (n=92) indicators f % mean ± sd (min-max) age (year) 49,13 ± 8,663 (35-65) length of hemodialysis (months) 18,3 ± 15,614 (2-66) gender male 46 50 female 46 50 idwg <4,8 % (normal) 56 61 >4,8% (excessive) 36 39 fluid adherence good 52 56 bad 44 44 ultrafiltration goal normal 51 45 over (excessive) 41 55 table 2 contributing factors of intradialytic hypertension indicators case control p-value* or (95%ci) f % f % sex male 26 56,5 20 43,5 0,149 0,592 (0,259-1,349) female 20 43,5 26 56,5 age < 45 years 24 58,5 17 41,5 0,104 0,537 (0,234-1,235) > 45 years 22 43,1 29 56,9 length of hemodialysis < 12 months 25 52,1 23 47,9 0,417 0,840 (0,370-1,905) > 12 months 21 47,7 23 52,3 idwg < 4,8 % (normal) 15 26,8 41 73,2 0,00 16.95 (5,56-51,65) > 4,8% (excessive) 31 86,1 5 13,9 fluid adherence good 18 34,6 34 65,4 0,00 4,41 (1,82-10,68) bad 28 70,0 12 30,0 ultrafiltration volume (ufg) normal 10 19,6 41 80,4 0,00 29,52 (9,23-94,46) over (excessive) 36 87,8 5 12,2 *chi-square test south east asia nursing research, vol 3 no 2, june 2021/ page 73-80 77 yunie armiyati / factors contributing to intradialytic hypertension in hemodialysis patients discussion the findings of this study indicate that idwg has a great contribution to the incidence of idh. this study found that hemodialysis patients with a high/over idwg 4.8% had a 16.95 chance of experiencing idh. idwg is the increase in body weight between two dialysis times which represents the addition of fluid in the body. an increase in fluid volume as manifested by an increase in body weight can be seen with an increase in idwg level.23 one kilogram of weight gain is equivalent to one litter of water consumed by the patient. this study confirms the findings of the previous studies. a study in china showed that post-dialysis volume expansion is an important factor for the development of idh.24 previous study in jakarta described there was a trend towards predialysis excess fluid in the idh group. subclinical fluid overload was higher in idh group.25 previous research at semarang also stated that idwg is the one of the important factor influencing hemodialysis blood pressure in patients with chronic renal failure.26 there is a significant relationship between interdialytic weight gain and changes in intradialytic blood pressure in ckd patients. the smaller the idwg level, the lower intradialytic blood pressure.12 the increase in idwg contributes to systolic blood pressure elevation, the bp will increase by about 3 mmhg for every 1 kg of extra body weight.27 the findings of another american study also showed that every 1% increase in the percentage of idwg is associated with an increase of 1.00 mm hg (95% ci ± 0.24) in predialysis systolic blood pressure and 1.08 mm hg ( 95% ci ± 0.22) in systolic blood pressure during hemodialysis.28 this means that excess idwg has a high chance of occurrence of idh. a case control study used bioimpedance spectroscopy and impedance cardiography to compare pre-dialysis, postdialysis, and intradialytic change in total body water and extracellular water, as well as cardiac index and total peripheral resistance index (tpri) found recurrent intradialytic hypertension is associated with higher post-dialysis extracellular volume and tpri. intradialytic tpri surges account for the vasoconstrictive state postdialysis.29 result of this study also linear with other study in south africa, there was a trend towards pre-dialysis overhydration in the idh group when compared with controls 2,6 l (95% ci 1.7-3.4) versus 1.8 l (95% ci 1.4-2.1), respectively; p = 0.06 as measured by bioimpedance spectroscopy.30 a study in china also showed that poor idwg control, left ventricel diastolic dysfunction might be associated with increasing prevalence of idh in maintenance hemodialisis patients.31 if the idwg level increases more than 4.8% of dry weight, it can cause complications, including idh, left heart failure and decreased quality.32 an excessive idwg describes a buildup of fluid in the body that is excess. excess fluid (overload) causes an increase in cardiac output which is one of the important causes of increased blood pressure. hypervolumia (fluid overload) is believed to play a role in the pathogenesis of intradialytic hypertension, so controlling the volume overload is important in preventing and managing the occurrence of idh.33 the findings of previous studies in medan also concluded that high idwg was associated with the incidence of intradialysis complications such as the occurrence of intradialysis hypertension.34 the high idwg also increases the occurrence of other intradialysis complications. a study in purwokerto showed that there was correlation between idwg and intradialytic complications in patients with a hemodialysis treatment. several intradialysis complications associated with high idwg including intradialytic hypertension (85.7%), followed by muscle cramps (55.4%), nausea (51.8%), headache (46.4%) and chest pain.35 south east asia nursing research, vol 3 no 2, june 2021/ page 73-80 78 yunie armiyati / factors contributing to intradialytic hypertension in hemodialysis patients patients with idh have an increased mortality risk compared to patients with modest decreases in bp during dialysis. idh is associated with extracellular volume overload in addition to acute increases in vascular resistance during dialysis. management strategies should include reevaluation of dry weight.29 control of idwg and modification dry body weight is needed to prevent an increase in the incidence of idh. a study in china showed that the decrease in dry weight was associated with significantly higher decreases in angiotensin-ii. reducing fluid overload in idh patients with high predialytic bp can effectively improve their bp, but had no effect on bp in normal predialytic bp idh cases.36 fluid excess (overload) can also be associated with adherence to fluid intake restriction. the findings of this study indicate that poor fluid adherence correlated with incident of idh. this study showed that hemodialysis patients who did not comply with fluid intake restrictions have a risk of having idh 4.41 times. this study showed 70% of patients who were not adherent to restriction of fluid intake had idh. patients who are were not adherent to fluid diet will experience an increase in idwg. the research findings and justification are supported by the findings of previous research, that there is a relationship between self-efficacy’s fluid restriction and idwg.22 an increase in idwg contributes to fluid overload and the incidence of intradialytic hypertension. a study on 41 hemodialysis patients in semarang also showed that 86.67% of patients who were non-adherent to fluid diet had idwg > 4.8%.37 patients are said to be compliant if the intake of fluids is not more than the recommended intake. if the patient is not adherent, the risk of idh is higher, the risk of intradialytic hypertension should be lower. the findings of this study suggest that increased ultrafiltration during hemodialysis increases the risk of idh. excessive / over ufg (ultrafiltration volume) is the most dominant risk factor in the high incidence of idh on this study, patients with excessive ultrafiltration have a 29.52 times risk of developing idh. the findings of this study reinforce the results of previous research, that the amount of ultrafiltration during hemodialysis has a positive correlation with the incidence of increased intradialytic blood pressure with p = 0.003 and r = 0.42.38 another study conducted on 112 hemodialysis patients in semarang showed that the greater the ufg and ufr the higher the intradialialysis blood pressure (r 0,211-0,320). the magnitude of ufg an asccociated with increase in intradialytic systolic (p=0,024; r=0,213), intradialytic diastolic (p=0,007; r=0,252) and mean arterial pressure (p=0,016; r=0,227). high ufr is associated with with increase in intradialytic systolic (p=0,037; r=0,211), intradialytic diastolic (p=0,001; r=0,320) and mean arterial pressure with p=0,034.39 excessive ultrafiltration during hemodialysis due to high idwg will lead to activation of the sympathetic nervous system, raas, and increased cardiac output. the process with intradialytic ultrafiltration risks reduce the relative blood volume (rbv) and total blood volume (tbv). the decrease in rbv and tbv will decrease blood flow to the kidneys and stimulate renin release. renin stimulates angiotensin i to angiotensin ii causing vasoconstriction and aldosterone secretion.2 determination of the amount of utrafiltration must be optimal to achieve normotensive conditions in hemodialysis patients. when hemodialysis ufg determination is determined to attract excess, the magnitude of the ufg may depend on the addition of the idwg and the target dry weight of the patient.23 high ufg can lead intradialytic vascular resistance. intradialytic vascular resistance surges remain implicated as the driving force for blood pressure increases.5 south east asia nursing research, vol 3 no 2, june 2021/ page 73-80 79 yunie armiyati / factors contributing to intradialytic hypertension in hemodialysis patients management of hemodialysis patients must include of controlling idwg, fluid adherence and ultrafiltration. a greater increase in interdialytic weight, requires lower fluid and higher ultrafiltration must be controlled precisely because it is a risk factor for the high incidence of idh conclusion the results of this study can be concluded that that contributing factors of idh are excessive idwg, low / bad fluid adherence and excessive ultrafiltration. excessive ultrafiltration volume is the most dominant risk factor in the high incidence of idh. idh incidence not correlated with sex, age and length of hemodialysis. acknowledgment special thanks to patients, nurses and doctors at two hemodialysis units in semarang. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. pernefri. 10th report of indonesian renal registry 2017. pernefri, editor. jakarta: perhimpunan nefrologi indonesia (pernefri).; 2017. 2. hinkle jl, cheever kh. brunner and suddarth’s textbook of medical surgical nursing. 14th ed. squazzo k, editor. vol. 1. philadelphia: wolters kluwer; 2018. p. 6112. 3. pernefri. 11th report of indonesian renal registry. 2018. jakarta: indonesia renal registry; 2018. p. 46. 4. kallenbach jz. review of hemodialysis for nurses and dialysis 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16. chazot c. use of a restricted-salt diet. semin dial. 2009;22:482–6. 17. kandarini y. peran ultrafiltrasi terhadap hipertensi intradialitik dan hubungannya perubahan kadar: endothelin-1, asymmetric dimethylarginin dan nitric oxide. universitas airlangg; 2012. 18. agarwal r, light rp. intradialytic hypertension is a marker of volume excess. nephrol dial transpl. 2010/04/20. 2010;25:3355–61. 19. chazot c, jean g. intradialytic hypertension: it is time to act. nephron clin pr. 2010/04/24. south east asia nursing research, vol 3 no 2, june 2021/ page 73-80 80 yunie armiyati / factors contributing to intradialytic hypertension in hemodialysis patients 2010;115:c182-8. 20. suwitra k. penyakit ginjal kronik. in: sudoyo aw, setiyohadi b, alwi i, k msi, setiati s, editors. buku ajar ilmu penyakit dalam. 6th ed. jakarta: fk-ui; 2014. p. 570–3. 21. istanti yp. faktor-faktor yang berkontribusi terhadap interdialytic weight gains pada pasien chronic kidney diseases yang menjalani hemodialisis. mutiara med j kedokt dan kesehat. 2016;11:118–30. 22. priska np, herlina s. efikasi diri pembatasan cairan terhadap intradialytic weight gain pasien gagal ginjal kronik di ruang hemodialisa rsud pasar minggu. j ilm ilmu keperawatan indones. 2019;9:601–8. 23. nkf. update of the kdoqi clinical practice guideline for hemodialysis adequacy. minessota: national kidney foundation; 2015. 24. ren h, gong d, he x, jia f, he q, xu b, et al. evaluation of intradialytic hypertension using bioelectrical impedance combined with echocardiography in maintenance hemodialysis patients. ther apher dial. 2017/12/08. 2018;22:22–30. 25. gathmyr d, nugroho p, awang i, lydia a, bawazier la, khumaedi i, et al. contributing factors of intradialytic hypertension in maintenance haemodialysis patients. j hypertens. 2021;39:e409. 26. lolyta r, solechan a. analisis faktor yang mempengaruhi tekanan darah hemodialisis pada klien gagal ginjal kronik (studi kasus di rs telogorejo semarang). j ilmu keperawatan dan kebidanan. 2012;1:58–70. 27. oshvandi k, fathabadi ma, falahi nia gh, mahjub h, adib-hajbaghery m. effects of small group education on interdialytic weight gain, and blood pressures in hemodialysis patients. nurs midwifery stud. 2013;1:128–32. 28. inrig jk, oddone ez, hasselblad v, gillespie b, patel ud, reddan d, et al. association of intradialytic blood pressure changes with hospitalization and mortality rates in prevalent esrd patients. kidney int. 2007;71:454–61. 29. van buren pn, inrig jk. mechanisms and treatment of intradialytic hypertension. blood purif. 2016;41:188–93. 30. sebastian s, filmalter c, harvey j, chothia my. intradialytic hypertension during chronic haemodialysis and subclinical fluid overload assessed by bioimpedance spectroscopy. clin kidney j. 2016/08/02. 2016;9:636–43. 31. zou lx, sun l. forecast post-dialysis blood pressure in hemodialysis patients with intradialytic hypertension. clin exp hypertens. 2018/10/17. 2019;41:571–6. 32. pace rc. fluid management in patients on hemodialysis. nephrol nurs j. 2007;34:557. 33. locatelli f, cavalli a, tucci b. the growing problem of intradialytic hypertension. nat rev nephrol. 2009/11/26. 2010;6:41–8. 34. widiyanto p, hadi h, wibowo t. korelasi positif perubahan berat badan interdialisis dengan perubahan tekanan darah pasien post hemodialisa. j ners dan kebidanan indones. 2014;2:1–8. 35. suparti s, febrianti h. is there anycorrelation between intradialytic complications and interdialytic weight gain (idwg)? ann trop med public heal. 2019;22:145–9. 36. zhang y, zhang x, li j, liu x, cui c, yuan a, et al. dry-weight reduction improves intradialytic hypertension only in patients with high predialytic blood pressure. blood press monit. 2019/02/27. 2019;24:185–90. 37. andriyani da, armiyati y. karakteristik pasien terhadap idwg pada pasien penyakit ginjal kronis yang menjalani hemodialisis di rsud kota semarang. semarang: unimus; 2013. 38. johan a. hubungan besar ultrafiltrasi saat hemodialisis dengan kejadian peningkatan tekanan darah intradialitik pada pasien gagal ginjal kronik. 2016; 39. armiyati y, hadisaputro s, chasani s, sujianto u. high ultrafiltration increasing intradialytic blood pressure on hemodialysis patients. south east asia nurs res. 2021;3:8–15. risk factors of stunting in toddlers 24-59 months in rembang regency, indonesia corresponding author: hema dewi anggraheny hemadewi@unimus.ac.id south east asia nursing research, vol 4 no 1, march 2022 issn:2685-032x doi: https://doi.org/10.26714/seanr.4.1.2022.7-13 original research risk factors of stunting in toddlers 24-59 months in rembang regency, indonesia galuh ramaningrum1, hema dewi anggraheny2, aisyah lahdji2 1 department of pediatric, faculty of medicine, universitas muhammadiyah semarang, indonesia 2 department of public health, faculty of medicine, universitas muhammadiyah semarang, indonesia article info abstract article history: submitted: dec 26th 2021 accepted: march 1st 2022 published: march 29th 2022 keywords: factors; stunting; toddlers rembang regency is an area in central java with a fairly high stunting rate, in 2017 it reached 32.36%. the sedan health center is located in rembang regency with a stunting prevalence in 2019 of 7.16%. this is still a serious problem in the region. risk factors for stunting include child and maternal risk factors. child risk factors include food intake, birth weight, gender, history of chronic disease, history of breastfeeding, complementary foods, socio-economic, environmental sanitation, and immunization status. the purpose of this study was to determine what factors influence stunting in the working area of the sedan health center. this research used observational analytic research with a case-control design and has been matched based on age. the research was carried out from january-february 2021. the number of samples was 45 cases (stunted toddlers) and 45 controls (non-stunted toddlers). data were collected by measuring the height of children under five and interviewing with a questionnaire. data analysis used the chi-square test and logistic regression test. variables of energy intake (p=0.000), protein, history of exclusive breastfeeding (p=0.000), history of complementary feeding (p=0.000), number of family members (p=0.001), and family sanitation (p=0.000) had significant outcome was associated with the incidence of stunting. the most influential factor is the history of complementary foods. stunting cases occur in children with low energy and protein intake. a varied food intake especially with a high-calorie and highprotein composition can prevent children from stunting. introduction stunting is a condition of failure to thrive due to chronic malnutrition, so that it looks short for its age. this nutritional deficiency occurs in the first 1000 days of life. stunting can be diagnosed at the age of 2 years. according to the 2018 global nutrition report (gnr), every country in the world experiences nutritional problems, including stunting 22.2% (150.8 million), wasting 7.5% (50.5 million), and overweight 5.6% (38 million). 3 million). indonesia is one of the countries with stunting, overweight, and wasting nutritional problems, and is the 5th country with the highest number of stunting underfives.1 based on riskesdas data, the prevalence of stunting in indonesia in 2007 was 39.8%, in 2013 there was 37.2% and in 2018 it was https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.4.1.2022.7-13&domain=pdf&date_stamp=2022-03-29 south east asia nursing research, vol 4 no 1, march 2022/ page 7-13 8 hema dewi anggraheny / risk factors of stunting in toddlers 24-59 months in rembang regency, indonesia 30.8%.2 according to the 2019 susenas integrated toddler nutrition status study, stunting cases in 2019 became 27, 67%.3 central java province in 2019 stunting cases were quite high at 27.68%.2 one of them that is of concern is rembang regency. the percentage of stunting cases in rembang regency in 2015-2017 was 38.5%, 25.99%, and 32.36%. meanwhile, the prevalence of stunting at the sedan health center in 2019 was 7.16% (274 toddlers), which is still below the expected target. the impact of stunting on toddlers can reduce intelligence, susceptible to infectious diseases. toddlers who experience stunting in early life will experience permanent damage, causing motor, cognitive, and intellectual development disorders that have an impact on education. in addition, stunting can also have an impact on income and work productivity so that economic growth will deteriorate.3 stunting is influenced by maternal and child factors. maternal factors include a history of infection in the mother, teenage pregnancy, hypertension in the mother, the level of education and knowledge of the mother. child factors include gender, age, birth weight, food intake, especially protein and energy, and history of infectious diseases, history of breastfeeding and complementary feeding, immunization, parents' socioeconomic, number of family members, and environmental sanitation.4–8 this study aims to analyze the relationship between risk factors including factors in children, namely gender, age, birth weight, food intake, especially protein and energy, and history of infectious diseases, history of breastfeeding and complementary feeding, immunization, socioeconomic status of people. old age, number of family members, and environmental sanitation. as well as factors in the mother include maternal education. by knowing which factors influence it, it can be a reference to prevent stunting by improving existing risk factors. methods this research is an analytic observational study with a case control design and has been matched based on age. the study was conducted in the working area of the sedan public health center, rembang regency in january-februari 2021. primary data were obtained from filling out a questionnaire on the variables of energy and protein intake using the semiquantitative food frequency questionnaire (sq-ffq) and measuring the height of toddlers. secondary data was obtained from the puskesmas to find out stunting data. the sample collection method used consecutive sampling technique by meeting the inclusion criteria in the case group, namely children aged 24-59 months with an index of height/age <-2 sd, a control group of children aged 24-59 months with an index of height/age >-2 sd and willing be a respondent. exclusion criteria were toddlers aged 24-59 months who suffered from congenital diseases such as congenital heart disease, bone dysplasia, and familial short stature. toddlers aged 24-59 months who have chromosomal disorders such as down syndrome, turner syndrome. toddlers aged 24-59 months suffering from endocrine disorders such as hypothyroidism, cushing's syndrome. the sample size used was 90 subjects, 45 were stunted and 45 were not stunted. analysis using chi-square and logistic regression. this research has received ethical approval from the health research ethics committee, faculty of medicine, university of muhammadiyah semarang with number 020/ec/fk/2021. results most of the respondents in the case and control groups were female (53.3% in both groups), normal birth weight (86.7% in cases and 97.8% in controls), middle maternal education (53.3% in cases and 55.6% in controls), had no previous history of chronic disease (93.3% in cases and 100% in controls), mothers did not work south east asia nursing research, vol 4 no 1, march 2022/ page 7-13 9 hema dewi anggraheny / risk factors of stunting in toddlers 24-59 months in rembang regency, indonesia (82.2% in cases, and 91.1% in controls), and with complete immunization status (91.1% in cases and 100% in controls). there were contradictory results between the case and control groups. most of the case group received low energy (75.6%) and protein (53.3%) intake, history of not exclusive breastfeeding (64.4%), history of complementary feeding for less than 6 months (60%), total family members more than 4 (64.4%), and unhealthy environmental sanitation (80%). while in the control group, most of them received adequate energy (91.1%) and protein (95.6%) intake, history of exclusive breastfeeding (86.7%), history of complementary feeding 6 months (91.1%), number of family members 4 (73.3%), and healthy environmental sanitation (60%). south east asia nursing research, vol 4 no 1, march 2022/ page 7-13 10 hema dewi anggraheny / risk factors of stunting in toddlers 24-59 months in rembang regency, indonesia table 1 stunting risk factors analysis child risk factors stunting total or (95% ci) lower-upper p yes = 45 no = 45 n % n % n % energy intake less enough 34 11 75,6% 24,4% 4 41 8,9% 91,1% 38 52 42,2 % 57,8 % 31,682 (9,248108,539) 0,000* protein intake less enough 24 21 53,3% 46,7% 2 43 4,4% 95,6 26 64 28,9% 71,1% 24,571 (5,300113,926) 0,000* gender male female 21 24 46,7% 53,3% 21 24 46,7% 53,3% 42 48 46,7% 53,3% 1,000 (0,437-2,289) 1,000 birth weight low birth normal 6 39 13,3% 86,7% 1 44 2,2% 97,8% 7 83 7,8% 92,2% 6,769 (0,78058,723) 0,110 history of chronic infection yes no 3 42 6,7% 93,3% 0 45 0,0% 100% 3 87 3,3% 96,7% 0,242 history of exclusive breastfeeding no yes 29 16 64,4% 35,6% 6 39 13,3% 86,7% 35 55 38,9% 61,1% 11,781 (4,10633,808) 0,000* history of complementary food < 6 bulan ≥ 6 bulan 27 18 60% 40% 4 41 8,9% 91,1% 31 59 34,4% 65,6% 15,375 (4,69050,404) 0,000* number of family member big small 29 16 64,4% 35,6% 12 33 26,7% 73,3% 41 49 45,6% 54,4% 4,984 (2,02812,253) 0,001* mother’s education basic medium high 10 24 11 22,2% 53,3% 24,4% 10 25 10 22,2% 55,6% 22,2% 20 49 21 22,2% 54,4% 23,3% 0,967 mom’s job work doesn’t work 8 37 17,8% 82,2% 4 41 8,9% 91,1% 12 78 13,3% 86,7% 2,216 (0,6167,970) 0,352 environmental sanitation not healthy healthy 36 9 80% 20% 18 27 40% 60% 54 36 60% 40% 6,000 (2,33715,406) 0,000* imunization statue not complete complete 4 41 8,9% 91,1% 0 45 0% 100% 4 86 4,4% 95,6% 2,098 (1,6812,617) 0,117 *p<0,05 from table 1, there are 45 toddlers who experience stunting, 34 (75.6%) toddlers have a nutritional adequacy rate of less energy. from the statistical test with the chi square test, the value of p = 0.000 (p < 0.05 or significant) and the value of odd ratio (or ) 31.682 (95% ci:9.248-108.539), it can be concluded that lack of energy intake has a risk factor. 31,682 times the incidence of stunting. in the risk factor for protein intake, the majority of stunting under-fives received a protein adequacy rate of 24 (53.3%) under five. from the chi square statistical test, the value of p = 0.000 (p <0.05 or significant) and the value of odd ratio (or) 24,571 (95% ci:5,300-113.926), south east asia nursing research, vol 4 no 1, march 2022/ page 7-13 11 hema dewi anggraheny / risk factors of stunting in toddlers 24-59 months in rembang regency, indonesia it can be concluded that protein intake has a 24 times chance of being stunted. in the risk factor for the gender of children under five who experience stunting, the majority of them are female, there are 24 (50%) children under five. from the chi square test, the value of p = 1,000 (p > 0.05 or not significant) and the value of odd ratio (or ) 1,000 (95% ci: 0.437-2.289), it can be concluded that gender is not a risk factor for stunting. the majority of stunting toddlers did not receive exclusive breastfeeding as many as 29 (64.4%). from the chi-square test, p value = 0.000 (p <0.05 or significant) and the odd ratio (or) value of 11.781 (95% ci: 4,106-33.808). in conclusion, a history of exclusive breastfeeding has an 11-fold chance of being stunted. the majority of under-fives who experienced stunting with the age of giving complementary food <6 months were 27 (60%). chi-square test obtained p value = 0.000 (p < 0.05 or significant) and the value of odd ratio (or ) 15.375 (95% ci: 4,690-50,404), it can be concluded that the history of the age of complementary feeding has a risk factor of 15 times the incidence of stunting. the majority of stunting toddlers with family members 4 (large) as many as 29 (64.4%). chi-square test obtained p value = 0.001 (p < 0.05 or significant) and the value of odd ratio (or) 4.984 (95% ci: 2.02812.253), it can be concluded that the number of family members has a risk factor 4 times against stunting incident. the majority of unhealthy environment sanitation is 36 (80%) who are stunted. the results of statistical tests using the chisquare test obtained a p value = 0.000 (p <0.05 or significant), and an odd ratio (or) value of 6.000 (95% ci: 2.337-15.406), it can be concluded that environmental sanitation has a risk factor of 6 times the incidence of stunting. the most important risk factor is history time to start complementary food, where toddlers with complementary food < 6 months have a risk factor of 15.375 times experiencing stunting than toddlers with complementary food ≥ 6 months. discussion in this study, it was found that nutritional intake of energy was lacking because the majority of toddlers consumed food that did not vary, the amount did not match their intake needs, and preferred to consume light food. the energy needed by toddlers is 2 times greater than adults because they are in the process of growth and development.9 the majority of respondents in the case group had a low nutritional adequacy rate. this happens because the majority of toddlers consume little protein, especially animal protein which is very high in content. toddlers prefer protein from vegetable sources, apart from the lack of knowledge about nutrition, also because of the socioeconomic status at the research site, so they are limited in consuming animal protein. this is similar to several other studies which state that there is a relationship between adequate protein intake and stunting.9,10 history of early time receiving complementary feeding is a variable associated with stunting in this study. most of the case groups received complementary feeding at the age of less than 6 months. toddlers who received complementary food less than 6 months, the majority of parents lacked knowledge about the dangers of inappropriate complementary food. besides that, mostly in the area, toddlers who were less than 6 months had already been given food. the provision of age-appropriate complementary food will prevent toddlers from stunting, because toddlers receive exclusive breastfeeding and at 6 months digestion is ready to digest so that the nutrients are fulfilled. this study is similar to other studies which state that there is a relationship between the early age of complementary feeding and the incidence of stunting.10 south east asia nursing research, vol 4 no 1, march 2022/ page 7-13 12 hema dewi anggraheny / risk factors of stunting in toddlers 24-59 months in rembang regency, indonesia the number of family members associated with the incidence of stunting in this study. the number of family members affects the supply and distribution of food in the family. family size determines intake intake for each family member. the large number of family members must be in line with high socio-economic conditions so that each family member is met with nutrients.4 environmental sanitation is also a factor associated with the incidence of stunting in this study. in the results of the study, for house components such as the state of the walls, floors, ventilation, smoke holes in less condition because the majority of houses are in a simple state. sanitation facilities such as waste water, latrines, waste water disposal and trash bins are not good because for disposal of waste directly flowed into rivers and for daily trash dumped in open dumps and some are dumped directly into rivers. this happens because they are in a densely populated house and are in an environment with low socioeconomic status. to support human health, good environmental sanitation is needed.11 unhealthy sanitation conditions will cause problems such as decreased quality of life, water pollution, and the emergence of infectious diseases. poor sanitation can lead to stunting associated with the possibility of the emergence of infectious diseases. several other studies have also stated that environmental sanitation is associated with stunting.11 conclusions the energy and protein intake, history of exclusive breastfeeding, history of complementary food, number of family member, and environmental sanitation were the risk factors of stunting. the most influencing factor is history of complementary food. stunting cases occur in children with low energy and protein intake. a varied food intake especially with a high-calorie and high-protein composition, can prevent children from stunting. acknowledgment the author would like to thank faculty of medicine universitas muhammadiyah semarang which has supported this research. references 1. kementerian kesehatan republik indonesia. kebijakan dan strategy penanggulangan stunting di indonesia. 2nd ed. 1. kementerian kesehatan republik indonesia; 2019. 3–6 p. 2. badan penelitian dan pengembangan kesehatan kementerian ri. riset kesehatan dasar tahun 2018. 2020. 3. yadika adn, berawi kn ns. pengaruh stunting terhadap perkembangan kognitif dan prestasi belajar. j major. 2019;8:273–82. 4. mugianti s, mulyadi a, khoirul a az. faktor penyebab anak stunting usia 25-60 bulan di kecamatan sukorejo kota blitar. j ners dan kebidanan. 2018;5:268–78. 5. winowatan g, malonda nsh pm. hubungan antara berat badan lahir anak dengan kejadian stunting pada anak batita di wilayah kerja puskesmas sonder kabupaten minahasa. kesmas. 2017;6. 6. nasrul, hafid f, thaha ra s. faktor risiko stunting usia 6-23 bulan di kecamatan bontoramba kabupaten jeneponto. media kesehat masy indones. 2015;11:139–46. 7. maywita e pn. determinan pengaruh tingkat pendidikan dan pengetahuan ibu dengan kejadian stunting bayi 6-24 bulan. hum care j. 2019;4:173–7. 8. lailatul m nc. hubungan tingkat pendidikan, tingkat pengetahuan dan pola asuh ibu dengan wasting dan stunting pada balita keluarga miskin. media gizi indones. 2015;84–90. 9. nurmalasari y, sjariani t sp. hubungan tingkat kecukupan protein dengan kejadian stunting pada balita usia 6-59 bulan di desa mataram ilir kec. seputih surabaya kabupaten lampung tengah tahun 2019. j ilmu kedokt dan kesehat. 2019;6:92–7. 10. prihutama ny, rahmadi fa hg. pemberian makanan pendamping asi dini sebagai faktor risiko kejadian stunting pada anak usia 2-3 tahun. j kedokt diponegoro. 2018;7:1419–30. 11. wulandari ww rf. hubungan sanitasi south east asia nursing research, vol 4 no 1, march 2022/ page 7-13 13 hema dewi anggraheny / risk factors of stunting in toddlers 24-59 months in rembang regency, indonesia lingkungan dan riwayat penyakit infeksi dengan kejadian stunting di wilayah kerja puskesmas kerkap kabupaten bengkulu utara tahun 2019. avicenna j ilm. 2019;14:6–13. reduction of anxiety levels in schizophrenia patients using progressive muscle relaxation corresponding author: yanah kuscianah kuswa ykuswa@moh.gov.sa south east asia nursing research, vol 3 no 2, june 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.2.2021.90-97 case study reduction of anxiety levels in schizophrenia patients using progressive muscle relaxation yanah kuscianah kuswa1 1 eredah complex mental health hospital, najran, saudi arabia. article info abstract article history: submitted: may 26th 2021 accepted: june 14th 2021 published: june 23rd 2021 keywords: progressive muscle relaxation; anxiety; schizophrenia anxiety neurosis is the most common mental disorder in society. progressive muscle relaxation is an independent nursing intervention that can be chosen to reduce anxiety in schizophrenia patients. this case study aims to prove that progressive muscle relaxation can help reduce anxiety levels in schizophrenic patients. the study design is descriptive in the form of a case study with a nursing process approach, applying progressive muscle relaxation techniques to schizophrenic patients who experience problems with anxiety levels. the sample was two adult schizophrenic patients who experienced anxiety in eredah complex mental health hospital. the patient's anxiety was measured by the zung-self anxiety rating scale. the progressive muscle relaxation procedure is performed 2 times over two days with a duration of 20-30 minutes each session. hemodynamic measurements and anxiety levels were performed pre-post progressive muscle relaxation. the results of the case study showed that progressive muscle relaxation interventions affected reducing patient anxiety levels. the mean score of the patient's anxiety decreased by 30.34% after being given progressive muscle relaxation. progressive muscle relaxation is effectively applied to schizophrenic patients with anxiety disorders in nursing service settings. introduction schizophrenia is a functional psychosis with major disorders of the thought process as well as disharmony between thought processes, affections or emotions, willpower and psychomotor accompanied by distortions of reality mainly due to delusions and hallucinations, dissociation so that incoherence, affective and emotional imbalance arise, psychomotor shows withdrawal, ambivalence and bizarre behavior.1 schizophrenic patients experience impaired current formation as well as the content of the mind. in addition, there are also disturbances of perception, self-insight, feelings and desires. in schizophrenia it is found that 7 per 1000 adults, aged mostly between 15-35 years’ patients experienced disinterest, isolation, unruly and anxious behavior.2 anxiety is an emotional response to judgment that describes a state of worry, anxiety, fear of insecurity accompanied by various physical complaints. these circumstances can occur in a variety of life situations besides illness disorders. in https://doi.org/10.26714/seanr.3.2.2021.90-97 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.2.2021.90-97&domain=pdf&date_stamp=2021-06-23 south east asia nursing research, vol 3 no 2, june 2021/ page 90-97 91 yanah kuscianah kuswa / reduction of anxiety levels in schizophrenia patients using progressive muscle relaxation addition, anxiety can cause a reaction that will occurs in a repeated manner, such as emptiness in the stomach, shortness of breath, heart palpitations, sweating profoundly, headaches, desire to urinate and defecate, this feeling is accompanied by a feeling of wanting to move to run away from things that are worried. anxiety if kept untreated it can affect both physical and psychological conditions.3 a who 2019 report shows that depression and anxiety can cause global economic losses of 1 trillion $ annually due to loss of human resource productivity.4 the most psychotic mental disorders are schizophrenia. such disorders can be in the form of speech and disorganized behavior, flat affect, excessive motor activity, uncontrollable movements, there is also anger, keeping isolated and even resulting in anxiety. if the anxiety is not resolved immediately, then the schizophrenic client will experience a deterioration of his life function including the healing process will be hamper.3 the most psychotic mental disorders are schizophrenia. such disorders can be in the form of speech and disorganized behavior, flat affect, excessive motor activity, uncontrollable movements, there is also anger, keeping isolated and even resulting in anxiety. if the anxiety is not resolved immediately, then the schizophrenic client will experience a deterioration of his life function including the healing process will be hampered.5 a person who is experiencing anxiety, tends to experience changes in perception and has negative thoughts related to the problems they face. if a person is always negativeminded then there are several impacts including: decreased health status, decreased function of one's adaptation to environmental changes, pessimistic attitude towards the future and tendency to depression and decreased quality of life. therefore, an intervention is needed that can break the cycle of negative thoughts experienced by individuals experiencing anxiety6, and progressive muscle relaxation.7 previous research suggests progressive muscle relaxation effectively that can have reduced anxiety in schizophrenic patients because progressive relaxation exercises are one of the proven muscle relaxation techniques in therapy programs against muscle tension abled to overcome complaints of anxiety, insomnia, fatigue, muscle cramps, neck and waist pain, high blood pressure, mild phobia and stuttering. progressive relaxation techniques can be used for the execution of psychic problems. relaxation produced by progressive muscle relaxation techniques can be beneficial for lowering anxiety.7 this case study relates to a progressive muscle relaxation technique which is one of the behavioral therapies used for schizophrenic patients experiencing anxiety. progressive relaxation is one of the nursing interventions that can be used as an action to improve comfort, relaxation that can affect physiological and psychological responses. this intervention was chosen because it is easy to do, can be used in a variety of situations, easy to learn, cheap and safe. relaxation is one form of mind body therapy in complementary therapy (complementary and alternative therapy). relaxation has the effect of a calming sensation of the limbs, lightness, and feeling warmth that spreads throughout the body. changes that occur during and after relaxation affect the work of the autonomic nervous system. the emotional response and calming effects posed by this relaxation turn the dominant physiology of the sympathetic into the dominant parasympathetic system.8 catecholamine and cortisol hypersecretion in anxious state is lowered and increases parasympathetic hormones as well as neurotransmitters such as dehydroepinandrosterone (dhea) and dopamine or endorphins. the regulation of this parasympathetic system eventually caused a calming effect.9 the purpose of this case study is to help lower the anxiety levels of schizophrenic patients with progressive muscle relaxation therapy. south east asia nursing research, vol 3 no 2, june 2021/ page 90-97 92 yanah kuscianah kuswa / reduction of anxiety levels in schizophrenia patients using progressive muscle relaxation methods this case study uses descriptive design with a nursing care process approach. the subject of this case study was a schizophrenic patient who was hospitalized at saudi arabia's eradah complex for mental health (ermhn). the study subjects were two schizophrenia patients who experienced anxiety who were random selected. the inclusion criteria of study subjects were female, mature age and able to communicate verbally. this case study was conducted on december 2020. regarding the selected case, the problem is anxious nursing care in schizophrenic clients with a study focus on the effect of progressive relaxation on patient anxiety levels. data collection is conducted by interviewing patients, the patient's family and from the patient's medical record. observation of anxiety levels is done by paying attention to the signs and symptoms of anxiety that appear, measured by the questionnaire zung–self rating anxiety, scale as a gauge of anxiety levels that have been tested validity and reliability.10 progressive muscle relaxation procedure, each session starts from recommending the subject to wear comfortable and not narrow clothes. the next procedure performs relaxation of the jaw muscles, recommends stretching the muscles for 5 to 10 seconds, relaxing the muscles 20-30 seconds, 8 to 16 times each, followed by stretching the leg muscles for no more than 5 seconds to avoid cramping. during the procedure the nurse recommends focusing on the stretched muscles, focusing on relaxing muscle sensations and recommending a slow deep breath. the procedure is carried out 2 times over two days with a duration of 20-30 minutes each session, carried out in a quiet place. both patients continued to take the drug according to their pharmacological therapy program. progressive muscle relaxation procedure is carried out 10-15 minutes after taking antidepressant drugs. the focus of interventions to lower anxiety levels, respondents helped create a therapeutic state to induce trust, assist patients to reduce their anxiety and listen attentively to all complaints. both patients are also advised to conduct their outside the meeting session. this study applies research ethics. case study subjects are given the freedom to be the subject of a case study after being given an understanding of the purpose and benefits of progressive muscle relaxation therapy. case study subjects are required to sign an approval sheet prepared by the researcher and the name of the case study subject is not displayed in the publication text. the management of the obtained case study data was presented and analyzed to determine the decrease in anxiety score after progressive muscle relaxation. the data of patient anxiety are presented in the form of tables . results two of subject studies were muslim, female with the age between 30-40 years. both subjects of the case study found anxiety was evidenced by complaints of insomnia, irritability, feeling sad, feeling confused and worried. objectively it looks tense and restless. measurement of the anxiety levels of both subjects using the zung–self rating anxiety scale. the results of the second anxious level measurement of the study subjects were a score of 45 for case 1 subjects and a score of 44 on case 2 subjects. both study subjects belonged to the moderate anxiety level category. both case study subjects obtained antidepressant medications. the subject of the first case study got therapy benzodiazepam (tablets clonazepam 2 mg hours of sleep and tablets escitalopram 10mg once daily). subject of two case studies given antidepressant therapy (tablets escitalopram 20mg once dalily and mirtazapin 30mg hours of sleep). south east asia nursing research, vol 3 no 2, june 2021/ page 90-97 93 yanah kuscianah kuswa / reduction of anxiety levels in schizophrenia patients using progressive muscle relaxation the primary nursing diagnosis of both patients is anxiety related to crisis situation.11 the diagnosis of nursing is characterized by the appearance of symptoms of subjective major signs that the patient feels confused and worried and physically appears tense, restless and has difficulty sleeping. other data supporting anxiety are an anxiety score with a score of 45 for case subject 1 and a score of 44 on case subject 2. the nursing intervention in the case study subjects was anxiety reduction with progressive relaxation therapy.12 the nursing plan of both subjects is after progressive muscle relaxation intervention for 48 hours, anxiety rate decreases. the criteria for this external result is decreased verbalization of confusion, verbalization is concerned due to the condition faced decreases, decreased restless behavior, decreased tense behavior complaints of dizziness, anorexia, palpitations, diaphoresis, tremor and pale absence, vital signs within normal limits.13 planning for the management of anxiety reduction with progressive muscle relaxation techniques in accordance with the principles of intervention, namely observation, therapeutic education and collaboration. observational nursing interventions include: identification when the level of anxiety changes, identification of decision-making ability, monitoring of verbal and nonverbal anxiety signs, identification of calm and comfortable places, regular monitors to ensure muscles relaxation and monitor the presence of indicators are not relaxed. therapeutic plans include: set the environment so that there are no interruptions during therapy, give the position leaning on the chair or other comfortable positions, stop the therapy session gradually and give time to express feelings about therapy. the educational plan consists of: recommend wearing comfortable and not narrow clothes, recommending progressive muscle relaxation according to the procedure). the collaboration plan is the administration of anti-anxiety drugs if necessary.12 the progressive relaxation procedure in this study was carried out in a seated position. in performing progressive relaxation techniques, perform the procedures described as well as repeat each instruction. respondents are recommended to stretch each muscle group for 5-7 seconds then relax for 20-30 seconds, then follow the next steps according to the progressive muscle relaxation therapy procedure. an overview of the evaluation of anxiety scores and vital signs before and after progressive muscle relaxation in both case study subjects can be seen in table 1. table 1 shows changes in anxiety levels after two days of intervention followed by changes in vital signs. the anxiety scores of both study subjects decreased by more than 40% after being given progressive muscle relaxation. the physiological response of both respondents was quite good after progressive muscle relaxation intervention. patients are more relaxed after being given progressive muscle relaxation as evidenced by a decrease in blood pressure, pulse and respiratory rate. both respondents were quite cooperative during progressive muscle relaxation techniques. evaluation of nursing care is done after 48 hours. after progressive muscle relaxation interventions were performed on both respondents, there was a decrease in anxiety levels from the moderate category to the mild category followed by changes in vital signs within normal limits. both respondents said they felt calm, relaxed and their worries diminished. south east asia nursing research, vol 3 no 2, june 2021/ page 90-97 94 yanah kuscianah kuswa / reduction of anxiety levels in schizophrenia patients using progressive muscle relaxation table 1 pre-post observation parameters of progressive muscle relaxation therapy on scizofrenia measurement indicators subject study 1 subject study 2 anxiet y score bp (mmhg) pulse (x/min) rr (x/min) anxiet y score bp (mmhg) pulse (x/min) rr (x/min) pre-intervention 45 120/80 86 20 44 130/80 88 20 post-intervention 32 118/80 76 18 30 120/70 80 18 % decrease score after intervention 40,6% 1,7%/0% 13,2% 11,1% 46,7% 8,3%/8,3 % 10% 11,1% discussion both of subjects were female. but some of the results of the study states that the gender of the women are prone to the onset of anxiety. a study at lampung hospital also found that there is a sex relationship with anxiety levels. gender factors can significantly affect a patient's anxiety levels, in the study it was also mentioned that female gender is more at risk of anxiety compared to male gender.14 gender differences in dsm-iv anxiety disorders were examined in a large sample of adults (n = 20,013) in the united states women showed that women have consistently higher prevalence rates of anxiety disorders.15 the average age of both study subjects was between 30-40 years. maturity or maturity of an individual can affect the coping ability of a person's mechanism so that individuals who are more likely to experience anxiety because the individual has a greater adaptability to anxiety than the age that has not mature. proven in the study obtained a mature age that is more prevalence of anxiety levels less compared to adolescence. this proves that mature age has sufficient coping ability in overcoming anxiety.14 anxiety that arises in both study subjects due to the occurrence of natural emotional disorders that arise by characterized by deep and sustained fear, so that there can be a disorder in assessing reality, full personality, behavior can be disturbed but still within normal limits, that this indicates they experience anxiety. schizophrenic patients experience anxiety where the symptoms of anxiety themselves are both severe and moderate are psychiatric disorders. the causes of anxiety arise because of fear of not accepting in certain environments, traumatic experiences, such as separation trauma, loss or natural disasters, and the frustration of failure when meeting their needs.3 the results of this study prove that progressive muscle relaxation therapy can reduce muscle tension, anxiety, fatigue, anxiety control so that it can affect the mental status of clients especially in schizophrenia patients. concentration of attention to tense muscles then lowers tension by performing relaxation techniques, to get a feeling of relaxation, provide comfort to the patient so as to affect the mental status of the patient. the feeling of relaxation will be directed to the hypothalamus to produce corticotrophin releasing hormone (crh) and corticotrophin releasing hormone (crh) activating the anterior pituitary to secrete encephalin and endorphins that act as neurotransmitters that affect mood to be relaxed. in addition, anterior pituitary secretion of adrenocorticotropic hormone (acth) decreases, then adrenocorticotropic hormone (acth) controls the adrenal cortex to control cortisol secretion. decreased levels of acth and cortisol cause stress and tension to decrease which can eventually lower depression levels.16 the results of this case study also match previous research that progressive muscle relaxation therapy has beneficial effects in reducing anxiety, depression, improved feelings of self-control, and also improving the ability to cope with stress in a variety of situations.17 south east asia nursing research, vol 3 no 2, june 2021/ page 90-97 95 yanah kuscianah kuswa / reduction of anxiety levels in schizophrenia patients using progressive muscle relaxation the results of this study are also in line with research on the influence of relaxation techniques on changes in the mental status of schizophrenic clients in surakarta mental hospital. this research is an experiment with the design of pre and post test with control group research. the conclusion of the study was that in the treatment group that obtained relaxation techniques there were significant changes to the assessment of mental status. in the control group that did not get relaxation techniques there were no significant changes to the assessment of mental status. the difference that occurs after being given relaxation techniques in the treatment group is very good and has a very significant effect with p-value is 0.001 (p < 0.05). while in the control group there is no significant influence.18 the results of the study conducted at cirebon also showed that there was a significant decrease in the level of anxiety in the intervention group after progressive relaxation therapy.9 also in line with the research conducted at yogyakarta also showed that there is an effect of providing progressive relaxation therapy to the anxiety level of preoperative patients. other research in magetan district shows that there is an influence of progressive muscle relaxation techniques on changes in anxiety levels.19 some studies on progressive muscle relaxation of anxious patients get quite good results. research on the effect of progressive relaxation techniques on anxiety levels in paranoid schizophrenic clients, states that the test results paired samples of anxiety levels in pretests and post-test obtained t value count 2.381 with a p-value of 0.029. there was an influence significant progressive relaxation techniques against anxiety levels in paranoid schizophrenic clients.20 both study subjects suffered from schizophrenia. initially experiencing a moderate level of anxiety, after relaxation therapy changed to a mild degree. there were significant differences in anxiety levels in both groups in post-implementation. the anxiety score of the first case study subjects decreased by 40.6% after being given progressive muscle relaxation, while the subjects of the second case study experienced a decrease of 46.7% after being given progressive muscle relaxation. these results are in line with the results of several studies that show that the administration of progressive relaxation techniques impact on the decrease in anxiety levels of schizophrenic patients.7 the results of this case study showed that progressive muscle relaxation therapy was able to lower anxiety levels in schizophrenic patients. it shows that progressive relaxation is effective to reduce muscle tension, anxiety and fatigue experienced by clients so that it will affect the client's mental status. these results are according to previous research that proves the benefits of progressive relaxation therapy are lowering muscle tension, reducing anxiety levels, stress-related problems such as hypertension, and insomnia.20 this case study showed that the study subjects experienced a decrease in anxiety levels from moderate to mild levels. changes in anxiety levels after being given progressive muscle relaxation interventions become mild anxiety, in addition to the administration of antidepressant therapy also due to the influence of progressive muscle relaxation that further strengthens relaxation. the findings of this case study corroborate all previous findings. previous study in taiwan demonstrated that progressive muscle relaxation training can effectively alleviate anxiety in patients with schizophrenia.21 research at surakarta indonesia also concluded that progressive relaxation is effective to reduce muscle tension, anxiety and fatigue experienced by clients so that it will affect the mental status of the client. there was a significant difference in the anxiety level of respondents in both groups on the posttest. these results showed that the south east asia nursing research, vol 3 no 2, june 2021/ page 90-97 96 yanah kuscianah kuswa / reduction of anxiety levels in schizophrenia patients using progressive muscle relaxation administration of progressive relaxation techniques had an impact on decreasing the anxiety levels of schizophrenic patients. so it is concluded there is a significant influence of progressive relaxation on the level of anxiety of schizophrenic clients.7 efforts to prevent disease is to manage the stressors that come, the management is related to how the individual maintains his health. health maintenance is the main brain function, the middle part of the brain when there is a stressor will stimulate the biochemical processes of the brain and relaxation response is the body's efforts to restore in a balanced state. relaxation techniques can help restore mental, physical and emotional processes. the results of the case study showed both case subjects experienced decreased levels of anxiety and reduced signs of anxiety after progressive muscle relaxation techniques were performed. this happens because the movement tightens and relaxes the muscles in a part of the body at a time to provide a feeling of physical relaxation in the muscle group performed in a row. progressive muscle relaxation therapy helps reduce the tension presented in the muscles and this often generalizes to other areas of the body, including the mind. learning to relax can reduce the damaging effects and symptoms of stress-induced diseases and improve a person's quality of life.8 this case study showed that progressive muscle relaxation was able to increase relax in patients who were shown decreased anxiety levels from the moderate category to the mild category followed by changes in vital signs in the form of decreased blood pressure, pulse and respiratory rate. both respondents said they felt calm, relaxed and their worries diminished. progressive muscle relaxation given to the study subjects stimulated the anterior pituitary to secrete encephalin and endorphins making the mood relax and happy. a pituitary gland also causes decreased secretion of adrenocorticotropic hormone (acth), which further controls the adrenal cortex to inhibit cortisol secretion. decreased cortisol causes reduced stress and lowers anxiety. previous study conclude that the efficacy of progtesive muscle relaxation extends to reduction in biologically expressed stress levels by decrease cortisol level.22 progressive muscle relaxation training is a useful intervention as it is proven to reduce anxiety levels across a spectrum of psychiatric disorders.21 conclusion progressive muscle relaxation therapy performed among schizophrenic patients for two days was able to reduce patient anxiety. there was a decrease in the anxiety scores of the two case study subjects. recommendations for nurses to apply progressive muscle relaxation to reduce anxiety in schizophrenic patients acknowledgment special thanks to patients, nurses and doctors at two hemodialysis units in semarang. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. maramis wf, maramis aa. catatan ilmu kedokteran jiwa. ii. surabaya: airlangga university press; 2009. 2. nasir a, muhith a. dasar-dasar keperawatan jiwa: pengantar dan teori. jakarta: salemba medika; 2011. 3. stuart gw. principle and practice of pscychiatric nursing. 10th ed. st louis: elsevier; 2013. 4. who. world health statistics 2019: monitoring health for the sdgs, sustainable development goals. 2019. 5. ulfa nm. efektivitas terapi relaksasi dzikir dalam menurunkan kecemasan pasien skizofrenia di upt (unit pelaksana teknis) rehabilitasi sosial bina laras kediri. uin south east asia nursing research, vol 3 no 2, june 2021/ page 90-97 97 yanah kuscianah kuswa / reduction of anxiety levels in schizophrenia patients using progressive muscle relaxation tulungagung; 2019. 6. wahyuningsih, sutanta, afifah va. pengaruh teknik relaksasi nafas dalam terhadap tingkat kecemasan pasien pre operasi fraktur femur. media ilmu kesehat. 2019;3:230–6. 7. ari pld, pratiwi a. pengaruh relaksasi progresif terhadap tingkat kecemasan pada pasien skizofrenia di rumah sakit jiwa daerah surakarta. 2010; 8. lindquist r, tracy mf, snyder m. complementary and alternative therapies in nursing. 8th ed. new york: springer international publishing; 2018. 9. hidayat e. pengaruh terapi relaksasi progresif terhadap penurunan tingkat kecemasan dalam menghadapi uji kompetensi mahasiswa tingkat iii akper muhammadiyah cirebon. j keperawatan soedirman. 2017;12:93–101. 10. nursalam. konsep dan penerapan metode penelitian ilmu keperawatan. jakarta: salemba medika; 2013. 11. nanda. nursing diagnoses definitions & classification 2018-2020. heather t. herdman sk, editor. new york: thieme; 2018. 12. pokja siki ppni. standar intervensi keperawatan indonesia definsi & tindakan keperawatan. i. jakarta: ppni; 2018. 13. ppni. standar luaran keperawatan indonesia. jakarta: ppni; 2019. 14. vellyana d, lestari a, rahmawati a. faktorfaktor yang berhubungan dengan tingkat kecemasan pada pasien preoperative di rs mitra husada pringsewu. j kesehat. 2017;8:108–13. 15. mclean cp, asnaani a, litz bt, hofmann sg. gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. j psychiatr res. 2011;45:1027–35. 16. asnaniar wos, agustini t. progressive muscle relaxation reduces depression in elderly. wind heal. 2018;1:1–5. 17. fhadilah nc, adi ws, shobirun s. pengaruh terapi relaksasi otot progresif terhadap pasien resiko perilaku kekerasan di rsjd dr amino gondohutomo provinsi jawa tengah. j forum kesehat. 2017;7:83–9. 18. kustanti e, widodo a. pengaruh teknik relaksasi terhadap perubahan status mental klien skizofrenia di rumah sakit jiwa daerah surakarta. j ber ilmu keperawatan. 2008;1:131–6. 19. suharno s, septiyani g. pengaruh progresif terhadap tingkat kecemasan pada pasien skizofrenia di panti gramesia kabupaten cirebon. j kampus stikes ypib majalengka. 2019;7:1–14. 20. anindita b, ambarwati wn, listyorini d. pengaruh teknik relaksasi progresif terhadap tingkat kecemasan pada klien skizofrenia paranoid di rsjd surakarta. universitas muhammadiyah surakarta; 2012. 21. chen w, chu h, lu r, chou y, chen c, chang y, et al. efficacy of progressive muscle relaxation training in reducing anxiety in patients with acute schizophrenia. j clin nurs. 2009;18:2187– 96. 22. chellew k, evans p, fornes-vives j, pérez g, garcia-banda g. the effect of progressive muscle relaxation on daily cortisol secretion. stress. 2015;18:538–44. effect of isometric quadriceps in reduce pain in patients of knee osteoarthritis corresponding author: warsono warsono warsono@unimus.ac.id south east asia nursing research, vol 3 no 4, december 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.4.2021.160-166 original research effect of isometric quadriceps in reduce pain in patients of knee osteoarthritis warsono warsono1, anita rachmawati1, faradisa yuanita fahmi2 1 universitas muhammadiyah semarang, indonesia 2 stikes muhammadiyah kendal, indonesia article info abstract article history: submitted: oct 26th 2021 accepted: dec 1st 2021 published: dec 24th 2021 keywords: isometric quadriceps; pain intensity; osteoarthritis knee osteoarthritis (oa) is a degenerative disease that often occurs, both in indonesia and abroad. oa is characterized by progressive destruction of joint cartilage and causes structural changes in the joints. oa disease from grades 1 to 4 has symptoms that are usually difficult for the sufferer's life. one of these symptoms is joint pain, but reducing pain intensity, especially oa grades 1 to 3, it can be done with exercise. the use of this exercise is an isometric quadriceps exercise. the design of this study used a quasiexperimental design with a pre-post test control group design with a sample of 40 respondents who met the inclusion and exclusion criteria, namely patients with knee osteoarthritis, stage ii, and iii who underwent the initial rehabilitation program. based on the results of data processing using the wilcoxon test in the control group, the p-value = 0.01 < 0.05, while in the intervention group the p-value = 0.00 < 0.05. from these results, it can be concluded that isometric quadricep exercise is effective in reducing pain intensity in osteoarthritis genu grades 1 to 3. so isometric quadricep exercise can be recommended as an independent therapy in reducing knee osteoarthritis pain intensity. introduction based on data from the world health organization (who) in 2016, osteoarthritis is the most common musculoskeletal disease, with a prevalence of knee osteoarthritis reaching 3.8% and hip by 0.85% globally (who, 2016). meanwhile in indonesia, based on the results of the 2018 riskesdas, it shows that the prevalence of the joint disease is around 7.3% and osteoarthritis is the most common joint disease. this disease is commonly associated with increasing age, or what is known as a degenerative disease. in the 15-24 year age range, the prevalence rate is only around 1.3%, in the 24-35 year age range it is around 3.1%, and the prevalence has doubled in the 35-44 year age range which is 6.3%.1 osteoarthritis (oa) comes from the greek words osteon meaning bone, arthro meaning joint, and itis meaning inflammation. osteoarthritis is a joint disorder characterized by progressive degeneration of articular cartilage, resulting in loss of joint space and the appearance of new bone.2 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.4.2021.160-166&domain=pdf&date_stamp=2021-12-24 south east asia nursing research, vol 3 no 4, december 2021/ page 160-166 161 warsono warsono / effect of isometric quadriceps in reduce pain in patients of knee osteoarthritis osteoarthritis is most common, especially in the adult and elderly age groups. almost all people over the age of 70 experience symptoms of osteoarthritis, with varying degrees of pain. before the age of 55 years, the ratio of osteoarthritis in men and women is comparable, but at the age of over 55 years, it is more in women. old age is the last period in the human life span. old age is marked by several changes, both physically, psychologically, and socially, where these changes will affect the physical and mental conditions of the elderly. old age is a risk factor for osteoarthritis. other risk factors include a family history of osteoarthritis, being overweight, work that requires squatting or kneeling for more than 1 hour per day. lifting goods, climbing stairs, or walking long distances are also risks.3 osteoarthritis has symptoms that are usually difficult for the sufferer's life. these symptoms include recurrent pain or tenderness in the joints, stiffness, limited range of motion, crackling sounds (crepitus), swelling in the joints (swelling in a joint), quadriceps muscle weakness, and muscle atrophy around the knee joint, knee joint instability.4 pain is the biggest main symptom in joints that experience osteoarthritis. pain is caused after doing activities with the use of joints and pain can be alleviated.5 patients with osteoarthritis pain will experience joint and muscle dysfunction so they will experience limited movement, decreased strength, and muscle balance. approximately 18% experience difficulties and limitations in activities, loss of function, work capacity, and decreased quality of life.6 analgesic is the main therapy in pain management. unfortunately, one of the biggest reasons for inappropriate pain management is the lack of knowledge about analgesic pharmacology. although pain management is through the use of drugs, several non-pharmacological techniques can also help control pain such as massage, exercise, relaxation and imagination, nerve stimulation with transcutaneous electricity, use of hot and cold compresses, therapeutic touch, meditation, hypnosis, acupressure, and tens (transcutaneous electrical nerve stimulation). these techniques are generally safe, readily available, and can be performed at home or in a care setting.7 exercise is recommended for the elderly with osteoarthritis with grades 1 to 3 to strengthen muscle and joint mobility, improve functional capacity, relieve pain and stiffness, and prevent further deformity. therefore, the management of the pain system should be a new target for both pharmacological and nonpharmacological interventions.8 physical exercise therapy can provide benefits to patients both directly and indirectly. isometric quadriceps exercise is another form of elastic resistance that allows people to perform different exercises to increase strength, mobility, function, and reduce joint pain.9 isometric quadriceps exercise is an exercise by contracting the muscles that are carried out to see changes in increasing muscle strength. this is due to changes in muscle morphology, namely the greater the muscle mass formed, the more mitochondria will be produced. the effect of strengthening exercises will increase the dynamic strength of the muscles so that muscle power increases. when muscle power increases, endurance and balance will also increase. blood circulation will increase due to vasodilation of blood vessels. in addition, it will also improve strength, size and prevent inflammation and increase the flexibility of fat tissue which can reduce pain.10 the american college of rheumatology explains that strengthening the femoral quadriceps muscle in patients with osteoarthritis of the knee can increase muscle strength, reduce joint pain, and reduce joint stiffness. in addition to this, muscle strengthening is also a step that can south east asia nursing research, vol 3 no 4, december 2021/ page 160-166 162 warsono warsono / effect of isometric quadriceps in reduce pain in patients of knee osteoarthritis speed up time to perform important activities in daily life such as the ability to walk. muscle strengthening is an effective therapy in reducing pain and increasing functional ability in patients with mild to moderate knee osteoarthritis.11–13 kendal 1 health center is one of the health centers in the kendal area with quite a lot of osteoarthritis patients with the number of osteoarthritis patients in the last 3 months in march 2021 was 43 patients. based on observations and interviews from 4 patients in the outpatient clinic and orthopedic rehabilitation room in patients diagnosed with knee osteoarthritis grade k/l ii, all patients underwent a physical examination and then were given pharmacological therapy in the form of analgesic drugs and supplements. from this preliminary study, the authors assessed the need to apply isometric quadriceps exercise therapy as a strengthening of the quadriceps muscle because based on the results of the latest research by.13 it has proven to be very effective in helping reduce pain intensity. methods this study uses a quasi-experimental research design or quasi-experimental research. the research design used a prepost test control group design, which was done by giving a pre-test before the treatment was given and a post-test was taken after the treatment was given, the intervention group was given analgesics and isometric quadriceps while the control group was given primary therapy, namely analgesics. . sampling in this study by probability sampling using a random sampling technique. the population in the study were all patients with knee osteoarthritis in the kendal 1 public health center with the criteria of the patient being >50 years old, moderate pain 4-7, knee flexion angle > 90o, and patients with a medical diagnosis of oa grade ii or iii (k/l scale). . the sample used in this study was 40 respondents consisting of an experimental group of 20 respondents and a control group of 20 respondents, this study was conducted on 2 july – 26 november 2021. univariate and bivariate analysis data using the wilcoxon test. the flow of this intervention is to select patients according to inclusion and exclusion criteria, explain the purpose and benefits of the procedure, ask for consent and sign informed consent, measure the initial pain scale before exercising, warm up by walking around the place that has been provided for 10 minutes, then sitting with a 90o tutu flexion angle while straightening the oa genu leg for 10 seconds and measuring the pain scale after the procedure, and evaluating on the 36th day of the intervention. collecting data in this intervention by measuring and interviewing respondents related to name, age, gender, body mass index (bmi), and occupation, while data assessing pain intensity before and after therapy using the numeric rating scale (nrs) instrument. results the results of the univariate analysis provide an overview of the distribution of participants according to participant characteristics (gender, age, and body mass index) and the evaluation results in the provision of isometric quadriceps exercise (pain scale). gender characteristics table 1 distribution of characteristics by gender intervention (n=20) and control (n=20) groups indicators f % jeni gender of control group man 3 15 woman 17 85 gender of intervention group man 4 20 woman 16 80 based on table 1 above, it can be concluded that the frequency of gender in the control south east asia nursing research, vol 3 no 4, december 2021/ page 160-166 163 warsono warsono / effect of isometric quadriceps in reduce pain in patients of knee osteoarthritis group is mostly female, with as many as 17 (85%) respondents with knee osteoarthritis. while the frequency of gender in the intervention group was mostly female, as many as 16 (80%) respondents. characteristics of age and body mass index table 2 distribution of characteristics of participants by age, and body mass index (n=40) indicators group intervention control age 61,55+1,317 61,70+1,525 body mass index 30,30+1,630 30,25+1,616 based on table 2 shows the average age of the control group respondents in this study was 61.7 years with a standard deviation of +1.525. then from the interval estimation results, it is known that 95% of respondents have an age range of 60.99 years to 62.41 years. meanwhile, the intervention group was 61.55 years old with sd: +1.317. then from the interval estimation results, it is known that 95% of respondents have an age range of 60.93 years to 62.17 years. then for the bmi of respondents in the control group, the average bmi is 30.25 with sd: +1.616. then it can be seen from the results of the interval estimation that 95% of the participants are in the range of bmi 29.49 to 31.01. meanwhile, the intervention group has a mean bmi of 30.30 with sd: +1.630. then it can be seen from the results of the interval estimation that 95% of participants are in the bmi range of 29.54 to 31.06. results of isometric quadriceps exercise before and after intervention in the intervention and control group based on the results of table 3 in the control group, it can be concluded that the average pain scale before and after being given primary intervention the first week to week 12 is 5.00 with an sd value: 2.693 and p-value: 0.01. while the average pain scale intervention group before and after the isometric quadriceps exercise in weeks 1 to 12 was 5.00 with an sd value: of 9.811 and p-value: 0.00. table 3 the effect of quadriceps exercise in reducing pain in the control group (n=20) indicators group intervention control pain level before intervention 5,25+0,444 5,5+0,513 pain level after intervention 0,90+0,308 4,75+0,716 p 0,000* 0,010* * wilcoxon test discussion in the provision of isometric quadriceps exercise therapy for 12 weeks where every week for 3 days (monday, wednesday, and friday) and 3 times a day (morning, afternoon, and evening) with each period of 10 minutes 10 seconds. in carrying out the implementation, respondents are required to warm up first for 10 minutes by walking around the exercise area. immediately discontinued if knee pain appears with a pain scale (> 6) or other responses that worsen the respondent's condition. second, participants were asked to sit in a chair by bending their knees at an angle of 900, then straightening their legs fully for 10 seconds. characteristics of respondents the results of the primary intervention and the application of quadriceps exercise with isometric quadriceps exercise in the control and intervention groups showed that most of them had an average age of 6065 years. in this age range, participants experienced knee joint disorders in the form of osteoarthritis. a study links the aging process with disorders of knee joint osteoarthritis. aging is associated with susceptibility to chronic diseases, including knee joint disorders such as osteoarthritis south east asia nursing research, vol 3 no 4, december 2021/ page 160-166 164 warsono warsono / effect of isometric quadriceps in reduce pain in patients of knee osteoarthritis and osteoporosis.14,15 osteoarthritis can occur during menopause, namely the age of 45-49 years 16, then 59% occur at the age of 55-74 years and 31% occur over the age of 75 years.17 the aging process is a normal thing. aging results in a progressive loss of physiological integrity, resulting in impaired function and decreased adaptive capacity to stress. in addition, aging also increases exposure to the environment.18 older age is also associated with the development of osteoarthritis due to biological changes such as decreased synovial fluid secretion over time.19 then increasing age is associated with cellular aging which plays a role in cell inflammation in the incidence of osteoarthritis.12 most of the respondents in the control group were women, as many as 17 people (85%) while in the intervention group there were 16 people (80%). this is the same as the other study showed that where most of the knee osteoarthritis participants were 57 women (89.06%) and 7 men (10.94%).19 this is also following the incidence of osteoarthritis in the other study that many as 685.9 per 1,000 for women and 324.1 per 1,000 for men.5 then the incidence of osteoarthritis increases the surgical program of joint replacement, either total knee replacement (tkr) or total hip replacement (thr) more in women over the age of 50 years and men over the age of 60 years. this is also stated by other research that women suffer from knee osteoarthritis more than men.20 women have twice the risk of knee injury and osteoarthritis because women's hips are wide, this causes the knees of the legs to be wider and "o" shaped so that the joint position is uneven, as well as less muscle mass around the knees of women than men. in addition, there are other factors, namely, the menopause process in women is faster than in men which has an impact on the decrease in the hormone estrogen where the function of this hormone is to give an effect of elasticity to the joints. respondents in the control group had a body mass index (bmi) above normal, which had a mean bmi of 30.25 with a standard deviation of +1, 616, while the intervention group had a mean of 30.30 with an sd of +1, 630. will have a high effect or impact on the occurrence of osteoarthritis. the results of this study are supported by other research who states that both male and female sexes have the opportunity to have an excessive bmi, because men experience visceral (abdominal) obesity while women can contribute to increased fat which is supported by modern times, namely a bad lifestyle that can affect the increase in bmi.21 effect of isometric quadriceps exercise on knee osteoarthritis pain intensity the results of the primary intervention on 20 respondents in the control group showed an effect with a p-value of 0.010. while the results of the isometric quadriceps exercise in the intervention group showed a significant effect with a pvalue of 0.000. this shows that the application of isometric quadriceps exercise for 12 weeks is effective in reducing pain intensity in patients with knee osteoarthritis. this is following several previous studies that the application of isometric quadriceps exercise for 2 months is effective in reducing the intensity of knee osteoarthritis pain with a p-value = 0.001.9,22 likewise, research on the effect of quadriceps exercise on pain intensity in knee osteoarthritis patients for 2 weeks decreased significantly (p = 0.002, 0.05) and was more effective in increasing daily activities.13 the existence of quadriceps muscle exercise is effective in reducing the intensity of knee osteoarthritis pain with a p-value of 0.000. these muscle south east asia nursing research, vol 3 no 4, december 2021/ page 160-166 165 warsono warsono / effect of isometric quadriceps in reduce pain in patients of knee osteoarthritis strengthening exercises can be done as a patient's routine and alternative therapy in reducing the pain intensity of grade i, ii, iii (k/l) knee osteoarthritis from mild to moderate pain. this is in line with research conducted by other research who said that isometric quadriceps exercise was very significant (p = 0.001) in reducing knee osteoarthritis pain and improving joint elasticity.23 wherewith the exercise of the hamstring and quadriceps muscles it will reduce other problems such as impaired muscle flexibility, joint stability, muscle wasting which further worsens the condition and increases pain. because no cure has been found for osteoarthritis except surgery, its management focuses on how to reduce symptoms such as relieving pain, increasing joint tasks is the main goal in providing nursing care.4 osteoarthritis also causes a decrease in knee joint stability due to impaired quadriceps muscle strength, pain, and altered joint structure.24 to maintain joint function and reduce knee instability, the hamstring muscles must be activated so that compensation occurs. thus, nursing actions are often recommended to reduce pain and increase mobility. so exercise movements must be done regularly to prevent muscle atrophy. a regular and measured exercise program is recommended for osteoarthritis patients. type of exercise therapy with a focus on muscle strengthening and stretching exercises (flexibility). several muscle groups that function to control the movement and stability of the knee are the quadriceps muscles in the front and the hamstrings muscles in the back.25 conclusion the characteristics in this study that can affect the occurrence of the osteoarthritis process are gender, age, and bmi. the isometric quadriceps exercise is effective in reducing pain intensity in patients with knee osteoarthritis grades i, ii, and iii from mild to moderate pain. with this exercise, there is an increase in the synthesis of proteoglycans which will increase the formation of the bone matrix and attract cations so that there is an increase in osmolality in the joint cartilage. this makes the joint surface slippery and the joint easy to move so that pain is reduced. in addition, the exercise can also improve the daily activities that become the routine of the participants. during the implementation of the isometric quadriceps exercise, there were no adverse side effects on the participants, but it was proven effective in reducing pain and drastically increasing the participants' daily activities. acknowledgment the researcher would like to thank all parties who have participated in this research, especially the respondents who are fully able to work well together. references 1. kemenkes ri. laporan_nasional_rkd2018_final.pdf. badan penelitian dan pengembangan kesehatan. 2018. p. 198. 2. neelapala yvr. influence of isometric exercise on pressure pain sensitivity in knee osteoarthritis proquest. 2018. p. 361–7. 3. ragni e, papait a, perucca orfei c, silini ar, colombini a, viganò m, et al. amniotic membrane-mesenchymal stromal cells secreted factors and extracellular vesiclemirnas: anti-inflammatory and regenerative features for musculoskeletal tissues. stem cells transl med. 2021; 4. khairurizal k. perbandingan pengaruh kombinasi latihan hold relax dan open kinetic chain dengan latihan hold relax dan close kinetic chain terhadap peningkatan kemampuan fungsional pasien osteoartritis knee. nusant med sci j. 2019;4:55. 5. madry h, kon e, condello v, peretti gm, steinwachs m, seil r, et al. early osteoarthritis of the knee. vol. 24, knee surgery, sports traumatology, arthroscopy. springer verlag; 2016. p. 1753–62. 6. pamungkas yi, hartati e, supriyono m, jurusan d, universitas k, semarang d, et al. efektifitas pemberian stretching terhadap di unit south east asia nursing research, vol 3 no 4, december 2021/ page 160-166 166 warsono warsono / effect of isometric quadriceps in reduce pain in patients of knee osteoarthritis pelayanan sosial lanjut usia. j ilmu keperawatan dan kebidanan. 2017;1–9. 7. vance cgt, rakel ba, blodgett np, desantana jm, amendola a, zimmerman mb, et al. effects of transcutaneous electrical nerve stimulation on pain, pain sensitivity, and function in people with knee osteoarthritis: a randomized controlled trial. phys ther. 2012;92:898–910. 8. hasanah k. pengaruh terapi transcutaneous electrical nerve stimulation dan kompres panas dalam menurunkan nyeri pada penderita osteoartritis lutut. 2014; 9. arif a, siddique ma, shahid g, khan r, usman m. international journal of physical medicine and effect of resistance training of quadriceps muscle in patients with knee osteoarthritis : a randomized control trial. 2020;8:3–6. 10. sriwijaya jk, titin t, akademi m, panti k, yogyakarta r. artikel penelitian efektivitas latihan lutut terhadap penurunan intensitas nyeri pasien osteoarthritis lutut di yogyakarta. vol. 2. 2015. 11. erviandani bw, ridwan m, agustin d. pengaruh penguatan otot quadriceps femoris terhadap kemampuan naik tangga pada pasien osteoarthritis genu di rsud dr. saiful anwar malang. vol. 3, majalah kesehatan fkub. 2016 nov. 12. wang j, xie y, wang l, lei l, liao p, wang sq, et al. hip abductor strength–based exercise therapy in treating women with moderate-tosevere knee osteoarthritis: a randomized controlled trial. clin rehabil. 2020;34:160–9. 13. yuenyongviwat v, duangmanee s, iamthanaporn k, tuntarattanapong p, hongnaparak t. effect of hip abductor strengthening exercises in knee osteoarthritis: a randomized controlled trial. 2020; 14. charlesworth j, fitzpatrick j, perera nkp, orchard j. osteoarthritisa systematic review of long-term safety implications for osteoarthritis of the knee. bmc musculoskelet disord. 2019;20:1–12. 15. rausch osthoff ak, juhl cb, knittle k, dagfinrud h, hurkmans e, braun j, et al. effects of exercise and physical activity promotion: meta-analysis informing the 2018 eular recommendations for physical activity in people with rheumatoid arthritis, spondyloarthritis and hip/knee osteoarthritis. rmd open. 2018;4:713. 16. lou c, xiang g, weng q, chen z, chen d, wang q, et al. menopause is associated with articular cartilage degeneration: a clinical study of knee joint in 860 women. menopause. 2016;23:1239–46. 17. jung jh, bang ch, song gg, kim c, kim jh, choi sj. knee osteoarthritis and menopausal hormone therapy in postmenopausal women: a nationwide cross-sectional study. menopause. 2019;26:598–602. 18. newberry sj, fitzgerald j sn. treatment of osteoarthritis of the knee: an update review. comp eff rev. 2017;1–1196. 19. hussain sm, cicuttini fm, alyousef b, wang y. female hormonal factors and osteoarthritis of the knee, hip and hand: a narrative review. vol. 21, climacteric. taylor and francis ltd; 2018. p. 132–9. 20. ibrahim sa, blum m, lee gc, mooar p, medvedeva e, collier a, et al. effect of a decision aid on access to total knee replacement for black patients with osteoarthritis of the knee a randomized clinical trial. jama surg. 2017;152:164225. 21. mutiwara e, najirman n, afriwardi a. hubungan indeks massa tubuh dengan derajat kerusakan sendi pada pasien osteoartritis lutut di rsup dr. m. djamil padang. j kesehat andalas. 2016;5. 22. wang d, wang y, madhu s, liang h, bray cl. total hemoglobin count has significant impact on a1c — data from national health and nutrition examination survey 1999–2014. prim care diabetes. 2019;13:316–23. 23. brosseau l, taki j, desjardins b, thevenot o, fransen m, wells ga, et al. the ottawa panel clinical practice guidelines for the management of knee osteoarthritis. part two: strengthening exercise programs. clin rehabil. 2017;31:596– 611. 24. sharma s, mishra aj. diabetes self-care management: experiences of the socioeconomically backward sections of jammu. diabetes metab syndr clin res rev. 2019;13:1281–6. 25. hatfield gl, costello ke, astephen wilson jl, stanish wd, hubley-kozey cl. baseline gait muscle activation patterns differ for osteoarthritis patients who undergo total knee arthroplasty five to eight years later from those who do not. arthritis care res. 2021;73:549–58. role model and family support related to self efficacy sleep in the sand in coastal elderly corresponding author: syaifurrahman hidayat sr.hidayat@yahoo.com south east asia nursing research, vol 3 no 2, june 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.2.2021.81-89 original research role model and family support related to self efficacy sleep in the sand in coastal elderly syaifurrahman hidayat1, mujib hannan1 1 universitas wiraraja madura, indonesia. article info abstract article history: submitted: may 9th 2021 accepted: june 16th 2021 published: june 23rd 2021 keywords: rolemodel, family support, selfefficacy, sleeping in sand, coastal elderly the elderly naturally experience a decrease in physical and psychological function so that it affects individuals in their daily activities. self-efficacy is the ability to carry out a series of actions to provide life satisfaction for the elderly who sleep in the sand. role models can provide role models for the elderly in doing activities to sleep in the sand where family support can influence the behavior of the elderly sleeping in the sand in the coastal elderly. the research method is descriptive-analytic with a cross-sectional approach. the population of this study were all the elderly who lived in the village, village, pasir lenggung batang batang -district, sumenep regency as many as 124 elderly. the sampling technique used is purposive sampling. the analysis used is the test spearman rank. the results of this study stated that most of the respondents had role models in the high category as many as 57.5% coastal elderly, respondents had family support in the medium category as many as 72.5% coastal elderly, and respondents had self-efficacy sleeping in the sand in the capable category as many as 72, 5% of coastal elderly. there is a relationship between the role model and the self-efficacy of sleeping in the sand in the coastal elderly and there is a relationship between family support and the self-efficacy of sleeping in the sand in the coastal elderly. role models can be role models and motivations for the coastal elderly to sleep in the sand. when the role model is good, self-efficacy will increase, with that the ability of the elderly to carry out activities in the sand is better as well as the higher family support, the higher self-efficacy the elderly. introduction elderlynaturally decreased physical and psychological functioning that can affect the ability of activities daily of the elderlyon the coast, the old process of becoming part of the process of life that occurred continuously which is generally experienced by all humans.1 the aging process is influenced by several factors such as genetics and the environment, where these factors affect cell metabolism which results in oxidative stress and causes damage to cells so that the aging process occurs.2,3 feelings of being able or independent, not depending on others, being able to clean their own home are indicators of selfefficacy achieved by living alone. self efficacy as an expectation of belief (hope) about how far individuals can carry out https://doi.org/10.26714/seanr.3.2.2021.81-89 https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.2.2021.81-89&domain=pdf&date_stamp=2021-06-23 south east asia nursing research, vol 3 no 2, june 2021/ page 81-89 82 syaifurrahman hidayat / role model and family support related to self efficacy sleep in the sand in coastal elderly activities in certain situations.4 self efficacy also determines individuals in carrying out certain behaviors, such as how strong individuals face difficulties and how these difficulties can affect individuals in the future.5 according to pramudita & wiwien (2015) stated that self efficacy is a person's ability to move a series of activities needed so that they will get the goals to be achieved and finally can provide comfort to the elderly who sleep on the sand. the need for sleep rest in the elderly is part of the life needs of each individual who has differences in sleep quality, health conditions and daily activities. sleep needs for sick people are different from healthy people even though they are of the same age, which is caused by a sense of discomfort in the individual.7 the elderly population has increased from year to year, in indonesia and even in the world the elderly population above 60 years is growing rapidly compared to other residents. as stated by the head of the bengkulu province bkkbn representative, widiati. based on projections, in 2020, the number of elderly people is estimated to increase by 4.8 million people and will always increase to 9.8 million people in 2035. based on the results of calculations and projections in 2020, the number of elderly people in bengkulu will reach 260,000 souls.8 sumenep regency is part of east java province which is located on the eastern tip of the island of madura. the district has land areas and islands and has a variety of cultures. its culture is related to food, art, and behavior. one of the villages named legung village, batang-batang district, sumenep regency has a community with a unique behavior tradition and is different from the surrounding villages. people who live in legung are people who live on the coast who have specific and unique behavior. the elderly and their families in legung village are synonymous with sand, which means that since ancient times until now, the legung people have considered sand to be a necessity of life.9 several factors affect self-efficacy among them the experience of a success (mastery experiences),the experience of others (vicarious experiences / social model of social persuasion,and physiological and emotional states. factors affecting including role models, where role models can actually increase the interest of the elderly to choose the behavior of sleeping in the sand. role models can be said to be parents, so the environment may be able to influence sleep behavior itself.10,11 family support plays an important role in influencing the behavior of the elderly sleeping on the sand. the need for family support and attention occurs throughout life, so that if an elderly person does not get support they will feel inferior, restless, irritable and so on. by getting family support, the elderly will always feel cared for by their families. family support can be shown by providing empathetic affection, giving advice, in sleeping behavior in the sand.12 based on the background above, this research is interested in examining the relationship between role models and family support with self-efficacy sleeping in the sand in the coastal elderly. methods the type of this research is descriptive analytic with aapproach cross sectional. the population in this study were all the elderly living in the village pasir lenggang batang batang -district, sumenep regency, as many as 124 elderly, the sample in this study were some of the elderly livings in thevillage, village pasir lenggung. sub-district, sumenep regency as many as 40 elderly and the sampling technique used is purposive sampling with inclusion criteria, namely the batang-batangelderly who live in the village of legung timur for more than 6 months, ages 60 to 70 years, elderly who south east asia nursing research, vol 3 no 2, june 2021/ page 81-89 83 syaifurrahman hidayat / role model and family support related to self efficacy sleep in the sand in coastal elderly has a sand bed at home, elderly with experience of sleeping in the sand and respondents who are willing and willing, while the exclusion criteria are the elderly with bed rest or bed rest, the elderly with infectious diseases, the elderly who are not at the research location when data collection is at risk. this research was conducted in june 2021 in the pasir village, lunggung village, batang-batang subdistrict, sumenep regency, madura.the analysis used in this study is spearman rank to determine the relationship between variables with a significance level of p <0.05. namely the relationship between the role model and the self-efficacy of sleeping in the sand in the coastal elderly and the relationship between family support and the self-efficacy of sleeping in the sand in the coastal elderly. results based on table 1. states that most of the elderly are female as many as 32 (80%) and male sex as many as 8 (20%) elderly. stating most respondents aged 64-69 years as many as 23 (42.5%) and a small proportion of elderly aged 60-64 years as many as 17 (42.5%). most of the respondents with education level did not go to school as many as 23 (42.5%) and a small proportion of elderly with the last education of junior high school or equivalent were 3 (7.5%) elderly and states most of the respondents work status as housewives (irt) as many as 32 (42.5%) and a small number of elderly with work status as fishermen as many as 3 (7.5%) elderly. based on table 2. states most respondents have a role models there are 23 (57.5%)in the high category and a small proportion of the elderly have a role model in the category low as many as 4 (10.0%) elderly, stated most respondents have support families in the moderate category as many as 29 (72.5%) and a small proportion of the elderly with family support in the category low as many as 4 (10.0%) elderly and it states that most respondents have self efficacy sleeping in the sand in the capable category as many as 29 (72.5%) and a small proportion of the elderly have self efficacy sleeping in the sand in the category unable as many as 4 (10.0%) elderly. based on table 3 states that most of the respondents with role models in the high category and having self-efficacy sleeping in the sand in the very capable category are 15 elderly (37.5%) and a small proportion of respondents with role models in low category and have self efficacy sleeping in the sand in the poor and unable category by 2 (5.0%) elderly. based on the results of statistical tests with spearman's rho = p. value 0.009 (<0.05) significantly stated that there was a relationship between the role model and the self-efficacy of sleeping on the sand in the coastal elderly and states that most respondents with family support are in the moderate category and have selfefficacy sleeping in the sand in the very capable category of 15 elderly (37.5%) and a small proportion of respondents with family support at low category and have self efficacy sleeping in the sand in the poor and unable category by 2 (5.0%) elderly. based on the results of statistical tests with spearman's rho = p. value 0.001 (<0.05) significantly stated that there was a relationship between family support and self-efficacy sleeping on the sand in the coastal elderly. table 1 distribution of respondents by sex, age, education level education and occupation indicators f % gender male 8 20.0 female 32 80.0 age 60 -64 years 17 42.5 64-69 years 23 57.5 education level not in school 23 57.5 elementary school 14 35.0 junior high school 3 7.5 occupation housewife 32 80.0 farmer 5 12.5 fisherman 3 7.5 south east asia nursing research, vol 3 no 2, june 2021/ page 81-89 84 syaifurrahman hidayat / role model and family support related to self efficacy sleep in the sand in coastal elderly table 2 role model respondent's, family support and self efficacy sleeping in the sand indicators f % role model high 23 57.5 enough 13 32.5 low 4 10.0 family support high 7 17.5 medium 29 72.5 low 4 10.0 self efficacy sleeping in the sand very capable 7 17.5 able 29 72.5 unable 4 10.0 table 3 cross tabulation of role models with self efficacy in the elderly sleeping on the sand coast and cross tabulation of family support with self-efficacy in the elderly sleeping on the sand coast variable self-efficacy sleeping on the sand p very capable able unable f % f % f % role model high 15 37.5 8 20.0 0 0.0 0.009 medium 6 15.0 7 17.5 0 0.0 low 0 0.0 2 5.0 2 5.0 family support high 6 15.0 1 2.5 0 0.0 0.001 medium 15 37.5 14 35.0 0 0.0 low 0 0.0 2 5.0 2 5, 0 discussion the results of the study stated that most of the respondents had role models in the high category as many as 23 (57.5%) respondents had role models as role models in carrying out actions or sleeping activities on a sand bed, so that the activity of sleeping on the sand was carried out the elderly is a behavior that has been passed down from generation to generation by the people of the sand village who are trusted by the elderly. according to alexandrova (2018) states that watching other people perform a behavior and observing the consequences of their actions is assumed to increase people's confidence in their own ability to master similar tasks, with comparable results. incidents about other people's success or difficulties can be used as learning material or someone's role model to serve as an example in carrying out daily activities.14 where this will affect individuals in carrying out activities similar to other people's experiences15, the effects of other people's experiences depend on factors such as the observer's perception of the similarity between himself and the model, the number of model variations, the perceived strength of the model. , and the similarities between the problems faced by the observer and the model. the experience of others generally has a weaker effect on expectations selfefficacy than direct personal experience.16. role models are part of the self-concept of the elderly, it is also influenced by the level of maturity of the individual. self-concept is formed in accordance with other people's assessment of him.17 self-concept can occur due to the occurrence of activities that are passed with other people, learning from oneself through other people's mirrors can be used as part of a way of seeing oneself which is a self-interpretation of the views of others in sleeping activities. people who play a role in the daily life of the elderly can affect the culture and daily activities, namely by sleeping on the sand in the coastal elderly. a small proportion of the elderly have a role model in the category low as 10.0% of the elderly, where education from the family is hereditary making the role model stronger and inspiring and motivating respondents to do activities sleeping in the sand and vice versa if education in the family in cultivating sleeping in the sand is not carried out it will reduce the role model more and more. low on family members. the behavior of imitating predecessors and culture plays an important role in the formation of role models because the thick culture adopted by the role models also makes the elderly follow or imitate these activities of sleeping in the sand. south east asia nursing research, vol 3 no 2, june 2021/ page 81-89 85 syaifurrahman hidayat / role model and family support related to self efficacy sleep in the sand in coastal elderly someone's experience that has been done can serve as an example or role model for others, so that in carrying out an action or activity such as sleeping on the sand, people will believe that from their observations of the role model, it will also apply to the activities they do. the results of the study stated that most of the respondents had family support in the moderate category as much as 72.5%, where family support included providing instrumental support about sand bed facilities in the family having many benefits in a family, by supporting the elderly to sleeping on the sand can foster a sense of comfort in the family. syaifurrahman hidayat (2020) revealed the factors that influence the quality of life of the elderly, namely instrumental support, where this instrumental support is a factor that has a significant effect on the welfare of the elderly. according to santoso (2019) instrumental support is support in the form of real and material assistance. material support from the closest people such as family, elderly friends in the vicinity, instrumental support can be in the form of housing, sand bed facilities, sand cleaning tools and so on which have become the daily lives of coastal elderly. the results showed that a small proportion of the elderly with family support in the category is as low as 10.0% of the elderly, where the lack of emotional support from the family will affect the elderly self-defense mechanism is not adequate. the selfdefense mechanism of the elderly who are not strong in dealing with problems will cause prolonged stress and eventually symptoms of depression will arise.20 according to stuart & laraia (2005) explains that emotional support can be given in the form of motivating the confidence of the elderly in dealing with the problems they face. sangian (2017) stated that family emotional support was in the 55% presentation. among them the family can take the time to complete the needs of the elderly and provide a sense of empathy when needed by the elderly, so that with this the elderly can accept any changes that are experienced and live their lives well.22 most of the respondents with the education level did not go to school as much as 42.5%, which shows that there is a lack of exposure to information in the elderly. elderly people with a lack of information from their families are due to the fact that the elderly are often at home and rarely gather with people around them. in addition, the answer is that the family does not remember about the benefits of sleeping on the sand in everyday life which is entrenched in the coastal elderly.(hidayat, mumpuningtias, et al., 2020) according to clarkson (2020) assessment support is needed by the elderly such as special attention, positive appreciation so that the elderly feel recognized for their existence so that it is useful as a prevention of post power syndrome in the elderly. the results of the study stated that most respondents had self efficacy sleeping in the sand in the category capable of as much as 72.5%, this indicates that the elderly are able to have self efficacy in sleeping on the sand such as. basically, self-efficacy is based on a strong belief in the role model carried out by their previous predecessors. self efficacy is an individual's belief in actions or activities in achieving goals that are part of daily activities, self efficacy can have an impact on thinking patterns and can motivate oneself in behavior.24 albert bandura (1986) in christianity describes the importance of self-efficacy as a belief that serves as "an important set of proximal determinants of human motivation, influence, and action". this belief is a form of activity or action that provides cognitive and affective south east asia nursing research, vol 3 no 2, june 2021/ page 81-89 86 syaifurrahman hidayat / role model and family support related to self efficacy sleep in the sand in coastal elderly encouragement, as well as cognitive processes related to setting personal goals, the higher the level of perceived selfefficacy, the better the level of one's goals, leading to a higher level of commitment to goals.26 anisa (2018) states the formation of selfefficacy which is believed by local people to maintain this unique habit by passing down the sand mattress tradition informally. parents socialize this sand bed culture through habits that are carried out continuously at home, so that children can see, and be involved in the habits of their parents. in addition, village officials who also play an important role in determining the policies taken in the areas they lead relate to sand beds, village officials are basically aware of the interest of people outside the village to the uniqueness of this sand bed village. so when observing from children to the elderly how the role models carry out activities on the sand bed, the increase in self-efficacy also occurs when the respondents believe in the hereditary traditions of their families. the results of the study show that a small proportion of the elderly with self-efficacy sleep in the sand in the category unable as much as 10.0% of the elderly, where selfefficacy in someone other than obtained from life experience is also determined by errors in self-assessment, if in daily activities by sleeping on the sand becomes part of a positive activity, then self-efficacy in individuals it will be good too, and vice versa if in daily activities sleeping in the sand is part of an activity that has a bad impact on a person then self-efficacy will deteriorate in the individual. events from past experiences will be part of learning in determining self-efficacy through cognitive representations including memory of the frequency of distress and difficulty.28,29 when self-efficacy increases, the ability to solve problems or the ability to do tasks in the elderly will also increase. the results of observations on success can motivate an increase in self-efficacy in respondents so that it can also increase success in carrying out various activities to sleep in the sand. the results of the study stated that most of the respondents with role models in the high category and having self efficacy sleeping in the sand in the very capable category of 37.5% and based on the results of statistical tests with the test spearman's rho = 0.009 (<0.05) significantly states that there is a relationship between role models and self-efficacy sleeping in the sand in the coastal elderly, where according to zulkosky (2009) self-efficacy will increase when people see other people doing tasks and feel confident that they can complete the same task successfully with favorable results. this is especially true if the observer assumes the model has the same capabilities. from the results of this study, it can be said that the role model has a relationship in self-efficacy in respondents. this research is in line with research sadewi (2012) where increasing self-efficacy when observing role models, not only observations but also the success of the role model which also increases the self-efficacy of respondents who have thoughts when the role model is successful, i will also managed to do so.30 role models are a powerful source of beliefs self-efficacy because they provide observers with the strategies and techniques needed to achieve desired goals. several correlational studies have measured representative experiences and investigated their relationship to health behaviors.13 role models, when included as part of an intervention, have been shown to effectively increase health behavior-specific selfefficacy. in a study examining the effects of vicarious experience, mastery experience, and verbal persuasion on self-efficacy, vicarious experience was found behind mastery experience to be the second south east asia nursing research, vol 3 no 2, june 2021/ page 81-89 87 syaifurrahman hidayat / role model and family support related to self efficacy sleep in the sand in coastal elderly strongest predictor of self-efficacy. qualitative study.13 basically, the elderly follow the activities that have been carried out by their ancestors and some beliefs that increase self-efficacy also play an important role in imitating role models, for example role model beliefs in healing several diseases that can be cured by sleeping in the sand. self-efficacy beliefs are representative experiences, or models. watching others perform a behavior and observing the consequences of their actions is assumed to increase people's confidence in their own ability to master similar tasks, with comparable results. vicarious experiences are a powerful source of beliefs self-efficacy because they provide observers with the strategies and techniques needed to achieve desired goals.(wanner et al., 2011) when self-efficacy increases, the respondent's ability to perform a task or an activity will be done better than respondents with low self-efficacy. role models can be role models and motivations for respondents in doing activities sleeping in the sand. the success of the role model will be a motivation for the respondents. starting from observing the success of this role model, respondents will experience an increase in self-efficacy. the results of the study stated that the majority of respondents with family support in the moderate category and having self-efficacy sleeping on the sand in the very capable category of 37.5% and based on the results of statistical tests using the test spearman's rho = 0.001 (<0.05) significantly states that there is a relationship between family support and self-efficacy of sleeping in the sand in the coastal elderly, where the higher the family support, the higher the self-efficacy of the elderly. meanwhile, the lower the family support, the lower the self-efficacy of the teenager.32 family support in this case is a motivation in the form of social persuasion by the family that affects the self-efficacy of the elderly. according to bandura (1986) individuals who are directed by guidance can improve their abilities so that they can support someone to achieve their desires. social persuasion will be effective if the persuasion is carried out by the closest person who is trusted by the person. sitanggang (2021)stated that health problems experienced by the elderly require advocacy where the elderly need support for several issues both from their families,caregivers, other professionals, and orphanages. this support can encourage the elderly to give hope, feelings, and rejection. according to ayuni (2020) stated that family support plays an important role in providing sec motivation physical and psychological means where the family has various functions such as informational support consisting of advice, suggestions, advice, instructions and information providers. assessment support which involves providing information, advice or feedback from the family to the elderly who face certain situations and conditions. instrumental support can be provided by helping the elderly directly, in terms of food, drink, and rest needs to avoid fatigue and emotional support which is manifested in the form of affection, trust and attention.12 high family support because the supportive environment, especially the family, plays a very important role in the process of sleeping in the sand on a daily basis, this is because the elderly rarely have the will that comes from themselves, most of them come from other people or family, so there are many forms of support. family needs that need to be given to the elderly include emotional support, rewards, material and information about the benefits of sleeping in the sand.35 the orientation of self-control is part of the factors that affect self-efficacy, where if south east asia nursing research, vol 3 no 2, june 2021/ page 81-89 88 syaifurrahman hidayat / role model and family support related to self efficacy sleep in the sand in coastal elderly someone is in the orientation of internal control, it will lead to the achievement of the desired goals. self-efficacy shows feelings in the elderly that he believes in the benefits of sleeping on the sand can provide benefits for health and comfort for the elderly, selfcontrol orientation is internal so that it can have a positive self-efficacy impact by illustrating that the elderly will try to solve their own problems in carrying out activities everyday by sleeping on the sand.36 conclusion most respondents have role models in the high category as many as 57.5% coastal elderly, most respondents have family support in the moderate category as many as 72.5% coastal elderly, most of the respondents have self efficacy sleeping in the sand in the capable category as much as 72.5% coastal elderly and there is a relationship between role models and selfefficacy sleeping in the sand in the coastal elderly and there is a relationship between family support and self-efficacy sleeping in the sand in the coastal elderly acknowledgments thank you to the chancellor of wiraraja university and lppm wiraraja university for the facilities that funded this research activity based on the university's internal fund research contract for fiscal year 2021 number: 052 /sp2h/pendi/lppm/unija/v/2021 and thank you to the sumenep district health office, especially for thehealth lenggung center who has been willing to give us permission to conduct this research. conflicts of interest neither of the authors has any conflicts of interest that would bias the findings presented here. references 1. hidayat s. dhikr khafi to reduce osteoarthritis pain scale in the elderly. j heal sci. 2014;1(1):13–22. 2. bhattarai p, newton-john tro, phillips jl. apps for pain self-management of older people’s arthritic pain, one size doesn’t fit all: a qualitative study. arch gerontol geriatr. 2020 jul;89(march):104062. 3. hidayat s, mumpuningtias ed, indriyani r. the combination therapy of self-surrender exercise and distraction against osteoarthritis pain scale of elderly in coastal area. str j ilm kesehat. 2020 nov;9(2):1212–22. 4. bandura a. self-efficacy: toward a unifying theory of behavioral change. psychol rev. 1977;84(2):191–215. 5. friedman m. family nursing: theory and practice. interpreting, ina drl., yoakim a, editor, yasmin a., setiawan, monica e., edition 3. jakarta: egc; 2008. 6. pramudita, wiwien a. a total of 36 million people worldwide live in orphanages. 2015. 7. hidayat s, mumpuningtias ed. pendampingan keluarga dan perawatan orang dengan gangguan jiwa bebas pasung. japi (jurnal akses pengabdi indones. 2018 dec;3(2):65. 8. hidayat s. klenengan music therapy on sleep quality in elderly patients at pratama barokah clinic. j med sci clin res. 2018 dec;6(12). 9. mulyadi e, dip. behavior, support system, and daily habits of the kampung pasir indigenous people. kendal coll heal sci j nurs. 2021;13(1):183–190. 10. lenz e, shortridge l. self efficacy in nursing. new york: springer publishing company; 2002. 11. lestari a, hartati n. relationship of self efficacy with subjective well being in elderly living at home alone. j rap unp. 2016;7(1):15. 12. oktaviana r, hidayat s, dwi m. the role of the family on the cognitive function of the elderly in pandian village, sumenep regency. j heal sci. 2019;4(2):13–9. 13. alexandrova e, shapekova, nl, ak b, ozcanaslan r. health sciences research in the globalizing world. turkey: st kliment ohridski university press sofia; 2018. 14. putri h, muqodas i. approach concretepictorial abstract (cpa), mathematical anxiety, mathematical self efficacy, instruments and learning designs. sumedang: upi sumedang press; 2019. 15. manuntung a. cognitive behavioral therapy in south east asia nursing research, vol 3 no 2, june 2021/ page 81-89 89 syaifurrahman hidayat / role model and family support related to self efficacy sleep in the sand in coastal elderly hypertensive patients. malang: wineka medika; 2018. 16. maddux j. self efficacy, adaptation, and adjustment: theory research and application. new york: springer science & business media.; 2013. 17. stuart g, laraia m. principles and practice of psychiatric nursing, 8th edition. st. louis: mosby book inc.; 2005. 18. hidayat s, hannan m, mulyadi e. the effectiveness of self-surrender exercise and dzikir therapy in improving the quality of sleep in a nursing home in pasuruan, indonesia road. int j psychosoc rehabil. 2020 feb;24(4):5188–97. 19. santoso m. quality of life for the elderly : review article. j mesencephalon heal. 2019;5(1):33–41. 20. hidayat s, mumpuningtias ed. terapi kombinasi sugesti dan dzikir dalam peningkatan kualitas tidur pasien. care j ilm ilmu kesehat. 2018;6(3):219. 21. sangian lm, wowiling f, malara r. hubungan dukungan emosional keluarga dengan penerimaan diri pada lansia di desa watutumou iii. j keperawatan. 2017;5(2):1– 8. 22. hannan m, hidayat s. the role of families in caring for patients with pulmonary tuberculosis in gapura district, sumenep regency. mkm. 2013;2(1). 23. clarkson tr, sidari mj, sains r, alexander m, harrison m, mefodeva v, et al. a multivariate analysis of women’s mating strategies and sexual selection on men’s facial morphology. r soc open sci. 2020;7(1):191–209. 24. oktarianti, irawan e, amelia f. relationship of self efficacy with hypertension elderly self care. bsi j nurs. 2017;5(2):4–7. 25. bandura a. social foundations of thought and action: a social cognitive theory. new jersey: prentice_hall, inc.; 1986. 26. zulkosky k. self efficacy: a concept analysis. researchgate. in: nursing forum. 2009. p. 93– 102. 27. anisa u. melestarikan tradisi lokal : kampung kasur pasir. j sej dan budaya. 2018;7(1). 28. rustika i. self-efficacy: an overview of albert bandura’s theory. psychology bulletin universitas gadjah mada. 2012;1–4. 29. hannan m, hidayat s, fatoni a. the effect of blood pressure on the quality of daily sleep in the elderly in pstw pandaan. str sci j heal. 2021;10(1):1201–6. 30. sadewi a, sugiharto d, nusantoro e. improving self efficacy in mathematics learning through content mastery services with symbolic modeling techniques. indones j guid couns theory appl. 2012;8. 31. m. wanner l, schuz b, knittle k, p. ziegelmann j, wurm s. sources of perceived self efficacy as predictions of physical activity in older adults. int assoc appl psychol. 2011;1–21. 32. widanarti n, indati a. the relationship betweensocial support familywith self efficacy in adolescents at sma negeri 9 yogyakarta. j psychol. 2002;2(1):112 – 123. 33. sitanggang y, frisca s, sihombing r, koerniawan d, tahulending p, febriana c, et al. gerontic nursing (1st ed.). our writing foundation; 2021. 34. ayuni d. textbook of nursing care in post cataract surgery patients. independent gallery library; 2020. 35. yunitasari i. hubungan dukungan keluarga dan self-efficacy dengan upaya pencegahan relapse pada penyalahguna napza pasca rehabilitasi. psikoborneo j ilm psikol. 2018;6(2). 36. raharjayanti y. dukungan sosial keluarga dan self efficacy siswa smp dalam menghadapi ujian nasional. j promkes. 2019 dec;7(2):133. the positive report of benson relaxation for acute miocard infark pain: a case report study corresponding author: sri rejeki srirejeki@unimus.ac.id south east asia nursing research, vol 3 no 4, december 2021 issn:2685-032x doi: https://doi.org/10.26714/seanr.3.4.2021.172-178 original research the positive report of benson relaxation for acute miocard infark pain: a case report study dwi nur rahmantika puji safitri1, sri rejeki1, edy soesanto1, muhammad ali2 1 universitas muhammadiyah semarang, indonesia 2 intensive care unit dr. kariadi central general hospital, indonesia article info abstract article history: submitted: nov 2nd 2021 accepted: dec 11th 2021 published: dec 24th 2021 keywords: benson relaxation, acute myocardial infarction, pain structured acute myocardial infarction (ami) is myocardial necrosis caused by inadequa te blood supply due to acute blockage of the coronary arteries. typical signs and symptoms experienced in ami patients are chest pain such as squeezing, pressing, stabbing, heat or being crushed by heavy objects. giving pharmacological therapy such as oxygen, nitroglycerin and aspirin can reduce ami pain, but if the effects of the drug begin to decrease the pain will back, so complementary therapy is needed to help reduce pain in ami patients. the purpose of the research is to evaluate benson's relaxation effect in reducing chest pain in acute myocardial infarction (ami). the descriptive method was used by involving 2 subjects who experience chest pain. the intervention was carried out once a day for 2 days with an intervention duration of 30 minutes. the results of the evaluation were obtained, there was a decrease in both patients from 5 scales to 2 scales in patient 1 and 1 scale in patient 2. the combination of both pharmacological therapy and benson relaxation can reduce the scale of pain. benson relaxation can be used as a complementary therapy in reducing pain in ami patients. introduction acute myocardial infarction or commonly known as ami is a myocardial necrosis caused by inadequate blood supply due to acute blockage of the coronary arteries. the blockage that occurs is largely due to the rupture of atheromatous plaques in the coronary arteries, which is then followed by thrombosis, vasoconstriction, inflammatory reactions, and distal microembolization. sometimes this acute blockage occurs due to coronary artery spasm, embolism, or vasculitis.1 ami is also caused by atherosclerosis in the coronary arteries which blocks blood flow to the heart. atherosclerosis is a condition in which the coronary arteries are narrowed due to the accumulation of extracellular lipids, the formation of foam cells which can eventually lead to thickening and stiffness of the arteries.2 globally, the epidemiology of acute myocardial infarction (ami) shows that the incidence of st segment elevation myocardial infarction (stemi) has decreased, while the incidence of non-st https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.4.2021.172-178&domain=pdf&date_stamp=2021-12-24 south east asia nursing research, vol 3 no 4, december 2021/ page 172-178 173 sri rejeki / the positive report of benson relaxation for acute miocard infark pain: a case report study segment elevation myocardial infarction (nstemi) has increased. about 3 million people have stemi, and about 4 million people have nstemi globally. every year, in the united states there are about 650,000 cases of acute myocardial infarction (ami), while in the uk it is around 180,000 cases.3 heart sufferers in indonesia are 16.8 million, with an age division of 15-35 years around 1.44 million, 36-44 years old around 6.55 million, and age 45-65 years around 6.88 million. the highest prevalence of heart disease is in the provinces of north kalimantan at 2.2%, yogyakarta 2.0%, and gorontalo 2.0%.4 based on health data from the province of central java, there were 42.854 cases of heart disease (4.54%) ranking the fourth of all cases of noncommunicable diseases. while the second rank of 16.42% experienced dm.5 the incidence of stemi at the central general hospital dr. kariadi was found to be more prevalent in men, namely 126 cases (67.02%) compared to women, which only had 62 cases (32.98%). the mean age of women (60 years) is older than the average age of men (45 years), the youngest age is 40 years for women and 22 years for men.6 typical signs and symptoms experienced by ami patients are retrosternal chest pain such as squeezing, pressing, stabbing, heat or being crushed by heavy objects. pain can radiate to the arm (usually the left), shoulder, neck, jaw and even to the back and epigastrium. pain may last longer than angina pectoris and is unresponsive to nitroglycerin. pain can be accompanied by feelings of nausea, vomiting, shortness of breath, cold sweat, palpitations or syncope7. pain caused by a sudden decrease in coronary blood flow following occlusion thrombus plaque atherosclerotic a preexisting thrombus coronary artery vascular injury.6 pain management must be done as soon as possible to prevent sympathetic nerve activation, because sympathetic nerve activation can cause tachycardia, vasoconstriction, and increased blood pressure which in the later stages can increase the burden on the heart and expand the damage to the myocardium. the purpose of pain management is to reduce the heart's oxygen demand and to increase the oxygen supply to the heart.8 appropriate pain management should include both pharmacological and nonpharmacological. nursing independent interventions include in nonpharmacological with kind of treatmen is relaxationbenson relaxation.9 benson relaxation isdiverting attention to relaxation so that the client's awareness of the pain is reduced, this relaxation is done by combine the relaxation provided with the client's beliefs.10 this relaxation leading to decrease in the activity of the sympathetic nervous system which can eventually dilate the arteries slightly and improve blood circulation which can then increase oxygen transport to all tissues so that pain can be reduced.11 benson relaxation is not only used to reduce chest pain in ami patients, but benson relaxation can be used to reduce pain in other cases of pain. research in iran, 64 patients who underwent surgery with general anesthesia benson relaxation effectively reduced postoperative pain.9 in addition to a study in egypt, 100 patients with postoperative knee and hip joint replacement, benson relaxation is effective for reducing pain at night and improving sleep quality.12 likewise, a study in tehran iraq in 2020, 93 patients who underwent benson's relaxation laminectomy surgery effectively reduced postoperative pain.13 research conducted at harapan kita hospital showed that the combination of benson relaxation and analgesic therapy was more effective in reducing chest pain.14 this is in line with research conducted in the icu room, benson relaxation intervention for 30 minutes 2 times a day, effectively reduces chest pain in patients with acute coronary syndrome.15 based on the author's observations while working in the icu rsup dr. kariadi, the intervention to reduce pain in ami patients south east asia nursing research, vol 3 no 4, december 2021/ page 172-178 174 sri rejeki / the positive report of benson relaxation for acute miocard infark pain: a case report study is to use pharmacological therapy, such as oxygen, nitroglycerin, clopidogrel, isdn, aspirin and analgesics if needed. therefore, the authors want to apply benson relaxation therapy as a complementary therapy so that pain can be reduced more effectively, but benson relaxation has not been included in the list of standard operating procedures dr. kariadi semarang. so, the author wants to apply the benson relaxation technique to reduce pain in ami patients who are treated in the icu of dr. kariadi semarang. method the study designis case study with a descriptive nursing process approach from assessment to evaluation by applying benson relaxation to reduce pain scale in ami patients. the subject of this case study is an ima patient who experiences chest pain at dr. kariadi semarang in january 2022. the case study subjects were 2 patients with inclusion criteria: diagnosed by ami on the icu first day admission, pain scale above 4 (nrs), muslim religion, age of patients over 50 years. exclusion criteria: experience oxygensaturation below 90%, respiration rate more than 30x/minute, consciousness score less than 13. this case study was conducted from january 24 to january 25, 2022 in the icu room of dr. kariadi hospital. purposive sampling were used by assement patient at fisrt admission, appropriate data will take as a sampel. pre and post pain scale measure with the numeric rating scale (nrs) with score 1 to 10. this case study begins by conducting an assessment to obtain comprehensive patient data,problem has determined in appropriate patient. patient got explained about the study and asked for opinion. intervention delivered after patient sign the inform concent. the procedure for the benson relaxation technique are put patient in comfort position such as supine or semifowler. nurse ask pastient to close the eyes, then relaxation and feel it flowing from toes to face. instruct patient to inhale through the nose and then exhale through the mouth slowly and comfortably. while exhaling say astaghfirullah, repeat it during 30 minutes continously. in the end procces your eyes slowly, do this activity at least once a day results the results of the study conducted on january 24, 2022 in case 1 obtained general data: name of patient mr.p, age 52 years, male gender, self-employed occupation. weak general condition, composmentist consciousness. subjective data obtained by the patient said that the chest pain radiated to the back, the pain was like heavy object with an nrs 5 pain scale, the pain lasted about 1 minute and repeated. objective data obtained were bp 169/105 mmhg, hr 72 bpm, rr 20 rpm, t 37.00c, spo2 99%, ecg results showed st elevation in lead iii and avf, laboratory results for ckmb 27 mcg/l, patient was grimacing. the patient has received therapy from the emergency departments at 08.00 wib infusion of nacl 0.9% 10 tpm, oxygen with a 6l/m mask, isdn 5 mg sub lingual/24 hours, bisoprolol 2.5 mg oral (po)/24 hours, sprinolactone 25 mg po/24 hours, captopril 6.25 mg po/24 hours, lactulac 15 cc po/24 hours, tikagrelor 180 mg po, aspilet 160 mg po/24 hours. in case ii, an assessment was carried out on january 24, 2022, general data obtained: name of patient mr.s, age 59 years, male gender, self-employed occupation. weak general condition, composmentist consciousness. subjective data obtained by patients said chest pain, pain like being squeezed with a pain scale of nrs 5, pain lasted about 30-50 minutes and repeated, the body felt weak. the objective data obtained were bp 154/98 mmhg, hr 92 bpm, rr 18 rpm, s 36.8c and spo2 98%. the results of the ecg examination showed st elevation in leads ii, iii and avf, the results of the ckmb laboratory examination were 37 mcg/l, the patient was grimacing. the patient has received therapy from the er at 15.00 wib infusion of nacl 0.9% 20cc/hour, south east asia nursing research, vol 3 no 4, december 2021/ page 172-178 175 sri rejeki / the positive report of benson relaxation for acute miocard infark pain: a case report study lansoprazole inj 30 mg/12 hours, arixtra inj 2.5 mg/24 hours sc, aspilet 160 mg oral (po)//24 hours, ramipril 2.5 mg po/24 hourly, amlodipine 10 mg po/24hr, isdn 5 mg sub lingual/24hr, tikagrelor 180 mg po/24hr, laksadinesyr cth/24hr.based on the results of the study above, it was found that both patients were male, aged over 50 years, had the same main complaint, chest pain on an nrs 5 scale, and both patients received oxygen therapy, nitrates, aspirin and hypertension therapy. the formulation of the main nursing diagnosis for the two patients was acute pain related to physiological injury agents. the definition of acute pain is a sensory or emotional experience associated with actual or functional tissue damage, of sudden or slow onset and of mild to severe intensity lasting less than three months 16. characterized by the presence of major data from both patients said chest pain, the patient grimaced, and increased blood pressure. the nursing plan for both patients refers to the standard of nursing outcomes that are carried out after the nursing process is carried out for 2 x 24 hours, it is expected that the level of pain will decrease and pain control will increase with the criteria for the results of not complaining of pain, not grimacing, improving blood pressure, reporting pain is controlled and able to use non-pharmacological techniques.16 the planned interventions are observation ( identify location, characteristics, duration, frequency, quality, pain intensity, identifypain scale), therapeutic (give nonpharmacological techniques of benson relaxation to reduce pain), education (explain strategies to relieve pain and teach benson relaxation techniques) to reduce pain and collaboration for administration of oxygen, nitrates, aspirin and analgesics. the first implementation of patient 1 was carried out on january 24, 2022 at 16.00 by examining the patient first, the patient's subjective data said he was still in pain with an nrs scale of 5,and objective data was bp 154/98 mmhg, hr 92 bpm, rr 18 rpm, s 36, 80c and spo2 98%, the patient's face looks grimacing in pain, at 16.15 the author teaches the benson relaxation technique after the patient does benson relaxation for 30 minutes then an evaluation is carried out at 17.00. : 160/98mmhg, hr: 90bpm, rr: 22rpm.in the second case, it was carried out on january 24, 2022 at 19.00 by conducting an assessment first, obtained subjective data from patients complaining of pain on a scale, nrs pain 5, objective data bp: 154/98mmhg, hr: 89 bpm, rr: 22rpm, 19 hours 15 taught the benson relaxation technique the same as patient case 1, after that it was evaluated at 19:45 with subjective data the patient said pain was reduced on the nrs 4 pain scale with objective data bp: 147/90mmhg, hr: 85bpm, rr: 21rpm. the second implementation in case 1 was carried out on january 25, 2022 at 06.00, providing therapy with isdn 5 mg, bisoprolol 2.5 mg, sprinolactone 25 mg, captopril 6.25 mg, lactulac 15 cc po, tikagrelor 90 mg po, aspilet 80 mg, then do a reassessment at 19.00, the subjective data obtained by the patient saying he was still in pain with an nrs scale of 2, and objective data for bp 138/83 mmhg, hr 87 bpm, rr 20 rpm, s 36.80c and spo2 98%, at 19.15 the patient asked to do benson relaxation. at 19.45 an evaluation was carried out, the patient's subjective data said the pain was reduced, with the nrs pain scale 1, the objective data was bp: 132/79mmhg, hr: 83bpm, rr: 18rpm, the patient looked calm and relaxed. implementation in case 2 was carried out on january 25, 2022 at 12.00 providing therapy inj lansoprazole 30mg/12 hours, injarixtra 2.5mg/24hours sc, aspilet 80 mg oral (po)//24hours, ramipril 2.5mg po/24 hours, amlodipine 10 mg po/24 hours, isdn 5 mg sub lingual/24 hours, tikagrelor 90 mg po/24 hours, laxadinesyr cth/24 hours, then reassessed at 20.00 obtained subjective data the patient said he was still in pain with the nrs 3 scale, objective data for bp: south east asia nursing research, vol 3 no 4, december 2021/ page 172-178 176 sri rejeki / the positive report of benson relaxation for acute miocard infark pain: a case report study 142/88mmhg, hr: 89 bpm, rr: 22rpm, at 20.15 the patient was asked to do benson relaxation, at 20.45 an evaluation was carried out, subjective data of the patient said the pain was reduced, with a pain scale of nrs 2, objective data bp: 137/92mmhg, hr: 80bpm, rr:16rpm. the results of the implementation carried out by the author, the pain of the two patients decreased, indicated by the patient saying that the pain was reduced, the patient's blood pressure fell, the pulse frequency fell, and the breathing frequency also decreased. the evaluation results showed a decrease in pain. both patients experienced moderate pain before the intervention, (nrs 5), after the intervention decreased to mild pain, (nrs 2 in patient 1 and nrs 1 in patient 2) which are presented in the graph below. graph 1 pain scale of ami patients with benson relaxation in the icu (n=2) discussion the results of the demographic assessment data obtained from patients 1 and 2 are male, aged more than 50 years and have a history of hypertension. broadly speaking, the risk factors forami are divided into two groups based on whether they can be modified. risk factors that canbe improved or modified include hypertension, hypercholesterolemia, dyslipidemia, smoking, obesity, diabetes mellitus, lack of physical activity, stress, and lifestyle. risk factors such as age, gender, race and family history of disease are factors that cannot be changed1. this is like a previous study conducted by muhammad, et al, which stated that the incidence of acute myocardial infarction with st-segment elevation at rsup dr. kariadi in 2017, the highest incidence of stemi in men included in the elderly category, which was as many as 85 cases. the risk of coronary atherosclerosis increases with age. serious illness rarely occurs before the age of 40. other risk factors can still be changed, so that it has the potential to slow down the atherogenic process. all types of coronary heart disease including stemi that occur in the elderly have a high risk of death and adverse events.17 in patients with hypertension, there is an increase in the concentration of angiotensin ii. angiotensin ii is a potent vasoconstrictor and contributes to atherogenesis by stimulating smooth muscle growth. this occurs through binding of angiotensin ii to specific smooth muscle receptors that activates phospholipase c. this activation increases intracellular calcium and smooth muscle contraction. another effect is an increase in lipoxygenase activity which can increase the inflammatory response and ldl oxidation. ecg investigations there is st elevation in lead ii and avf abnormal ecg images appear because of ischemia in the heart muscle that occurs in the inferior region of the heart, as well as increased ckmb enzyme values as a biomarker of cardiac necrosis, this is in accordance with the theory which in investigations of ami patients will get abnormal features on the ecg and an increase in the ck-mb enzyme.1 both patients received oxygen therapy, ticagrelor, nitrates, aspirin. ticagrelor therapy competitively and irreversibly blocks the adenosine diphosphate (adp) p2y12 receptor. adenosine diphosphate binding to the p2y12 receptor induces a 5 4 1 5 4 2 0 2 4 6 before intervention first day relaxation second day of relaxation pain scale case 1 case ii south east asia nursing research, vol 3 no 4, december 2021/ page 172-178 177 sri rejeki / the positive report of benson relaxation for acute miocard infark pain: a case report study change in platelet size and temporarily attenuates platelet aggregation. ticagrelor has an onset of action 30 minutes after oral administration. the time to reach peak levels is obtained in different ranges from several studies, where ticagrelor is 1.5 hours, ticagrelor has a half-life of 7 hours. isdn is a nitrate preparation that has an isdn duration of action ranging from 1 to 2 hours, while the duration of action of sublingual nitroglycerin is only 20-30 minutes. aspirin works by inhibiting the cyclooxygenase enzyme thereby inhibiting the production of thromboxane a2 (txa2). peak blood levels 1 hour after drinking. (national drug information center of the indonesian national drug and food control agency 2018). in patients 1 and 2, the implementation of benson relaxation was carried out 7-8 hours after giving pharmacological therapy, this was intended so that there was no confusion about effectiveness in reducing pain in ami patients, after the duration of drug action was reduced or lost, benson relaxation as a companion therapy can help in reducing ami patient pain. this is in line with the research conducted by sunaryo (2014) on “the effect of benson relaxation on reduction of left chest pain scale in acute myocardial infarct patients. the combination of analgeticc and benson relaxation therapy has more effect on reducing pain scale in patients with acute myocardial infarct compared to analgesic therapy alone. benson relaxation intervention for 30 minutes 2 times a day, effectively reduces chest pain in patients with acute coronary syndrome.18 patient i pain scaoe decreased more than patient 2, it is may everyone's perception of pain threshold is different.18 everyone has a different meaning in viewing the pain response, both at different times in the same individual or with the same complaint. some individuals have a positive response and are faster than other individuals, it depends on the condition and the individual's interpretation of the pain). the second factor is individual tolerance for pain, a person's tolerance related to the intensity of pain to which the individual can respond well or vice versa. the third factor is a limit of a person's ability to adapt and respond to pain which affects a person's behavior, and the fourth factor is age, the difference in a person's age has different influences in viewing pain. adults usually tolerate pain better, but children have a lower upper pain threshold for discriminating between pain and pressure, whereas older people fail to perceive tissue damage, due to degenerative changes in pain nerve pathways compared to adults. young age.19 conclusion the combination of pharmacological therapy with benson relaxation is effective in reducing pain scale in ami patients. the evaluation results obtained a decrease in pain on 3 nrs scales (scale 5 down to scale 2) in patients 1 and 4 on the nrs scale (scale 5 down to scale 1) in patient 2. suggestions from the author, benson relaxation can be applied as a complementary therapy in reducing chest pain in ami patients. hospitals can make pain management with benson relaxation a standard operating procedure (sop), and nurses can develop further related to non-pharmacological therapy to reduce exposure to pharmacological therapy. acknowledgments the author would like to thank allah swt who has given all his guidance, so that the writing of the final research runs smoothly. references 1. perki. pedoman tatalaksana sindrom koroner akut. edisi iv. jakarta: perki; 2018. 2. mach f, baigent c, catapano al, koskinas kc, casula m, badimon l. esc/eas guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. eur hear j. 2019;00:1–78. 3. ibanez b, james s, agewall s, antunes mj, bucciarelli-ducci c, bueno h, et al. esc south east asia nursing research, vol 3 no 4, december 2021/ page 172-178 178 sri rejeki / the positive report of benson relaxation for acute miocard infark pain: a case report study guidelines for the management of acute myocardial infarction in patients presenting with st-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with st-segment elevation of the european society of. eur heart j. 2017;39:119–77. 4. riskesdas. laporan nasional riset kesehatan dasar 2018.badan penelitian dan pengembangan kesehatan. kementerian kesehatan republik indonesia; 2018. 5. dinkesjateng. profil kesehatan provinsi jawa tengah. semarang: dinas kesehatan jawa tengah; 2018. 113 p. 6. muhammad gr, ardhianto p. profil faktor risiko atherosklerosis pada kejadian infark miokard akut dengan st-segment elevasi di rsup dr kariadisemarang. media med muda. 2017;4:849–858. 7. eka pranata a. keperawatan medikal bedah dengan gangguan sistem kardiovaskuler. nuha medika. jogjakarta; 2017. 8. anderson jl, n engl j med mdaa. european society of cardiology. esc guidelines for the management of acute coronary syndromes in patients presenting without persistent stsegment elevation. eur heart j. 2017;79:2053– 64. 9. zahra k, msc rj, phd mbs, phd ns, phd. effect of benson relaxation on the intensity of spinal anesthesia–induced pain after elective general and urologic surgery. elsevier, inc behalf am soc perianesthesia nurses. 2020;114:424–433. 10. rasubala m, f g, kumat lt. pengaruh teknik relaksasi benson terhadap skala nyeri pada pasien post operasi di rsup prof dr rd kandou dan rs tk iii rw mongisidi manado. vol. 5. 2017. p. 44–54. 11. febtrina r, febriana w. teknik relaksasi imajinasi terbimbing ( guided imagery ) menurunkan nyeri pasien pasca serangan jantung. nurs curr. 2017;5:41–49. 12. masry, e s, e.ahmed ae, el-mawgoud na. effect of benson’s relaxation technique on night pain and sleep quality among adults and elderly patients undergoing joints replacement surgery. int j nurs didact. 2017;18:40–44. 13. seyed a, pishgooie, akbari f, shahrestanaki sk. effects of relaxation techniques on acute postlaminectomy pain: a three-arm randomized controlled clinical trial. am soc perianesthesia nurses. 2020;51:1089–9472. 14. rustono a. effectiveness of benson relaxation in reducing the scale of chest pain in patients with acute coronary syndrome ( acs ) in the intermediate medical ward of the heart hospital blood vessel and we hope to jakarta. univ muhammadiyah jakarta. 2018; 15. titi s sat, retno u, daryani. benson relaxation relieve a pain in coronary syndrome patients. educ humanit res. 2017;31:191–196. 16. p.p.n.i. standar luaran keperawatan indonesia. ppni; 2018. 17. kowalak jp, welsh w, mayer b. buku ajar patofisiologi (professional guide to pathophysiology. jakarta: egc; 2017. 18. mutika na, mulfianda r, desreza n. pengaruh terapi guided imagery terhadap respon nyeri pada penderita reumathoid arthritis di gampong jeulingke kota banda aceh. j semdi unaya. 2019;3:629–636. 19. shalahuddin i, eriyani t, pebrianti s. determinan epidemiologi penyakit pada mahasiswa akademi keperawatan di garut, jawa barat tahun 2015. j keperawatan indones. 2019;22:92–100. aplication of family centered care on the impact of hospitalization in intensive care unit in parents’ perspective: literature review corresponding author: mariyam mariyam mariyam@unimus.ac.id south east asia nursing research, vol 4 no 1, march 2022 issn:2685-032x doi: https://doi.org/10.26714/seanr.4.1.2022.35-46 review article aplication of family centered care on the impact of hospitalization in intensive care unit in parents’ perspective: literature review staningsih herlambang kurniawati1, mariyam mariyam1, , dera alfiyanti1, amin samiasih1 1 universitas muhammadiyah semarang, indonesia article info abstract article history: submitted: jan 12th 2021 accepted: march 5th 2022 published: march 29th 2022 keywords: family centered care; pediatric intensive care; parents / family family-centred care (fcc) is an effective intervention in reducing the impact of hospitalization. the aim of this literature review was to identify published research articles on the application of the fcc concept to the reduction of the impact of hospitalization in pediatric intensive care wards from the perspective of the parents. the literature review research took 14 journals from various databases published in 2015-2021. searching for titles was obtained through identification and screening, entering inclusion criteria, so that 13 international journals and 1 national journal were obtained. the results of this study identified parental perspectives regarding the application of the core concepts of the fcc in reducing the impact of hospitalization, where each concept is accompanied by theme findings, for respect and dignity: a) the physical and cultural environment of the picu, b) the expression of compassion and support from staff; sharing information: a) using understandable language, b) medical cycles, and c) satisfaction with communication; participation: a) parents as experts, b) how parents participate, c) environmental / staff impact on participation, and d) medical cycles; and collaboration. this review reveals parents' reports that the implementation of the fcc concept in reducing the impact of hospitalization has not been fully fulfilled, as evidenced by the finding of positive and negative implementations related to the fcc concept. introduction children are individuals who are in a range of changes starting from infants to teenagers who experience changes in growth and development in a fast or slow time1 children can experience illness and even critical illness. critical illness is a condition that is not expected and endangers the patient's life. these conditions can be in the form of acute illness, trauma and chronic disease. critical illness in children causes high morbidity and mortality rates.2 in critical condition, children need intensive care. the pediatric intensive care unit is a unit dedicated to treating pediatric patients aged over 28 days to 18 years who experience illness, accident/trauma, which is life threatening, requires intensive care, comprehensive observation, and special care3 his room includes most of the sophisticated and complex equipment such https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://jurnal.unimus.ac.id/index.php/seanr/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.4.1.2022.35-46&domain=pdf&date_stamp=2022-03-29 south east asia nursing research, vol 4 no 1, march 2022/ page 35-46 36 mariyam mariyam / aplication of family centered care on the impact of hospitalization in intensive care unit in parents’ perspective: literature review as intravenous lines, drugs, ventilators, monitors, and alarm sounds that are unusual for the patient's family4 hospitalization in the intensive care unit is a crisis for patients and families because of the emotional intensity experienced and the complexity of the care provided.5 the main stressors of hospitalization in children include separation, loss of control, bodily injury, and pain. the child's reaction to the stressor of hospitalization at separation showed that the child restrained the parent to stay (64.5%), the reaction to the loss of control was obtained by the child depending on the parent (64.1%) and the reaction to injury and pain was obtained by the child asking for action. ended (60.3%).6 other studies have identified anxiety in parents that can arise as a response to being alienated from the hospital environment, such as not knowing the room and the people in it, not understanding medical rules and procedures, and feeling unable to control themselves and not being able to put themselves in a position to care for themselves. determine what role he must do while the child is in the hospital7 <sup>8</sup><sup>8</sup><sup>8</su p><sup>8</sup><sup>8</sup><sup>8</ sup>families with children in intensive care units may experience significant psychological symptoms, including acute stress, post-traumatic stress, anxiety, and depression.9 families with patients in critical care rooms experience post trauma syndrome disorder (ptsd) as much as 33%, 33% experience anxiety and 20% experience depression.10 families are an important part of child care during illness. creating a relationship between parents and health professionals is necessary, such as involving parents in making decisions and facilitating parental participation in child care11 increasing the role of parents in child care from an early age can reduce the negative impacts of hospitalization of children in intensive care.5 family-centered care (fcc) as a model of care is a way of caring for children and their families in health services.12 the institute for patient family centered care developed four core concepts for implementing the fcc, namely respect and dignity; information sharing involves communicating and providing clear and unbiased information; participation includes family involvement in decisionmaking and child care; collaboration consists of partnerships with families to improve policies, programs and infrastructure (https://www.ipfcc.org/). the results of observations by researchers in the picu room at a semarang hospital, showed that parents with children who were treated in the picu room waited more outside the room and experienced limitations in participating in caring for their children. the family feels anxious about the condition of their child in the intensive room without parental supervision. the partnership between the family and the health care team is very important in pediatric nursing. parents are the constant voice, advocate and caregiver for the child. in addition, it is the parents who are most responsible for the care of the child after being discharged. the policy of family visits at the hospital makes parents or families have limited time in visiting hours, so they do not have 24-hour access to participate in caring for children. families experience high levels of anxiety, stress and depression continuously.13 the purpose of this literature review is to describe the perspective of parents in the implementation of fcc in the pediatric intensive care unit. methods this study can be classified as a literature review. the data based searches sciencedirect, springer link, pubmed dan google scholar. the keywords used in the article search using ‘family centered care, pediatric intensive care, parents/family’. the search results obtained 13 https://www.ipfcc.org/ south east asia nursing research, vol 4 no 1, march 2022/ page 35-46 37 mariyam mariyam / aplication of family centered care on the impact of hospitalization in intensive care unit in parents’ perspective: literature review international journals and 1 national journal with the year published between 2015-2021. the articles discussed in the literature review were obtained in the form of open access, relevant and free full text with the theme of family centered care in the child intensive care room from the perspective of parents. the title search results can be seen in figure 1 figure 1. flowchart of screening articles result based on this literature review, there are four core fcc concepts, namely respect and dignity, information sharing, participation and collaboration. in this section, we will discuss the findings of the theme based on each of the fcc core concepts, about whether the application of the fcc core concepts has been applied in the picu as a form of implementation to reduce the impact of child hospitalization in the eyes of the parents, which is summarized in table 2. tabel 1 data synthesis no title. researcher, year, journal source research design result conclusion 1 family-centered care and traumatic symptoms in parents of research design: cross-sectional study sample: 90 parents of children treated in support from nurses is high in both parents and is associated with acute stress disorder. 1/3 of parents have asd. there were no significant gender differences when symptoms parents' traumatic experiences with child care in the picu were associated with acute stress, but not disease s cr e e n in g in cl u d e d id e n ti fi ca ti o n sciencedirect (n= 319 articles) pubmed (n= 220 articles) researchgate (n=31 articles) google schoolar (n=180 articles) articles that meet the inclusion criteria (n articles are screened with inclusion criteria in the year of publication (2015-2021) (n = 467) screening of the same title and abstract that has been read (n=46) articles included in the analysis (n-13) full text articles were excluded because not related family centered care in intensive care unit total number of articles (n=750) full-text articles included in literature review (n=30) south east asia nursing research, vol 4 no 1, march 2022/ page 35-46 38 mariyam mariyam / aplication of family centered care on the impact of hospitalization in intensive care unit in parents’ perspective: literature review no title. researcher, year, journal source research design result conclusion children admitted to picu, 14 scandinavian journal of caring sciences picu in university hospital of aarhus. method: parents fill out a self-report questionnaire package when their child is discharged from the hospital were dimensionally measured. if measured categorically, 17% of mothers and 7% of fathers suffer from asd. mothers with very young children had higher levels of acute stress; fathers whose children have high disease severity scores exhibit more acute stress severity, or fear of losing the child. more research is needed to understand the dynamics of familycentered care 2 family presence during pediatric tracheal intubations (sanders et al., 2016). journal of jama pediatrics research design: prospective cohort study sample: with or without family presence, all intubations of patients younger than 18 years in 22 international picus from july 2010 march 2014 in the multicenter ti database (national emergency airway registry for children) method: comparing intubation actions on patients with family presence or without family presence a total of 4969 tracheal intubations, 81% of intubations were performed with family present with a mean patient age of 2 years, 19% intubations were performed without family presence with a mean patient age of 1 year family presence was not associated with the success rate of tracheal intubation attempts or adverse events such as oxygen desaturation (<80%), or increased stress on the medical team. data suggest that family presence during intubation can be safely applied as part of the fcc model in the picu 3 parental satisfaction with the quality of care in a south african paediatric intensive care unit (mol, argent, & morrow, 2018). southern african journal of critical care research design: descriptive study sample: 100 parents whose children were cared for in the picu for 48 hours method: participants completed a questionnaire at the children's red cross hospital, south africa (empathic-30), which includes 30 closed questions assessing satisfaction in different domains and four open questions to qualitatively describe the picu experience overall, parents reported positive experiences during their child's care in the picu. however, the lowest response scores were found to be related to 'information' and 'parental participation', which are important aspects of the fcc. active involvement of parents in decisionmaking about the care and treatment of their child as well as properly informing about the indications, effects and possible side effects of drugs, are highlighted areas for improvement of fcc practice in the picu. although parents are generally very satisfied with the quality of care, increasing family involvement and providing adequate information in the picu can contribute to the quality of the fcc. 4 parental sources of support and guidance when making difficult decisions in the pediatric research design: prospective cohort study sample: 86 englishspeaking parents of 75 children in the pediatric intensive most parents choose doctors, nurses, friends and extended family as their main source of support and guidance when making difficult decisions parents rely heavily on doctors, nurses, and extended friends and family when making difficult decisions for their critically ill child south east asia nursing research, vol 4 no 1, march 2022/ page 35-46 39 mariyam mariyam / aplication of family centered care on the impact of hospitalization in intensive care unit in parents’ perspective: literature review no title. researcher, year, journal source research design result conclusion intensive care unit. 17 the journal of pediatrics, care unit at children's hospital of philadelphia who were hospitalized more than 72 hours. method: each parent completed the survey instrument independently, and team members were present to answer any questions 5 a qualitative study of parents' experiences in the pediatric intensive care unit. alzawad, lewis, kantrowitzgordon, & howells, (2020) journal of pediatric nursing research design: qualitative research sample: 15 parents of children with complex medical conditions who were admitted for 48 hours or more in the picu method: semistructured face-toface interviews were conducted in the picu at the bedside of the sick child riding a roller coaster is a core construct that describes the parental experience. the analysis revealed four domains: being in a new stressful situation, thinking hard all the time, going through emotional storms, being in a safe place with great people despite the exceptional medical services, parents are traumatized by seeing their child in a lifethreatening situation and being hit by a tidal wave of emotions. parents live in a state of uncertainty, helplessness and fear, not knowing if their child will survive or have a bad outcome such as permanent disability. 6 implementasi perawatan berpusat pada keluarga. andra saferi dkk.(2018) google scholar research design: qualitative phenomenology sample: 12 people consisting of nurses, parents and doctors by purposive sampling generated 6 themes: meaning of parents with children, perceptions of parents and nurses, implementation, benefits, challenges, expectations of implementing family-centered care in the picu strict regulations at picu prevent families from participating in caring for their children in picu 7 parents' perceived satisfaction of care, communication and environment of the pediatric intensive care units at a tertiary children's hospital. (abuqamar, arabiat, & holmes, 2016). journal of pediatric nursing research design: cross-sectional, descriptivecorrelational design quantitative approach sample: 123 parents with children hospitalized in amman 90% of parents believe that nurses ignore their child's needs by not listening to parents and responding slowly to their child's needs. stepwise regression analysis showed that the number of hospitalizations, health insurance and disease severity were the main predictors of parental satisfaction the availability of health professionals, the support and information they provide to parents and children, are all important for parent satisfaction and for a better quality of care. 8 dominance of paternalism in family-centered care in the pediatric intensive care unit (picu): an ethnographic study research design: etnographic research design method: data collection, participant observation, field work, and there are five themes: "non-owned environment", "separation of children from their parents," non-interactive communication", "restricted participation", and "combination of affection and sympathy". he prevailing atmosphere in care is paternalistic because there is a large gap between the conceptually or theoretically accepted implementation of the fcc in the picu and the south east asia nursing research, vol 4 no 1, march 2022/ page 35-46 40 mariyam mariyam / aplication of family centered care on the impact of hospitalization in intensive care unit in parents’ perspective: literature review no title. researcher, year, journal source research design result conclusion 19 jurnal comprehensivechi ld and adolescent nursing interviews with the main picu actors, namely supervisors, nurses, and parents applied fcc. bridging the gap between theory and practice can help improve the social and organizational cultural environment for children, parents, and medical teams and their performance in picu services 9 what impact do hospital and unitbased rules have upon patient and family-centered care in the pediatric intensive care unit? 20 research design: qualitative studies sample: 7 parents of patients treated in picu and 12 nurses observation and interview the existence of explicit and implicit rules in the pediatric intensive care unit, has a negative impact on the ability of families to receive care that is attentive to their needs agencies make rules and norms, which apply to nurses as service providers and families/patients as service recipients. however, there is a difference between what parents are looking for and what is provided by the staff as a result of the fcc's suboptimal implementation of institutional rules and norms. so a wider fcc model is needed. 10 parents' experiences of their child being admitted to a paediatric intensive care unit: a qualitative study–like being in another world 21 scandinavian journal of caring sciences research design: qualitative studies method: interviews were conducted on 12 parents whose child is being treated in the picu parents' experiences of picu care are summarized under the overarching theme of 'it's like being in another world. the analysis of the study led to the identification of two categories namely, 'engaged' and 'informed', with seven subcategories, namely caring for parents, security and trust, changing parental roles, stress and fear, importance of knowing interactions in care, preparation of information before action. a parent's experience of having their child admitted to a pediatric intensive care unit is fraught with various emotions and fears. good information, involvement and positive experiences of being transferred to the pediatric ward reduce stress and anxiety related to care in the picu. the results of this study can be used as a basis for follow-up services for children and their families after treatment in the picu 11 elements of family-centered care in the pediatric intensive care unit: an integrative review 22 jurnal physiology & behavior research desain: literature review five themes were identified: 1) information sharing; 2) hear the voice of parents; 3) make decisions for or with parents; 4) negotiating role; and 5) individual communication picu puts health staff in touch with families and protects them from distress. asking parents about their preferences for participation across these domains can improve doctor-family relationships 12 an evaluation of family-centered research desain: cross sectional family and staff agree that medical team visits keep families informed and report positive statements family and staff agree that medical team visits keep families informed and south east asia nursing research, vol 4 no 1, march 2022/ page 35-46 41 mariyam mariyam / aplication of family centered care on the impact of hospitalization in intensive care unit in parents’ perspective: literature review no title. researcher, year, journal source research design result conclusion rounds in the picu 23 jurnal pediatric critical care medicine regarding family presence at the time of visite; however, picu colleagues disagreed that families provided relevant information and nurses reported that family presence limited discussion about patients. the main advice families offer providers to improve the well-being of medical team visits is to be more considerate and courteous, including adjusting family schedules, minimizing distractions, and limiting computer viewing. report positive statements about family presence during visits; however, picu colleagues disagreed that families provided relevant information and nurses reported that family presence limited discussion about patients. the main advice given by families to health workers to improve the goodness of medical team visits is to be more attentive and polite, including adjusting family schedules, minimizing distractions, and limiting computer viewing 13 the conceptualization of family care during critical illness in kwazulu-natal, south africa. 24 jurnal of health sa gesondheid research desain: qualitative sample: 31 participants (family members, intensive care nurses and doctors) who voluntarily participated data collection includes in-depth interviews family care is conceptualized as togetherness, partnership, respect and dignity during critical illness, the patient's family fulfills an additional important role for the patient who may be unconscious or unable to communicate or make decisions. families not only provide vital support to their loved ones, but also become the “voice” of the patient 14 exploring the experiences of parent caregivers of children with chronic medical complexity during pediatric intensive care unit hospitalization : an interpretive descriptive study 25 bmc pediatrics interpretive descriptive study semi-structured interviews were conducted with 17 caregivers of 14 critically ill patients parents of patients with chronic medical complexity (cmc) are expected to continue to provide care but feel that their knowledge and expertise is not always recognized by staff. they stress the importance of parent-staff partnerships. four themes were identified: (1) "we know our child best;" (2) when skills collide; (3) negotiating parenting boundaries; and (4) importance is known. results support the need for a picu parenting approach for cmc that recognizes parental expertise partnership between staff and parents, good communication with staff, continuous attention in the picu are very important, especially in the case of cmc tabel 2 summary of journal description (n = 14) fcc concept theme parents' perception n % reference respect and dignity perception of the physical environment and trigger culture the bathroom in the unit and the waiting room furniture are not available. noise level in the picu, small room size, comfortable chair near the patient's bed, facilities for 5 35 18 (mol, argent, & morrow, 2018), south east asia nursing research, vol 4 no 1, march 2022/ page 35-46 42 mariyam mariyam / aplication of family centered care on the impact of hospitalization in intensive care unit in parents’ perspective: literature review fcc concept theme parents' perception n % reference meeting parents' personal needs (cleaning, nutrition, rest) (alzawad, lewis, kantrowitz-gordon, & howells, 2020). 19 (baird, davies, hinds, baggott, & rehm, 2015) expressions of affection and support from the staff expressions of affection and support from the staff 8 57 25 madrigal et al., 2016) (mortensen et al., 2015) (alzawad et al., 2020); ( dahav & sjöströmstrand, 2018) (sanders et al., 2016). 19 ( levin, fisher, cato, zurca, & october, 2015a) sharing information use a language you can understand difficult terms, absorption of information, parent's choice of language, misunderstood 3 21 -26 -(de beer & brysiewicz, 2017). -(alzawad et al., 2020; baird et al., 2015). visit the medical team parents can receive information, feel accepted, feel opinionated, can ask questions, feel reassured, transparency, cause stress, discomfort and anxiety 3 21 (levin et al., 2015a) -27 (levin et al., 2015a). satisfaction with communication satisfied with feedback, easier to get information, introduced to staff. dissatisfied when staff speak coldly, ignore emotional and spiritual needs, poor admissions, disparate information, too many staff 7 50 (richards, starks, o’connor, & doorenbos, 2017) (levin et al., 2015a; rennick et al., 2019). -16 abuqamar et al., 2016 vasli et al., 2015) saferi wijaya et al., 2018) participation parents as experts staff: treats parents as experts, accepts advice, asks for consideration, puts it into practice, parents: feel unheard, hesitate to express opinions, worry about disturbing 5 35 -25,28 18–20 how parents participate parents look after children, are involved in care, entertain children, as child advocates 5 35 -(abuqamar et al., 2016; 2015; -rennick et al., 2019 -(baird et al., 2015) 17,28 environmental/s taff impact on participation staff guiding parents parents have limited participation, because of the picu rules, the trigger environment is not childfriendly 4 28 -(mortensen et al., 2015). -(baird et al., 2015) -18 19 visit the medical team as an avenue for participating in treatment decision making, equate perceptions in participation 2 28 -(richards et al., 2017) -(levin et al., 2015) kolaborasi south east asia nursing research, vol 4 no 1, march 2022/ page 35-46 43 mariyam mariyam / aplication of family centered care on the impact of hospitalization in intensive care unit in parents’ perspective: literature review disscusion based on a review of the identified literature, it provides an overview of the application of the fcc core concept as an intervention to reduce the impact of hospitalization on children in the picu in the view of parents. the concept of respect and dignity with the theme of the perception of the physical and cultural environment of the picu and expressions of compassion and support from staff. the physical condition of the picu environment is a factor that influences parents in getting respect and dignity. parents' perception that a clean and comfortable room, close to the waiting room is an indicator of respect.18 the lack of respect was communicated by the unavailability of a bathroom for the family, so that during a visit the parents had to leave the picu to find a bathroom, then return to the unit which had to pass through the security guard/door with an automatic lock button.16,27 parents, expressed other indicators of a lack of respect due to noise levels in the picu, disrupting rest, small room size, insufficient space to accommodate personal items or providing a comfortable chair near the patient's bed.18,27 there are no facilities for parents to meet their personal needs such as cleanliness, nutrition, or a place to rest.19 in the pediatric intensive care unit, parents comment that the waiting room is generally an uncomfortable social space where stressed family members exhibit various emotional behaviors and annoy other patients' families.20 one report describes waiting room furniture that is not conducive to sitting or resting.16 having an environment where parents can be present, make unlimited visits, perform basic activities of daily living and fulfill their own hygiene needs, and feel comfortable, safe, and welcome is a basic form of respect and dignity that every parent should give when their child is in the picu as a form of implementation of the fcc concept in reducing the impact of hospitalization. children's room environment is considered by parents to affect their ability to physically participate in child care, in order for parents to be active in care, staff should explain to parents about equipment installed in children and how parents can safely touch, hold, and participate in care. equipment placement can be modified so that parents can physically reach the side of the bed to care for the child. the concept of sharing information, related themes are using understandable language, medical team visits, and satisfaction with communication. information sharing is defined as health workers communicating and sharing complete and unbiased information with patients and families. patients and families receive timely, complete, and accurate information to participate effectively in care and decision making. for parents, the most important aspect of communication is that the doctor uses language that the family can understand26, shows that the speed with which information is provided is important for the patient's family in absorbing information, considering the stress, fatigue, and emotions caused by the information itself 24 several parents indicated that the terms used by the health team led to a misunderstanding of the severity of the child's illness, or why certain procedures were not performed.20,27 parents recommend that when communicating with families where multiple languages are spoken, staff should communicate in the parent's preferred language as a sign of respect and to maximize understanding. regarding the medical team visit or better known as the doctor's visit in the pediatric intensive care unit, it is an opportunity for parents to participate and be an active part of exchanging information about their child's care. parents' experiences with doctor visits relate to information sharing south east asia nursing research, vol 4 no 1, march 2022/ page 35-46 44 mariyam mariyam / aplication of family centered care on the impact of hospitalization in intensive care unit in parents’ perspective: literature review and participation. based on the results of previous studies, 74% of family members reported having received information about the medical round, 92% felt accepted, 97% felt that listening to child case discussions by the provider team was very helpful, 92% felt comfortable asking questions, parents also reported that participating in the medical round about their child provides an opportunity to receive and exchange information with the team.26 although parents are not happy to be in the picu and see their child being monitored intensively, they believe this is the kind of care their child needs, which gives them "a little peace of mind". parents feel "reassured" when surrounded by the medical team during a doctor's visit to discuss the child's case and treatment plan.27 although parents reported that listening to the various treatment options discussed during the medical round was stressful and uncomfortable participating in these activities, 36% believed doctor visits promoted transparency between parents and the care team. parents report feeling anxious about the information they hear.26 regarding the theme of satisfaction in communicating, parents expect and need regular and frequent feedback about their child's progress and condition.28 parents indicated that they know their child best, part of the role of parents is to obtain information about their child's care and condition.25,26 parents expressed satisfaction and dissatisfaction about communication with the service team in the picu. in the intensive care unit, parents reported that it was easier to get information such as doctor's visit schedule than in other wards because the ratio of nurses to patients was one to one. the parents said “the doctor immediately informed me about the procedure to be performed”. "we can ask any questions and they are willing to answer." “we were introduced to the staff and got complete information about our son's condition."16 parents reported that they were introduced to service staff. doctors and nurses communicated well, answered questions thoroughly, staff immediately informed parents about the procedure to be performed.16,18 n contrast to those who expressed satisfaction with communication, parents were dissatisfied when staff spoke coldly and ignored their emotional and psychological needs.19 other parents reported that the staff did not do a good job of preparing them for hospitalization in the picu.18 para orang tua melaporkan mendapatkan informasi yang tidak konsisten dari berbagai staf layanan, yang menyebabkan kebingungan dan frustrasi. parents reported getting inconsistent information from various service staff, leading to confusion and frustration. parents report receiving disparate information or among service staff they think there are too many staff involved in care to know what others are doing.25,28,29 although there are several reports of examples of communication being considered poor, the implementation of good information sharing is mostly fulfilled from the perspective of parents with children who are being cared for in intensive care. reducing the impact of hospitalization on parents with children being treated in the picu, there is a need for continuous communication of understandable information to parents of children in the picu, validating that what the family "hears" is what the provider wants to convey, and for clarification of misunderstandings . repeating information in multiple formats (oral, written, or visual demonstration), and using simple, familyunderstandable terms in the family's language of choice, and then verifying that parents understand the information correctly, can help exhausted parents absorb a lot of the information. complex information they provide when stressed. south east asia nursing research, vol 4 no 1, march 2022/ page 35-46 45 mariyam mariyam / aplication of family centered care on the impact of hospitalization in intensive care unit in parents’ perspective: literature review the concept of participation, discusses the theme of parents as experts, how parents participate, the impact of the environment/provider on participation, and visits to the medical team as a forum for participation. some parents view participation in medical team visits as a means to exchange information with the health care team. however, some parents refuse to participate in medical team visits due to confusion or anxiety, in which case staff must find other ways to share information with parents. parental participation in medical rounds should not replace the individual's frequent exchange of information with the family. treating parents with respect includes respecting their decision whether to participate in the medical round and determining what alternative opportunities are available to them to participate in care and exchange information with staff. parents should be encouraged and supported to participate in care at the level of their choosing. the key is a shared understanding between parents and providers of how, when, and the amount of participation each parent wants. develop a plan for parental participation re-evaluate it from time to time to find out what level of participation they desire. this is expected to reduce the impact of stress experienced by parents. on the concept of collaboration as defined by the ipfcc there are no data showing its implementation in the summarized literature review. there is no evidence that parents reported having been involved in efforts with health care institutions or health care systems about policy and program development, facility design, and education. conclusion the application of the fcc is a benchmark in caring for pediatric patients and their families. parents of children who are admitted to the picu often relate to the severity of their child's illness and how to treat their child in the picu environment which results in different levels of anxiety or stress. the findings from this literature review reveal parental reports that the application of fcc in reducing the impact of hospitalization has not been fully realized. there are still positive and negative implementations related to the fcc concept. the medical services team must be aware of the fcc's core concepts and how their actions can impact parents in both positive and negative ways. acknowledgments the author would like to thank all those who have helped and supported the research process and writing this research article. references 1. mariyam m, yosafianti pohan v. optimalisasi kualitas balita melalui peningkatan kemampuan kader bkb dalam deteksi dini gangguan perkembangan balita. pros semin nas int [internet]. 2017 oct 18 [cited 2020 jul 21];1(1). available from: http://103.97.100.145/index.php/psn120120 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