Vol-10-No-1-2020-April-2020.pdf

e-ISSN: 2406-8799

p-ISSN: 2087-7811

Nurse Media

Journal of Nursing

Volume 10 Number 1 Year 2020

Accredited by

Indonesian Ministry of Research, Technology and Higher Education

(Decree No: 60/E/KPT/2016)

Editorial Office

Department of Nursing

Faculty of Medicine, Diponegoro University

Jl. Prof. Soedarto, SH., Tembalang, Semarang 50275

Email: media_ners@live.undip.ac.id

Website: http://ejournal.undip.ac.id/index.php/medianers

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Editor-in-Chief

Sri Padma Sari

Department of Nursing, Faculty of Medicine, Diponegoro University, Indonesia

Editorial Board

▪ Andrew Cashin Southern Cross University, Australia

▪ Rozzano C. Locsin Department of Nursing, Tokushima University, Japan

▪ Yati Afiyanti Faculty of Nursing, University of Indonesia, Indonesia

▪ Sri Warsini School of Nursing, Universitas Gadjah Mada, Indonesia

▪ Jennieffer A Barr School of Nursing and Midwifery, Central Queensland University, Australia

▪ Maarten M Kaaijk School of Nursing, Hanze University of Applied Sciences, Netherlands

▪ Ferry Efendi Faculty of Nursing, Universitas Airlangga, Indonesia

▪ Mardiyono Mardiyono Department of Nursing, Health Polytechnics of Semarang, Indonesia

▪ Faustino Jerome Gulle Babate Beta Nu Delta Nursing Society, Philippines

▪ Tantut Susanto School of Nursing, University of Jember, Indonesia

▪ Cyruz P. Tuppal St. Paul University Philippines System, Philippines

Associate Editors

▪ Meira Erawati Department of Nursing, Faculty of Medicine, Diponegoro University, Indonesia

▪ Nana Rochana Department of Nursing, Faculty of Medicine, Diponegoro University, Indonesia

▪ Meidiana Dwidiyanti Department of Nursing, Faculty of Medicine, Diponegoro University, Indonesia

Managing/Technical Editors

▪ Asih Nurakhir Department of Nursing, Faculty of Medicine, Diponegoro University, Indonesia

▪ Pradipta Ary Pamungkas Department of Nursing, Faculty of Medicine, Diponegoro University, Indonesia

▪ Septi Harni Wahyuningtyas Department of Nursing, Faculty of Medicine, Diponegoro University, Indonesia

EDITORIAL TEAM

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The Nurse Media Journal of Nursing (NMJN) is an international nursing journal which

publishes scientific works for nurses, academics and practitioners. NMJN welcomes and

invites original and relevant research articles in nursing as well as literature reviews and

case reports particularly in nursing.

This journal encompasses original research articles, review articles, and case studies,

including:

▪ Adult nursing ▪ Emergency nursing ▪ Gerontological nursing ▪ Community nursing ▪ Mental health nursing ▪ Pediatric nursing ▪ Maternity nursing ▪ Nursing leadership and management ▪ Complementary and Alternative Medicine (CAM) in nursing ▪ Education in nursing

The Nurse Media Journal of Nursing (NMJN) is published three time a year, every April,

August and December.

For year 2020, 3 issues (Volume 10, Number 1 (April), Number 2 (August), and Number

3 (December) are scheduled for publication.

The NMJN is published by the Department of Nursing, Faculty of Medicine, Diponegoro

University and available at http://ejournal.undip.ac.id/index.php/medianers.

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Total articles indexed in DOAJ : 152 (since 2015)

SINTA h-index / i10-index : 14/12 (since 2017)

Total Citations in SINTA : 632 (since 2017)

AIMS AND SCOPE

PUBLICATION INFORMATION

JOURNAL CITATION

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INDEXING AND ABSTRACTING

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Editorial Team ………………………………………………………………………………………….i

Aims and Scope, Publication Information, Journal Citation ……………………………ii

Indexing and Abstracting …………………………………………………………………………..iii

Table of Contents ……………………………………………………………………………………..iv

Preface, NMJN Vol. 10 No. 1 Year 2020 …………………………………………………….v-vii

Mental Distress in Rural Areas of Indonesia

(Azam David Saifullah, Nur Latifah, Eria Riski Artanti, Kadek Dewi

Cahyani, Umi Rahayu, Lalitya Paramarta, Rahma Mahdia Izzati, Robert

Priharjo, Sri Warsini) ………………………………………………………………………………. 1-10

The Application of Acceptance Commitment Therapy (ACT) and Family

Psychoeducation (FPE) to Clients with Scizophrenia and Aggressive Behavior

(Andi Buanasari, Budi Anna Keliat, Herni Susanti) ……………………………………… 11-21

The Lived Experiences of the Lombok Earthquake Survivors

(Ahmad Mumtaz Tauba, Suryani Suryani, Imas Rafiyah) ………………………………. 22-35

Determinants of Stunting in Children Aged 12-59 Months

(Erna Julianti, Elni Elni) …………………………………………………………………………… 36-45

English Language Proficiency and Its Relationship with Academic

Performance and the Nurse Licensure Examination

(Ryan Michael Flores Oducado, Marianne Sotelo, Liza Marie Ramirez,

Maylin Habaña, Rosana Grace Belo-Delariarte) …………………………………………. 46-56

The Experiences of Mothers with Intrauterine Fetal Death/Demise (IUFD)

in Indonesia

(Alma Dormian Sinaga, Justina Purwarini, Lina Dewi Anggraeni) ……………….. 57-65

A Comparison of Patient Safety Competencies between Clinical and

Classroom Settings among Nursing Students

(Rizqi Amilia, Devi Nurmalia) ………………………………………………………………….. 66-75

Casey-Fink Graduate Experience Survey for Nurses and Preceptors in

the Kingdom of Saudi Arabia

(Omar Ghazi Baker, Musaad Salem Alghamdi) …………………………………………… 76-85

Deep Breathing Exercise and Active Range of Motion Influence Physiological

Response of Congestive Heart Failure Patients

(Novita Nirmalasari, Mardiyono Mardiyono, Edi Dharmana, Thohar Arifin) … 86-95

Family’s Experience: Nursing Care for Colorectal Cancer Patients with Colostomy

(Untung Sujianto, Roland Billy, Ani Margawati) …………………………………………. 96-106

Author Guidelines ……………………………………………………………………………………App.1-4

Publication Ethics and Malpractice Statement ………………………………………………App.7-10

Submission Information …………………………………………………………………………….App.11

Acknowledgment ……………………………………………………………………………………..App.12

Author Indexing ………………………………………………………………………………………..App.13

Keyword Indexing …………………………………………………………………………………….App.14

TABLE OF CONTENTS

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The Nurse Media Journal of Nursing (e-ISSN: 2406-8799, p-ISSN: 2087-7811) is an open

access international journal that publishes the scientific works for nurse practitioners and

researchers. The journal is published by the Department of Nursing, Faculty of Medicine,

Diponegoro University and strives to provide the most current and best research in the

field of nursing. The journal has been indexed in the Google Scholar, Portal

Garuda/Indonesian Publication Index (IPI), Indonesian Scientific Journal Database

(ISJD), Directory of Open Access Journal (DOAJ), and Science and Technology Index

(Sinta).

It is also with pleasure to inform you that the Nurse Media Journal of Nursing (NMJN)

has been accepted to be included in the Scopus Database. Upon this achievement, the

NMJN would like to thank all people (the NMJN editorial team, reviewers, authors) who

have given their support and contribution to achieving this success. Starting from 2020,

NMJN will publish three issues a year (April, August and December).

This issue (NJMN, Vol 10(1), 2020) has published ten articles, consisting of nine research

articles and one case study. This issue was authored and co-authored by the researchers

and professionals from diverse countries, including Indonesia, Philippines, Saudi Arabia,

and the United Kingdom. All papers have been doubled-blindly reviewed by the editors

and reviewers of this journal.

Saifullah et al. (2020) conducted a descriptive cross-sectional study to identify the

population’s status and related factors of mental distress in rural areas in Indonesia among

872 residents. The prevalence of mental distress was 6%, which was lower than that of

the national level. The correlated factors of mental distress were age, gender, occupation,

housing dimension, and illness status. Therefore, future mental health programs may be

focused on improving mental health on the elderly, male, vulnerable workers,

overcrowded housing, and people with a chronic illness.

Buanasari, Keliat, and Susanti (2020) investigated the effectiveness of acceptance and

commitment therapy (ACT) and family psychoeducation (FPE). This study used the Stuart

Stress-Adaptation Model to conduct a case study of four clients with schizophrenia and

aggressive behaviour for six weeks. After the intervention, the clients showed to have

better symptoms of aggressive behavior in cognitive, affective, physiological, behavioral,

and social aspects and increased ability to control anger, to accept their problems, and to

commit to the therapy. Hence, ACT and FPE could be implemented to decrease the

symptoms of aggressive behavior and increase the ability to control anger on clients with

schizophrenia.

Tauba, Suryani, and Rafiyah (2020) conducted a qualitative study on exploring and

gaining deeper meaning from the lived experiences of the Lombok earthquake survivors.

Six themes have emerged on this study, including problems solving skills when disaster

strikes, surviving from the limitations and difficulties, feeling accustomed to an

earthquake, the family is a key source of strength to continue life, getting closer to God

by doing religious prayers and actions to have peace of mind, and learning from the

disasters to become a better human being.

PREFACE

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Julianti and Elni (2020) examined the determinant factors of stunting in children aged 12-

59 months. A total of 205 respondents were recruited using a consecutive sampling

technique. This study showed that there is a relationship between exclusive breastfeeding

history, the history of infection, and the eating habits of children with stunting. This study

suggested that the peer group community could prevent and overcome stunting and

improve the nutritional status and optimal development of the children.

Oducado, Sotelo, Ramirez, Habaña, and Belo-Delariarte (2020) employed a retrospective

descriptive correlational study that aimed to examine the influence of English language

proficiency on the academic performance of 141 nursing students in professional nursing

courses and the Nurse Licensure Examination(NLE). Findings showed that there were

significant correlations between academic performance and the Verbal Ability subscale

of the Nursing Aptitude Test and the three English courses included in the nursing

curriculum. Nursing schools should ensure that approaches in improving students’ English

language proficiency must be well integrated into the undergraduate nursing program.

Amilia and Nurmalia (2020) investigated differences in patient safety competencies

between the classroom and clinical settings among 181 nursing students in Indonesia.

Nursing students showed a higher patient safety competencies in the classroom setting

than in the clinical setting. This study recommended a further investigation on the factors

that increase the achievement of patient safety competence among nursing students in the

clinical setting.

Baker and Alghamdi (2020) conducted a cross-sectional study to evaluate the relationship

between nurses’ experiences using Casey-Fink Graduate Nurse Experience Survey and

the number of preceptors in Saudi hospitals. No statistically significant relationship was

found between those variables. This study found that 33.8% of nurses had stress, whereas

significant causes of stress were student loans, personal relationships, living situations,

and finances.

Sinaga, Purwarini, and Anggraeni (2020) employed a descriptive qualitative study to

explore the experiences of mothers with Intrauterine Fetal Death/Demise (IUFD) in

Indonesia. The results showed four major themes, including the mothers’ response to a

loss such as painful and traumatic experience; moral support received by mother; negative

behavior from others such as stigma and lack of support; and physical and psychological

changes that interfere with the role as wife and mother. The health professional must

integrate therapeutic communication and support for mothers with IUFD.

Furthermore, Sujianto, Billy, and Margawati (2020) conducted descriptive

phenomenology to explore the experiences of ten famililes of colorectal cancer patients

toward colostomy nursing care. Three themes emerged in this study, including positive

and negative behavior in nursing care, living with a colostomy, and expectations for

nursing care. The study showed that the colostomy nursing care still needs to be improved.

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Finally, the NJMN would like to thank the respectful authors, reviewers, and editors for

their contribution and collaboration in publishing this current issue. Furthermore, the

editors would like to appreciate and call for academic papers from the nurse-practitioners,

academicians, professionals, graduates and undergraduate students, fellows, and

associates pursuing research throughout the world to contribute to this international

journal.

Semarang, April 2020

Sri Padma Sari

Editor-in-Chief

The Nurse Media Journal of Nursing

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DOI: 10.14710/nmjn.v10i1.23244

Mental Distress in Rural Areas of Indonesia

Azam David Saifullah1, Nur Latifah2, Eria Riski Artanti3, Kadek Dewi Cahyani4, Umi Rahayu4, Lalitya Paramarta4, Rahma Mahdia Izzati4, Robert Priharjo5, Sri Warsini1

1Mental Health and Community Department, School of Nursing, Faculty of Medicine, Public Health, and

Nursing, Universitas Gadjah Mada, Indonesia 2Puskesmas Jetis II Bantul, Yogyakarta, Indonesia

3dr. Sardjito Central Hospital, Yogyakarta, Indonesia 4 School of nursing, Faculty of Medicine, Public Health, and Nursing,

Universitas Gadjah Mada, Indonesia

5 School of Nursing and Midwifery, Faculy of Health, Education, Medicine, and Social Care,

Anglia Ruskin University, United Kingdom

Corresponding Author: Azam David Saifullah (azam.david.s@ugm.ac.id)

Received: 25 May 2019 Revised: 25 October 2019 Accepted: 28 October 2019

ABSTRACT

Background: There is a higher prevalence of mental distress in rural areas compared to

urban areas in Indonesia. The rural areas of Indonesia have various socio-demographic

and sophisticated cultural characteristics, but less exposed to foreign cultures. Thus, the

study about the prevalence, associated factors, and predictors of mental distress in rural

areas is necessary.

Purpose: This study aimed to identify the population’s status and related factors of

mental distress in rural areas in Indonesia.

Methods: A descriptive cross-sectional study was conducted to achieve the aims of the

study. An Indonesian version of the Self-Rated Questionnaire, consisting of 20 items,

was used to measure mental distress status of population in rural areas in Yogyakarta,

Indonesia. A number of 872 records were included and analyzed using both univariate

and bivariate analyses in this study.

Results: The prevalence of mental distress in this population was 6%. The correlated

factors of mental distress were age (χ2=6.93, p=0.01), gender (χ2=0.07, p=0.03),

occupation (χ2=0.26, p=0.02), housing dimension (χ2=5.45, p=0.02), and illness status

(χ2=0.01, p<0.01).

Conclusion: The prevalence of mental distress in rural areas of Indonesia is relatively

lower than that of the national level. Future mental health programs may be focused on

improving mental health on the elderly, male, vulnerable workers, overcrowded

housing, and people who got a chronic illness.

Keywords: Community based screening; mental distress; mental health; rural area

How to cite: Saifullah, A. D, Latifah, N., Artanti, E. R., Cahyani, K. D., Rahayu, U., Paramarta, L., … & Warsini, S. (2020). Mental distress in rural area of Indonesia. Nurse Media Journal of Nursing, 10(1), 1-10. doi:10.14710/nmjn.v10i1.23244 Permalink/DOI: https://doi.org/10.14710/nmjn.v10i1.23244

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Nurse Media Journal of Nursing, 10(1), 2020, 2

BACKGROUND

Mental health is one of the psychological components in the biopsychosocial model that

arranges health during the human life span (Lehman, David, & Gruber, 2017). Mental

distress is one of the mental disorders characterized by an emotional change that can

develop into a pathological condition (Idaiani, 2010; Idaiani, Kusumawardani,

Mubasyiroh, Nainggolan, & Nurchotimah, 2017). An overlook on stress management

may develop severe mental illness on many people with chronic diseases and mild

distress (DE Hert et al., 2011).

In Indonesia, the rural population has a higher prevalence of mental distress (10%)

compared to urban areas. A rural population also tend to have these sociodemographic

characteristics such as a rather high proportion of people aged over 75 years old

(15.8%), females (12.1%), less educated (13.9%), and unemployed (13.0%) (Ministry of

Health of Republic Indonesia, 2018). A study in low-middle income countries showed

that gender (female), employment status (employed and self-employed), daily alcohol,

and abuse were found to be the correlated factors of developing mental distress (Abbay,

Mulatu, & Azadi, 2018). In rural India, women’s work demand (high amount of

housework, including cleaning and collecting water) is also associated with mental

distress (Richardson, Nandi, Jaswal, & Harper, 2017). Furthermore, mental distress is

also associated with a history of diseases. The risk of mental distress is in line with the

number of chronic illnesses. Subsequently, respondents with hepatitis and stroke were

the most experienced mental distress (Widakdo & Besral, 2013).

The Indonesian government’s recent effort to promote mental health is by the Mental

Health Awareness Village program (Desa Siaga Sehat Jiwa [DSSJ]) that is initiated by

the Ministry of Health of the Republic of Indonesia (Ministry of Health of Republic

Indonesia, 2018). One of the DSSJ programs is mental distress screening using the self-

rated questionnaire (SRQ-20). This program has been implemented both in urban and

rural areas to get the prevalence of mental distress data. However, Indonesian people

have various social-demographic, sophisticated cultural characteristics in dealing with

the problem, and less exposed to foreign cultures. Therefore, a study about the

prevalence and factors of mental distress in rural areas is needed, so that an appropriate

prevention and promotion program can be effectively developed in the future

PURPOSE

This study was conducted to identify the population’s status and factors of mental

distress among the population in rural areas in Indonesia.

METHODS

Design and samples

This study used a descriptive cross-sectional research design. It was conducted from

February to July 2018 in rural areas in Yogyakarta, Indonesia. Three of five villages

were chosen purposively by its population. These villages included Kralas, Sraten, and

Suren Wetan, with an estimation of the total population that met the inclusion criteria,

were 1500 residents. The inclusion criteria were people age over 15 years old and

literate.

Nurse Media Journal of Nursing, 10(1), 2020, 3

Research instrument and data collection

Two questionnaires were used in this study, including the SRQ-20 (Indonesian version)

and the socio-demographic questionnaire. The SRQ-20 was developed by WHO and

modified into the Indonesian version by the Ministry of Health of Indonesia to measure

mental distress. This questionnaire consists of 20 items question with Guttman scale

(Yes/No), and a total score equal to or more than 6 represent cases. The sensitivity of

SRQ-20 in the English version is 83% and 80% for specificity (Harding 1989). The

sociodemographic questionnaire consisted of age, sex, occupation, religion, family

history of physical disability or diagnosed with a severe mental disorder, monthly

income, and housing dimension.

Training in administering the set of questionnaires was given by the research team to the

youth cadres in the three villages. This was also part of the study to enable the

population to perform screening by themselves. The data collection was conducted by

trained Posbindu cadres. Within four weeks, the cadres did the data collection using a

set of questionnaires, including informed consent. In order to ensure a high response

rate and solve any data collection challenges during the period, there was an evaluation

process every two weeks.

Data analysis

There were 1500 distributed questionnaires, and the response rate of the questionnaire

was 1225 of 1345 (89.7%), with 872 data included in the analysis. Data obtained were

inputted, cleaned, and statistically analyzed in SPSS. A descriptive analysis was used to

identify demographic data and mental distress status. Meanwhile, the bivariate analysis

was used to identify the factors of mental distress in rural Indonesia. The Chi-square test

and logistic regression were used depending on the data type of the variables.

Ethical consideration

The ethical approval of this study was obtained from the Ethics Committee, Faculty of

Medicine, Public Health, and Nursing, Universitas Gadjah Mada.

RESULTS

The response rate of this study was 89.7%; despite the incomplete data, 71.2% of the

returned questionnaire was able to be analyzed. The mean age of respondents was 39.96

years old (SD=16.48), and there were more females (50.5%). Most of the respondents

work as non-civil servants, while the average monthly income was IDR 1,426,632

(SD=IDR 709,112). The average housing dimension was 83.74 m2, with three to four

people on average living in the same house. Most of the respondents reported being in a

healthy condition (87.5%). In addition, there were 71 respondents with family members

suffering from severe mental health illness (Table 1).

Table 1. Distribution of the demographic data of respondents (n=872)

Variable(s) f % Mean (SD) Min-Max

Age 39.96 (16.48) 15-92 Gender

Male 570 46.5

Nurse Media Journal of Nursing, 10(1), 2020, 4

Variable(s) f % Mean (SD) Min-Max

Female 619 50.5

Occupation

Civil servant 39 4.5 non-civil servant 448 51.4

Entrepreneur 80 9.2

Student/not yet employed 287 32.9

Retired/unemployed 18 2.1 Education

Not educated 59 6.8

Elementary to high school 667 76.5 University 146 16.7

Religion

Islam 824 94.5

Christian 42 4.8 Catholic 6 0.7

Monthly income (IDR) 1,426,632

(709,112)

150.000-

7,000,000 Housing dimension (m

2) 91,18 (96,35) 2 – 1160

Number of people at home 4 (1.34) 1 – 11

Illness status Being sick 109 12.5

Not sick 763 87.5

The family member with severe

mental health illness

Yes 71 8.1

No 801 91.9

The SRQ-20 interpretation, as presented in Table 2, showed that the prevalence of the

mental distress in those three villages was 6%. Dusun Kralas has the lowest prevalence

of residents with mental distress (5.3%), and Dusun Suren Wetan has the highest

prevalence, of 6.8%. As shown in Table 2, there is also a relatively similar trend on

mental health status, around 93.2 to 94.7% of the population with normal distress status.

Table 2. Distribution of SRQ-20 score interpretation (n=872)

Area Mental distress status Total (n)

Normal Mental distress

All villages 820 (94%) 52 (6%) 872

Kralas 429 (94.7%) 24 (5.3%) 453 Sraten 159 (93.5%) 11 (6.5%) 170

Suren Wetan 232 (93.2%) 17 (6.8%) 249

The bivariate analysis of the social-demographic data and SRQ-20 interpretation

showed that age, monthly income, housing dimension, the number of families living

together, and illness status had a statistically significant relation with mental distress

(Table 3).

Nurse Media Journal of Nursing, 10(1), 2020, 5

Tabel 3. Mental distress and the related factors (n=872)

Variable(s) Frequency

Normal

Distress

Frequency Mental

Distress

χ2 df p-value

Age 6.93 1 0.01*

Gender 0.07 0.03*

Male 397 17 Female 423 35

Occupation 0.26 0.02*

Civil servant 39 0 Non-civil servant 427 21

Entrepreneur 71 9

Student/not yet employed 269 19

Retired/unemployed 15 3 Education 0.08 0.08

Not educated 54 5

Elementary to high school 623 44 University 143 3

Religion 0.20 0.78

Islam 774 50 Christian 40 2

Catholic 6 0

Monthly income (IDR) 2.76 1 0.10

Housing dimension (m2) 5.45 1 0.02*

Number of people at home 0.34 1 0.56

Illness status 0.17 <0.01*

Being sick 91 18 Not sick 729 34

The family member with severe

mental health illness

0.01 1 0.97

* Significant with p=0.05

DISCUSSION

This study aimed to identify the population’s status and related factors of mental

distress among the population in rural areas in Indonesia. This study showed that mental

distress prevalence at the coverage area of Puskesmas (public health center) Jetis II was

lower than that of Yogyakarta province and Indonesia (6%: 10.0%: 9.8%) (Ministry of

Health of Republic Indonesia, 2018). This result slightly differs from a previous study

by Islam (2019), which found that people in rural areas tend to have a higher prevalence

of mental distress compared to the urban area. Similar to an estimation of psychological

distress prevalence in Bangladesh in 2018, it is shown that people who live in a semi-

urban area significantly more prevalent with psychological distress than rural (Islam,

2019).

According to socio-demography data, some variables that significantly related to mental

distress are highlighted. Those variables are age (χ2=6.93; p=0.01), gender (χ2=0.07;

p=0.03), occupation (χ2=0.26; p=0.02), housing dimension (χ2=0.45; p=0.02), and

illness status (χ2=0.01, p<0.01). This result is in line with the WHO report, which stated

Nurse Media Journal of Nursing, 10(1), 2020, 6

that the social and economic status had an effect on mental health (World Health

Organization, 2018).

People with chronic illness, low welfare, and the elderly had a risk of developing mental

disorders (World Health Organization, 2018). In a veteran housing, depression was

observed among 13.4% of patients with Chronic Obstructive Pulmonary Disease

(COPD) while there are only 9.3% of patients without COPD (p<0.001) (DE Hert et al.,

2011; Garrido et al., 2017). Moreover, health problems such as deterioration of health,

mobility function, daily activity, and socioeconomic are rising in older people (Cao,

Chen, Tian, & Jiang, 2015). All of those problems can increase the stressor, so it raises

the case of mental distress, which may explain that mental distress is more common in

older people compared to younger and middle adults (Sutin, Stephan, & Terracciano,

2018).

Both women and men have their own context of resistance and disability of social life

functions that may affect mental distress (Timander & Möller, 2018). Furthermore, a

study by Lowry, Johns, Gordon, Austin, Robin, & Kann (2018) reported that those who

do not meet society’s expectations (behavior and appearance) based on gender or so-

called gender nonconformity have a strong association with mental distress among

young adults in the US. The form of this mental distress includes substance use and

suicide, and feeling sad and hopeless. It is also known that males are more prevalent

with gender nonconformity than females, moreover with lesbian or gay, bisexual, and

they who “are not sure” about their gender. This research adds further evidence of the

correlation between gender and mental distress. Apparently, males tend to have a higher

risk of developing mental distress (Smith, Schacter, Enders, & Juvonen, 2018).

The average monthly income of the respondent’s was IDR 1,426,632 (SD=709,112) for

all occupations, and it was grouped by low income (below IDR 1,454,154,15) based on

the minimum wage at Yogyakarta Province (Pemerintah Daerah DIY, 2017). This

finding in line with a study by Suyoko (2012), which reported that the prevalence of

mental distress in people with low economic status is 0.8 times higher than those with

high economic status (Suyoko, 2012). This research shows that there is no correlation

between monthly income and mental distress. On the other hand, occupations were

statistically significant to the presence of mental distress.

It is argued that occupation is not only related to economic status, but also the work

demands, including psychological and social work demands (Finne, Christensen, &

Knardahl, 2016). However, it is supported by the result of the basic health research by

the Ministry of Health of Republic Indonesia (2018) that the unemployed (13.0%) were

the group with the highest prevalence of mental distress. Regarding the relation between

financial distress and overall distress, it was reported that financial distress was

associated with overall distress, while emotional distress mediated this association. In

addition, the total effect of financial distress on overall distress was – 0.727 (Meeker et

al., 2016)

Even though this research shows that there is no correlation between mental distress and

the number of families in one home, another study shows the opposite. Grinde and

Nurse Media Journal of Nursing, 10(1), 2020, 7

Tambs (2016) found this factor difference in the group of age. In children, they will

have a lower risk of mental distress with an increasing number of member families who

live together. Their family members, especially adults, will protect them and become

their playmates, which can support their mental condition. In contrast, that situation can

add a stressor for adults. It can increase the possibility of sibling conflicts or conflict

between children and parents, which can improve the risk of mental distress (Grinde &

Tambs, 2016). However, Indonesia has a sophisticated culture that flourished by the

society. Intergenerational support may bring support in maintaining better mental health

in the rural area (Schröder-Butterfill, 2004).

The dimension of the home is significantly related to mental distress (Grinde & Tambs,

2016). It is assumed that these factors were also linked to the number of family

members who live together, which indirectly affects the personal space of the home.

Personal space is a space that makes people feel safe and comfortable. If the invasion of

this space presents, stress might happen. A previous study stated that caregiver of

people with mental illness who lack social support is strongly associated with mental

distress, although, in this study, those dependent variables failed to be factors that

statistically significant related to GME (Sintayehu, Mulat, Yohannis, Adera, & Fekade,

2015).

In addition, respondents with a chronic illness have a risk of 2.6 times of mental

distress. Respondents with two chronic illnesses have a risk of 4.6 times of mental

distress, and respondents with three chronic illnesses have a risk of >11 times (Widakdo

& Besral, 2013). That physiological disorder has a direct effect on the deterioration of

social function and finally improved mental distress (Stuart, 2007). Furthermore, based

on the health statistic and information system estimates for 2000-2012 data, depression

caused by chronic disease can decrease life expectancy for around 20 years (Islam,

2019). Depression or anxiety that develops from physical illness might be one of the

risk factors to heart disease, stroke (Clarke & Currie, 2007), diabetes (Aikens, Rosland,

& Piette, 2015; Clarke & Currie, 2007), cancer (Meeker et al., 2016), and also acute

illness (Stewart-Ibarra et al., 2017); thus, it can increase morbidity and mortality (Clarke

& Currie, 2007)

This study has limitations. A cross-sectional research design was used in this research,

as it draws a better understanding in terms of current information regarding the mental

distress topic in the rural areas. However, this research may not be relevant in the long

run, so a follow-up survey may be needed in the future. Aside from a rather high

participation rate, the results of this study may not be generated to all rural areas in

Indonesia as the data were collected from specific areas in Yogyakarta province. More

sites need to be included to draw generalizations in interpreting the result of the study.

As this study was concerned with rural areas, further investigation is needed to study

mental distress is urban areas.

CONCLUSION

The sociodemographic status, such as older age, gender (male), occupation, small-size

housing, and being ill, were found to be correlated factors of having mental distress in

rural Indonesia. Based on the results of this study, it is suggested that Puskesmas may

Nurse Media Journal of Nursing, 10(1), 2020, 8

consider developing mental distress prevention programs by considering age, gender,

occupation, housing size, and illness status to improve their outcome, particularly in

mental health. Further research on the same topic in other rural areas in Indonesia,

including the remote ones, is necessary.

ACKNOWLEDGEMENT

The researchers would like to thank Puskesmas Jetis II Bantul, Yogyakarta, for the

valuable contribution to the identification of the research area and training facilitation.

We also thank all recruited Posbindu cadres for their dedication to the data collection

process.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

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Nurse Media Journal of Nursing, 10(1), 2020, 11-21 Available online at http://ejournal.undip.ac.id/index.php/medianers

DOI: 10.14710/nmjn.v10i1.22220

The Application of Acceptance Commitment Therapy (ACT)

and Family Psychoeducation (FPE) to Clients with

Schizophrenia and Aggressive Behavior

Andi Buanasari1, Budi Anna Keliat2, Herni Susanti2

1Nursing Department, Faculty of Medicine, Sam Ratulangi University, Indonesia

2Faculty of Nursing, Universitas Indonesia, Indonesia

Corresponding Author: Budi Anna Keliat (budianna_keliat@yahoo.com)

Received: 1 March 2019 Revised: 22 April 2020 Accepted: 24 April 2020

ABSTRACT

Background: Aggressive behavior frequently occurs in clients with schizophrenia and

causes injuries to the clients themselves, others, and the environment. It becomes one of

the most common factors causing rehospitalization in schizophrenic clients. Aggressive

behavior can be managed by the intervention administered by nurses in the usual way

(treatment as usual; TAU) as well as psychotherapy (acceptance and commitment

therapy; ACT and family psychoeducation; FPE).

Purpose: This study aimed to investigate the effectiveness of acceptance and

commitment therapy (ACT) and family psychoeducation (FPE) on schizophrenic clients

with aggressive behavior.

Methods: This study used a case series method to report four selected cases of

schizophrenic clients with aggressive behavior. Acceptance and commitment therapy

(ACT), family psychoeducation (FPE), and treatment as usual (TAU) were delivered to

four clients with aggressive behavior for six weeks using the Stuart Stress-Adaptation

Model.

Results: The finding showed decreased symptoms of aggressive behavior in cognitive,

affective, physiological, behavioral, and social aspects and increased ability to control

anger, to accept their problems, and to commit to the therapy after ACT, FPE, and TAU

interventions.

Conclusion: This report showed that TAU, ACT, and FPE effectively decreased the

symptoms of aggressive behavior and increased the clients’ ability to control anger.

Keywords: Acceptance and commitment therapy; family psychoeducation; aggressive

behavior; case series; schizophrenia

How to cite: Buanasari, A., Keliat, B. A., & Susanti, H. The application of acceptance

commitment therapy (ACT) and family psychoeducation (FPE) to clients with

schizophrenia and aggressive behavior. Nurse Media Journal of Nursing, 10(1), 11-21.

doi:10.14710/nmjn.v10i1.22220

Permalink/DOI: https://doi.org/10.14710/nmjn.v10i1.22220

http://ejournal.undip.ac.id/index.php/medianers

Nurse Media Journal of Nursing, 10(1), 2020, 12

BACKGROUND

Aggressive behavior is one of the responses to stressors that appears as self-destruction

and causes damage to others and the environment either verbally or non-verbally.

Aggressive behavior is exhibited mostly by clients with schizophrenia (Stuart, 2013).

According to previous research, 3,187 clients with schizophrenia experienced the risk of

violent behavior such as attacking and threatening 4.3 times higher than the general

population (Fleischman, Werbeloff, Yoffe, Davidson, & Weiser, 2014). Another study

showed that of 1,033 patients with schizophrenia, 31% (1 in 3 patients) were aggressive

and hostile (Knezevic et al., 2016).

Aggressive behavior in schizophrenia is associated with the lack of 5-

hydroxyindoleacetic acid (5-HIAA) concentration and the enhancement of dopamine

and norepinephrine metabolism in cerebrospinal fluid which causes an impulsive

response (Stanley et al., 2000). Command hallucinations such as listening to the voice

of command to harm and to commit suicide are also the trigger factors of aggressive

behavior in clients with schizophrenia (Haddock, Eisner, Davies, Coupe, &

Barrowclough, 2013), while other factors include a history of childhood aggressive

behavior, antisocial personality disorder, substance abuse, and unpleasant experiences

(Volavka & Citrome, 2011). Unpleasant experiences that cause feelings of insecurity,

rejection, and tenderness tend to be expressed by someone with aggressive behavior to

cover up those feelings (Stuart, 2013).

The aggressive behavior committed by clients with schizophrenia might increase the

cost of health care because it is the most frequent cause of clients’ admission to the

hospital, and the length of stay will be longer since the signs of aggressive behavior are

persistent (Volavka, 2014). Another impact of aggressive behavior is the enhancement

of stigma in society because people with mental disorders are considered to be

dangerous and should be avoided, leading to discrimination and social inequality

(Torrey, 2011). This stigma becomes the strongest reason for the family to undertake

confinement or locking (pasung) of clients with schizophrenia and aggressive behavior

(Buanasari, Daulima, & Wardani, 2017).

There are three stages of aggressive behavior management in clients with schizophrenia

which are prevention strategies through education and assertive training; anticipatory

strategies such as proper communication and environmental modification, including

family, medication, and psychotherapy; and crisis management through seclusion and

restrain (Stuart, 2013). The effectiveness of prevention strategies through social way

and de-escalation has been revealed in the previous studies to be able to improve the

clients’ ability to control anger and to reduce the intensity of seclusion and restrain as

well as invasive interventions (Richmond et al., 2012; Keliat, Azwar, Bachtiar, &

Hamid, 2009).

Anticipatory strategies through usual nursing intervention which combines physical,

social, spiritual, and medication methods significantly reduce the length of stay in the

hospital (Keliat, Azwar, Bachtiar, & Hamid, 2009). Crisis management strategies such

as restrain and seclusion are the last option if all the ways are unsuccessful. However, it

should be conducted according to the standard and procedure, and it even requires

Nurse Media Journal of Nursing, 10(1), 2020, 13

debriefing or expressing feeling sessions after the restrain involving both the clients and

the health workers, given that restrain and seclusion are traumatic experiences (Goulet

& Larue, 2016). In the case of this research, the clients were to be given interventions

that focused on preventive and anticipatory strategies through treatment as usual (TAU),

acceptance and commitment therapy (ACT), and family psychoeducation (FPE).

One of the anticipatory strategies for the management of aggressive behavior is

psychotherapy such as acceptance and commitment therapy (ACT). ACT is a third-

wave behavioral therapy with the purpose of not changing the clients’ unpleasant

experience but to get them to respond to the stressors in order to live with the problem

peacefully and of fostering positive behaviors for them to achieve their goals (Hayes,

2004). ACT in previous literature was shown to have significantly reduced signs of

aggressive behavior (53.49%) (Sulistiowati, Keliat, & Wardani, 2014) and effectively

decreased rehospitalization after a 4-month to 1-year follow-up (Bach, Hayes, &

Gallops, 2012).

The environmental modification that involves the family is also important since the

family plays a crucial role in the client’s care management (Susanti, Lovell, & Mairs,

2018). This statement is true as the burden felt by families living with clients with

schizophrenia is significantly high and affecting the families’ quality of life (Stanley,

Balakrishnan, & Ilangovan, 2016). Family psychoeducation (FPE) is one of the nursing

interventions for the family to improve the family’s ability to provide appropriate care

for the client (Caqueo-Urízar, Rus-Calafell, Urzúa, Escudero, & Gutiérrez-Maldonado,

2015). FPE has been proven to be effective in improving the prognosis and social

functioning and in reducing the recurrence rate of children with psychosis (Gearing,

2008). FPE was also effective in reducing symptoms of aggressive behavior in clients

with schizophrenia by increasing the clients’ ability to control anger and improving the

families’ ability to care for the family members with aggressive behavior (Setiawan,

2017).

Nursing treatment as usual (TAU) has been conducted widely by psychiatric nurses on

clients with schizophrenia in Indonesia, but psychotherapies are still rarely known and

applied by nurses in the country. Several studies showed a better outcome when TAU

combined with psychotherapies (Bach, Gaudiano, Hayes, & Herbert, 2013; Ghouchani

et al., 2018). Previous studies already showed the effectiveness of acceptance and

commitment therapy in schizophrenia, but there was no study published in case series

about administering ACT and FPE together in Indonesia, specifically on clients with

schizophrenia and aggressive behavior. This case series study showed a nursing process

that combines ACT and FPE with TAU as a feasible and effective treatment option for

nurses in treating aggressive behavior in psychosis.

OBJECTIVE

This case series study aimed to investigate the effectiveness of acceptance and

commitment therapy (ACT) and family psychoeducation (FPE) combined with

treatment as usual (TAU) on clients with schizophrenia and aggressive behavior.

Nurse Media Journal of Nursing, 10(1), 2020, 14

METHODS

Design and participants

This study was conducted using a case series as an observational descriptive research

design. The case series was selected to present several cases with the same

characteristics, same intervention, and specific selection criteria. Four cases of clients

with aggressive behavior were selected to be reported in this article according to some

certain criteria such as clients having paranoid schizophrenia, having a history of

aggressive behavior, having an unpleasant experience related to aggressive behavior,

having a relapse history, having received TAU and ACT, and having families receiving

FPE.

Ethical consideration

Each client has provided written informed consent to ensure that he/she joined the

therapy voluntarily and met the ethical criteria. This study has received permission from

Marzuki Mahdi Hospital for reporting.

Interventions

The interventions were carried out by providing nursing treatment as usual (TAU) and

ACT for the clients and FPE for the families. TAU was conducted in collaboration

between the researchers and the ward nurses 7 times and evaluated at each meeting.

TAU consisted of 1) physical intervention such as deep breathing exercise and anger

release methods like hitting soft objects, 2) medication management, 3) social

intervention such as feeling expression and asking and rejecting exercise, and the last,

4) spiritual intervention.

Acceptance and commitment therapy was applied 7 times as well by the researchers in 4

sessions for an average of 30–45 minutes each session. The sessions consisted of 1)

discussing unpleasant events or experiences, 2) discussing responses related to

unpleasant experiences, 3) identifying impacts of responses and acceptance exercise,

and 4) identifying the value of the clients and discussing how to commit to the therapy

and to achieve the clients’ goals based on their value. The intervention was not only

given to the clients but also for the families.

FPE was administered by the researchers to the families for them to provide support for

the clients during visits to the hospital or when in contact with family members at the

hospital by telephone. The researchers called the family to ask for approval and invited

them to the hospital to join the research. FPE was conducted on the families 2–3 times

in 6 sessions for 45–60 minutes each session. FPE sessions consisted of 1) identifying

clients’ health problems and educating the families to care for the health problems, 2)

educating the families about other health problems, 3) family stress management, 4)

family burden management, 5) utilizing the support system, and 6) evaluating the

benefits of family psychoeducation. The whole interventions were conducted for 6

weeks using the stress adaptation model by Stuart.

Evaluation

The evaluation process carried out by assessing the symptoms and abilities of the

clients. The symptoms assessment used a tool assessment instrument that developed

Nurse Media Journal of Nursing, 10(1), 2020, 15

based on the Stuart model with a total number of symptom items of 47, consisting of 12

cognitive symptom items, 12 affective symptom items, 9 physiological symptom items,

9 behavioral symptom items, and 5 social symptom items. The score ranged from 0 to

47; the higher the score, the worse the symptoms, and vice versa.

The clients’ ability assessment for TAU consisted of 4 items, namely, 1) the ability to

do deep breathing relaxation, 2) the ability to understand the right drug administration,

3) the ability to express feelings when angry and know how to reject and ask for help in

a good way, and 4) the ability to do spiritual activities to control anger. Meanwhile, the

ability assessment for ACT consisted of 3 items, namely, 1) the ability to express

unpleasant events and identify the values in them, 2) the ability to accept illness and

unpleasant experiences, and 3) the ability to commit to preventing recurrence. There are

7 ability items in total, and the score ranged from 0 to 7; the higher the score, the better

the ability. The evaluation performed by assessing the alteration of the symptoms score

and the clients’ ability for each meeting.

RESULTS

Characteristics of clients

All participants were clients with schizophrenia who were treated in the adult ward. The

specific history of each client is shown in Table 1.

Table 1. Client’s history

No Name (Age) History

1 Mr. W

(25)

Has a mental illness since 2013, admitted to the hospital for the 3rd time

due to aggressive behavior, and had a command hallucination to harm

others. Withdrawal from antipsychotic drugs over the last few months

had been stocked for two weeks, felt pressured by his brother. Antipsychotic drugs included Depakote 2×2 mg, Onzapine 1×15 mg,

and Trihexyphenidyl 2×2 mg.

2 Mr. S (31)

Has a mental illness since 2014, admitted to the hospital for the 3rd time because of aggressive behavior toward friends. Discontinuous

antipsychotic drugs for the last 6 months, an unpleasant experience due

to humiliation by friends and parents. Antipsychotic drugs included

Haloperidol 3×5 mg, THP 3×2 mg, Risperidone 2x2mg, Clozapine 1x25mg.

3 Mr. Wi (22) Has a mental illness since 2013, admitted to the hospital for the 3rd time

due to aggressive behavior, consumed excessive cigarettes, and antipsychotic drugs. Had experiences related to parental divorce and has

been pressured by his mother. Antipsychotic drugs included were

Haloperidol 3×5 mg, THP 3×2 mg, Risperidone 2×2 mg, Clozapine 1×25

mg.

4 Mr. D

(27)

Has a mental illness since 2009, admitted to the hospital for the 2nd time

because of attacking his neighbors. Had a history of irregular

antipsychotic medication, consumed tramadol, and marijuana. Unpleasant experiences were the death of his grandmother and bullied

by his schoolmates. Antipsychotic drugs including Haloperidol 3×5 mg,

THP 3×2 mg, Risperidone 2×2 mg, Clozapine 1×25 mg.

Nurse Media Journal of Nursing, 10(1), 2020, 16

Symptoms and clients’ ability after TAU, ACT, and FPE

The alteration of the symptoms number and clients’ ability number during the seven

meetings are explained in Table 1.

Table 2. Symptoms and clients’ ability alteration at each meeting

Meeting Symptoms Client’s Ability

Mr. W Mr. S Mr. Wi Mr. D Mr. W Mr. S Mr. Wi Mr. D

M1 9 12 9 13 1 1 2 2

M2 9 11 9 12 3 2 3 3

M3 7 9 7 10 4 4 4 4

M4 6 6 4 7 4 4 5 4

M5 4 6 2 7 5 4 5 4

M6 1 3 2 5 6 6 6 6

M7 1 2 0 4 7 7 7 7

M=Meeting

Table 2 shows the results of the symptoms evaluation and the clients’ ability from the

first day to the seventh day after TAU, ACT, and FPE. In general, the table explains that

the clients experienced decreased numbers of symptoms and increased ability after

interventions. In all clients, the frequency of meetings was more in social ways and drug

adherence intervention. In ACT intervention, most clients experienced repetition two to

three times in session 3, while in FPE intervention, the second session repeated more

often. In Client 1, there was a consistent decline in symptoms at each meeting.

However, there was still one cognitive symptom left at the end of the intervention. The

client still revealed that he was unable to communicate and express his feelings well. In

Client 2, an increase in ability and decrease in symptoms also obtained after the

combination of intervention, but there were still two residual symptoms left. They were

cognitive symptoms (blaming) and social symptoms (feeling rejected).

In Client 3, there were no more behavioral and physiological symptoms found in the

initial assessment. The most symptom reduction was obtained at meeting 4 after giving

FPE to the family. At the last meeting, there were no signs of risk of aggressive

behavior found in Client 3. This might be caused by the contribution of the family along

with the nurses to meeting patient needs and healthcare outcomes. In Client 4, there

were more symptoms of aggressive behavior left at the last meeting compared to the

other clients. The symptoms included blaming, irritability, instability, and feeling

rejected by the people around him. We also found that Client 4 had a history of drug

abuse, which could be a factor that contributed to the worsening of the symptoms of

mental illness.

DISCUSSION

The results of this study revealed that all clients showed a significant decrease in

aggressive behavior symptoms and an increase in the ability to control anger after TAU

and ACT. The better the ability of the client, the lesser the symptoms show, as seen in

Nurse Media Journal of Nursing, 10(1), 2020, 17

Table 2. The effectiveness of TAU already discussed in the previous research. Clients

with aggressive behavior showed an improvement in the ability to control anger

independently through the physical intervention, medication compliance, social way,

and spiritual way as well as a reduction of length of stay at the hospital (Keliat, Azwar,

Bachtiar, & Hamid, 2009). TAU delivered along with acceptance and commitment

therapy. The results showed that ACT also reduced the symptoms of aggressive

behavior and increased the clients’ commitment to the therapy. Commitment capability

proved by the adherence of the clients to the therapy program and the medication. This

result is in line with that of a previous study, which stated that medication adherence of

the clients had increased both after the provision of education and ACT (52.7%) and

after the provision of only ACT (36.85%). A combination of ACT and TAU also

reported being more effective in decreasing aggressive behavior and in improving the

general health of the clients with psychosis than a sole TAU (Ghouchani et al., 2018).

ACT was also significantly effective in improving the positive symptoms of

schizophrenia (Shawyer et al., 2016), reducing the rate of relapse, and reducing the cost

of care for clients with psychosis (Butler et al., 2016).

Unpleasant experiences were found in all clients as factors of aggressive behavior, and

most of the clients reported family conflicts as one of such factors. However, problems

with the environment, including with friends, could also trigger aggressive behavior in

the clients. A previous study confirmed that the aggressive behavior committed by

clients with schizophrenia was a response to the sense of loss, or rights deprivation by

others, followed by feelings of frustration, fear, unfairness, and anger, which caused

them to conclude that others were responsible for their problems (Rueve & Welton,

2008). Unpleasant experiences or feeling humiliated could influence the content of the

hallucinations experienced by clients with schizophrenia (Hayward, Strauss, &

McCarthy-Jones, 2014). In this case, one client experienced command hallucinations to

injure others. Clients who experienced hallucinations to injure themselves and others

felt like the voice makes them very powerful and obliged to follow the command

(Shawyer, Mackinnon, Farhall, Trauer, & Copolov, 2003; Bucci et al., 2013).

The results stated that there were still residual symptoms left in cognitive and social

aspects, such as blaming and feeling rejected. The reasons why residual symptoms

persisted in several clients might be related to the duration of ACT intervention. A

previous study revealed that ACT effectively decreased the symptoms of psychosis in

clients with traumatic experiences such as sexual abuse and schizophrenia and increased

their acceptance of the disease as well, albeit over a longer duration (12 sessions)

(Jansen & Morris, 2017). Another factor that caused the higher number of residual

symptoms in Client 4 might be due to the client’s substance abuse history that might be

worsening the symptoms of schizophrenia (Green, Noordsy, Brunette, & O’Keefe,

2008).

Conflict in the family, as expressed by Clients 1, 2, and 3 was critical because family is

the main support system for the clients. The bad relationship between the clients and the

families was often due to the high burden of care. Families who were living with the

schizophrenic clients revealed burdens (Rafiyah, 2011; Susanti, Lovell, & Mairs, 2019),

both objective burden such as time and cost of care (85.3%) and subjective burdens

Nurse Media Journal of Nursing, 10(1), 2020, 18

such as feelings of shame, worry, and disruption to personal time (84.2%) (Lasebikan &

Ayinde, 2013). The high burden of caring for a family member with schizophrenia then

attributed to a high expressed emotion (EE) in the family. EE defined as a behavior or

emotion such as criticism, anger, or blame, or an inclination to show rejection to people

with mental illness (Amaresha & Venkatasubramanian, 2012; Nirmala, Vranda, &

Reddy, 2011). High EE in the family causes people with schizophrenia to feel

unaccepted and unsupported and causes their risk of relapse to increase (Bogojevic,

Ziravac, & Zigmund, 2015).

Family psychoeducation (FPE) was delivered to the families to improve their ability to

perform the five family health tasks as the families expected to be the main support

system for the clients. The important roles of the family can be seen from the results

showing all clients experienced significant symptoms of relief following FPE therapy.

As Client 4 had no family conflict history, the feeling of being taken cared for by and

getting support from the family seemed to be a great cause of the client’s symptoms

improvement. The effectiveness of FPE was also shown in a previous study, which

stated that FPE was effective in reducing the severity of schizophrenia symptoms in the

clients not only shortly after the intervention but also 1 month after (Sharif, Shaygan, &

Mani, 2012). Another study has also shown that FPE increased the family’s active

participation in client care management as well as enhanced the client’s compliance

with medication, prevented relapse, and improved social functioning (Ran, Chan, Guo,

& Xiang, 2015).

This study described the whole process of nursing care for clients with schizophrenia

and aggressive behavior, but it also had some limitations that should be addressed. The

limitations to consider are that this study had no control group and that it had no

analysis of client medication which allowed the researchers to compare and ensure the

effectiveness of the therapies.

CONCLUSION

This study stated that nursing intervention as usual and acceptance and commitment

therapy combined with family psychoeducation could be a better choice to help clients

reduce the symptoms of aggressive behavior and improve their ability to control anger.

This study recommends combining the nursing intervention as usual with another

psychotherapy in a clinical setting and to strengthen family involvement in clients’

treatment through family psychoeducation to get a better outcome, especially in clients

with aggressive behavior. Furthermore, ongoing follow-up research is necessary to

measure how well clients are committed to their therapy.

ACKNOWLEDGEMENT

The researchers would like to thank all participants in this study.

CONFLICT OF INTEREST

None

Nurse Media Journal of Nursing, 10(1), 2020, 19

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Nurse Media Journal of Nursing, 10(1), 2020, 22-35 Available online at http://ejournal.undip.ac.id/index.php/medianers

DOI: 10.14710/nmjn.v10i1.24964

The Lived Experiences of the Lombok Earthquake Survivors

Ahmad Mumtaz Tauba1, Suryani2, Imas Rafiyah2

1 Master Program in Nursing, Faculty of Nursing, Universitas Padjadjaran, Indonesia 2 Faculty of Nursing, Universitas Padjadjaran, Indonesia

Corresponding Author: Ahmad Mumtaz Tauba (tobatajama@gmail.com

Received: 15 August 2019 Revised: 17 April 2020 Accepted: 18 April 2020

ABSTRACT

Background: The large-scale earthquake which had struck off Lombok, an island in

West Nusa Tenggara, made the survivors faced poor conditions, difficulties, and lack of

supplies. Besides physical losses, the survivors also experienced various psychological

health disorders that significantly affected their psychological condition as well as life.

Purpose: This study was aimed at exploring and gaining deeper meaning from the lived

experiences of the Lombok earthquake survivors.

Methods: This study used a qualitative method with a descriptive phenomenological

approach to elucidate the phenomena from experiences. The participants were ten (10)

survivors of the Lombok earthquake, who were determined by purposive sampling.

Data were collected through in-depth interviews and analyzed using Colaizzi’s method.

Results: The results showed six emerging themes, including (1) problems solving skills

when disaster strikes, (2) surviving from the limitations and difficulties, (3) feeling

accustomed to earthquake, (4) family is a key source of strength to continue life, (5)

getting closer to God by doing religious prayers and actions to have peace of mind, and

(6) learning from the disasters to become a better human being.

Conclusion: The lived experience of the Lombok earthquake survivors was a long

journey where they survived and adapted the difficult situations, as later, they could turn

the under-pressure conditions to chances for their personal development. Findings of

this study provide insights for nurses to greatly contribute to solving post-disaster

psychological issues by strengthening the survivors’ religious aspects, trauma healing,

play therapy, and peer-support group.

Keywords: Lived experience, Lombok earthquake, natural disaster, survivors

How to cite: Tauba, A. M., Suryani, & Rafiyah, I. (2020). The lived experiences of the

Lombok earthquake survivors. Nurse Media Journal of Nursing, 10(1), 22-35.

doi:10.14710/nmjn.v10i1.24964

Permalink/DOI: https://doi.org/10.14710/nmjn.v10i1.24964

BACKGROUND

The context of this study is based on interviews with Mr. Z as one of the earthquake

survivors in Lombok, an island in West Nusa Tenggara, Indonesia. Mr. Z stated that

besides causing physical damage and injuries, the earthquake disaster also caused

survivors to experience psychological problems. Marthoenis, Yessi, Aichberger, and

http://ejournal.undip.ac.id/index.php/medianers

mailto:tobatajama@gmail.com

Nurse Media Journal of Nursing, 10(1), 2020, 23

Schouler-Ocak (2016) stated that most survivors will experience serious psychological

impacts and can last in the long term so that it affects their behavior in living their daily

lives. Psychological disorders occurred among survivors include acute stress, post-

traumatic stress, and depression related to trauma. According to Shenk, Mahon, Kalaw,

Ramos, and Tufan (2010), trauma is the main psychological impact of a disaster.

Trauma is an emotional response to terrible events such as natural disasters. This

happens immediately after the incident. If the trauma is not handled properly, it will

result in acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). Birmes

et al. (2009) revealed that ASD occurred three days to one month after experiencing

trauma, whereas PTSD occurred after one month experiencing the event of trauma. In

the context of life experience to face and overcome difficult conditions after a disaster, a

person who experiences it is named a survivor, not a victim. He/she struggles to survive

and overcome problems despite the limitations and difficulties caused by the disaster

(Suryani, Welch, & Cox, 2013).

Several studies on natural disaster survivors have been conducted either in Indonesia or

other countries. However, the earthquake disaster that occurred in Lombok has different

characteristics from previous studies. This characteristic is a long period of disaster. A

report from BMKG (Meteorological, Climatological, and Geophysical Agency) stated

that in August 2018, there were five significant earthquakes in Lombok with earthquake

strength above 6.3 to 7.0 SR. Over the next 20 days, 2.566 aftershocks have occurred

(Meteorological, Climatological, and Geophysical Agency, 2019). Based on data

collection through preliminary interviews, a year after the Lombok earthquake,

participants and surrounding communities still felt several aftershocks. Supported by

data from BMKG on July 18, 2019, that the earthquake again struck Lombok with a

magnitude of 4.1 SR. On July 24, 2019, there was still an earthquake with a magnitude

of 4.3 SR (Meteorological, Climatological, and Geophysical Agency, 2019). The

earthquake results in differences in the psychological response of earthquake survivors

in Lombok and other regions.

In Indonesia, several studies have been conducted on natural disaster survivors,

including research on tsunami survivors in Aceh in 2004 and the earthquake in

Yogyakarta in 2006. According to Sunarti (2007), in the case of the tsunami in Aceh

and earthquake in Yogyakarta, mental disorders are one of the main post-disaster health

problems besides physical health problems such as the tetanus outbreak. Different

results were found in Lombok. Based on reports obtained from the medical records of a

mental hospital in West Nusa Tenggara during a preliminary study, it was shown that

the number of mental disorders in 2017 amounts to 20,554 people. At the end of 2018,

the number of mental disorders was 20,711. This means that after the earthquake in

Lombok, there was no significant increase in the number of mental patients.

Results of observations also show another phenomenon that not all survivors in Lombok

experience severe psychological disorders after the disaster. Even some of them became

volunteers who participated in helping other victims of disaster, such as rescuing

victims trapped in the rubble of buildings, initiators of the relocation of refugee villages,

and carrying out trauma healing for refugees. This condition can occur because the life

Nurse Media Journal of Nursing, 10(1), 2020, 24

experiences that disaster survivors have are different, subjective, and individual so that

they produce different psychological responses to each individual in dealing with

traumatic experiences. Subjective experiences mean how survivors live their daily lives

in the limitations and pressures of life, the efforts made to survive, the symptoms they

feel, their hopes, and the quality of life of survivors (Suryani, 2013; Bowers, Kreutzer,

Cannon-Bowers, & Lamb, 2017).

Research on natural disaster survivors is important because a person’s survival process

can be known through his life experience. The journey of survivors in the process of

dealing with traumatic experiences can make an effective contribution to preventing and

overcoming psychological problems compared to medical treatment (Allott, Liu,

Proffitt, & Killackey, 2011). Therefore, it is necessary to conduct in-depth research and

explore the experiences of earthquake survivors in Lombok.

PURPOSE

This study was aimed at exploring and gaining deeper meaning from the lived

experience of the Lombok earthquake survivors.

METHODS

Design and participants

This research is related to the experiences, perceptions, and feelings of individuals who

became survivors of the earthquake disaster in Lombok. Therefore, researchers used a

qualitative method with a descriptive phenomenological approach to describe and

explain the phenomena from experiences (Creswell, & Poth, 2012). There are two

reasons why phenomenology is suitable for this research. First, this research deals with

the lives of people who have encountered specific experiences such as becoming natural

disaster survivors, and second, this phenomenon is firstly observed in Lombok. In

phenomenology studies, a deeper understanding of philosophical assumptions is

important to identify these assumptions (Suryani, Welch, & Cox, 2016). This research

explores the experiences of survivors who encountered the earthquake disaster in

Lombok.

The participants in this study were ten survivors who directly experience the earthquake

disaster in Lombok. The determination for the number of participants is based on the

achievement of the level of data saturation.

Research instrument and data collection

In qualitative research, the researcher acts as a key instrument. The researcher conducts

the collection, documentation, and interviewing the participants to obtain all the data

that is desired by the researcher (Creswell, & Creswell, 2017). The data in this study

were collected using in-depth interview techniques in the form of open-ended questions

from participants who met the inclusion criteria. The interview lasted for about 40 to 65

minutes. In the interview process, each participant provided different information

despite having the same experiences. Therefore, the researchers investigated and learned

the background of specific participants, and then asked questions naturally and

spontaneously, using the language that was mostly understood by participants. The

researchers gave participants the broadest opportunity to answer the questions raised.

Nurse Media Journal of Nursing, 10(1), 2020, 25

The researchers also tried to encourage participants to share their experiences honestly.

In the final stage, the researcher evaluated the results of the interview then validated the

data that required confirmation from the participants.

Data analysis

The data analysis used in this study was the Colaizzi method by validating the results of

the final data to the participants. It means that what is written by the researcher is

following the participant’s intentions (Polit & Beck, 2010). According to Suryani et al.

(2016), the Colaizzi method is suitable for analyzing phenomena. The steps of data

analysis are: (1) obtaining the essence of each interview transcript, (2) extracting

important statements, (3) formulating the meaning of a significant statement regarding

the research objectives, (4) organizing the meaning formulated into a collection of

themes, (5) writing a complete description of the research phenomenon, (6) describing

the basic structure of the research phenomenon, and (7) validating the results of existing

transcripts to all participants. During the data analysis process, an important thing that

the researchers did was bracketing. It means that the researchers focused on the

statements that the participants expressed and tried to put aside understanding and

prejudice about the phenomenon under study.

Ethical consideration

Participants who were willing to become research respondents were asked to fill out an

informed consent sheet. The researchers respected the privacy and confidentiality of

participant data, explored participant experiences in accordance with research ethics,

and used language that could be understood by each participant. This research was

reviewed and approved by the Health Research Ethics Committee of the Faculty of

Medicine, Padjadjaran University, number 712/UN6.KEP/EC/2019.

RESULTS

The results of this study showed that the age of participants ranged from 19 to 92 years

old. Six were males, and the other four were females. Participants had diverse religious,

educational, and occupational backgrounds. All participants were survivors who had

been refugees; seven of whom were volunteers who participated in helping other

disaster victims.

The results of interviews with the participants found six essential themes, consisting of

the ability to overcome problems in disaster situations, surviving in limitations and

difficulties, feeling accustomed to earthquakes, the presence of a family as a strong

source to continue life, getting closer to God by performing worship rituals, and taking

wisdom from disaster to become a better human being. The themes are described

separately to express the meaning of the participant’s life experience. However, there

are interrelations between each theme.

Ability to overcome problems in a disaster situation

In the first theme, participants revealed various efforts made to overcome every problem

experienced during the earthquake disaster. The incident was expressed as a gripping

experience causing stress, panic, and fear. In this condition, six out of 10 participants

Nurse Media Journal of Nursing, 10(1), 2020, 26

expressed they were trying to overcome feelings of stress, panic, and fear by being

calm. The following was the expression of participant 4:

“… Sad, we are so sad, we are lost, the mind wanders … In that state, we try to

calm down, but it is very difficult. After feeling calm, finally, the tense

atmosphere diminished” (P4).

In addition to overcoming panic by being calm, there was a phenomenon in which

laughter and joking become one of how participants dealt with psychological problems

caused by disasters. Furthermore, for participant 7, joking and laughing was not only a

way to overcome problems but rather a way to enjoy life during difficult conditions:

“… We made many jokes when we gathered, that what makes us happy, the mind

is not only focused on the earthquake. Emotions, anxiety, and fatigue reduced.

That is how we enjoy life when it is tough” (P7).

Different from other participants, participant 3 overcame panic, fear, and depression by

trying to think positively:

“… Because when the situation is panic, nothing is easy, just open the door, it’s

hard to ask for forgiveness, even though we just have to check it, we try to control

ourselves by thinking we will be safe, so we feel calmer” (P3).

Survival in limitations and difficulties

In this study, all participants expressed feeling that they were living in limitations and

difficulties during the disaster. So, they made various efforts to survive. The following

was the expression of participant 4:

“… We use whatever we found, especially at that time, the water was very

difficult. Before help comes, we drink turbid water, and we surely survive” (P4).

During the conditions of limitations and difficulties, the majority of participants

revealed that they found strength in togetherness. They together strengthened each other

so they could survive. The following was an expression from participant 4:

“… Equally advising each other, the bond of brotherhood in the refugee camp was

tight. If someone seems to have problems, all immediately gathered. We are like

returning to our childhood that togetherness is back again” (P4).

Furthermore, participants realized that they could not deal with disaster alone, as

illustrated in the following expression of participant 1:

“… We cannot escape from our neighbors and family, because this disaster cannot

be faced alone. Some families and neighbors help, where to ask for help and

assistance” (P1).

Nurse Media Journal of Nursing, 10(1), 2020, 27

Apart from having to survive the limitations and difficulties caused by the disaster, most

participants felt threatened by thieves and looters shortly after the earthquake shook. To

preserve property, participants conducted social cooperation in the form of mobile

patrols and security posts. The following was the expression of participant 6:

“… When the dusk has begun to tense, like when fighting against the Dutch, at 5

p.m., the teenagers return to their respective posts to patrol, we must ensure that

the tents of families and residents are safe, the atmosphere is like the 80s” (P6).

Feeling accustomed to earthquakes

Most of the participants in this study revealed that they felt accustomed to the

earthquake. The change in reaction to the earthquake was expressed by participant 4, as

follows:

“… We cannot count it, … because there must be an earthquake every 10-20

minutes, until now. However, the earthquake is big, but we tried to get used to it.

At first, our feet felt shaking, but now we are getting used to it” (P4).

Based on the experiences expressed by the participants, earthquakes were previously

perceived as tense cases, but afterward, they were considered as normal cases to

produce a better psychological response. Participant 5 stated the following:

“… After that, aftershocks still came. I gradually got used to it. After the big

earthquake, small quakes came. So I just stayed in the room not in a hurry, tired of

running, even running could make us fall and get hurt” (P5).

The presence of a family as a strong source to continue life

On this theme, all participants revealed that the presence of the family was a source of

strength to continue living. Specifically, the presence of the family was very beneficial

for participants in living a life full of stresses and difficulties, both during and after

disasters disaster. The following was the expression from participant 2:

“… Family is everything. The first that motivates us is the family, not others. So,

don’t leave your family.” (P2).

Six out of 10 participants in this study lost their homes due to the earthquake disaster.

For the six participants, the family was more meaningful than the house and property

they owned, as expressed by participant 3:

“… For me family is everything, a family is more valuable than property” (P3).

Furthermore, the family was the main reason for most participants to survive and move

on, as illustrated in the expression of participant 6:

“… The thing that makes me conquer it all is family, why? …because if I were

alone, I would not be able to control myself. I would be frustrated. If I were

frustrated, then who would strengthen them?” (P6).

Nurse Media Journal of Nursing, 10(1), 2020, 28

Getting closer to God by performing worship rituals

A total of four participants expressed gaining peace through worship rituals such as

prayer, prayer, recitation, remembrance, and charity. There were also spiritual aspects

that make participants feel calm in the form of resignation (submission to God),

sincerity, and belief in destiny (faith), as illustrated by participant 2:

“…Not as agitated as before, like when it first happened, now we feel calmer in

anticipating things. Reciting, praying, doing dhikr, and then asking for forgiveness

from God, sharing fortune if there is, giving alms.” (P2).

Meanwhile, for participants 3, belief in destiny made him feel calmer in interpreting the

occurrence of disasters. According to him, the natural disasters that occurred was

provisions set by God. Participant 3 stated the following:

“Fostering a sense of calmness in the heart, that’s for sure, surely feeling calmer if

you believe in God’s destiny” (P3).

After experiencing the earthquake disaster, almost all participants revealed that they

were trying to increase worship to prepare for life in the afterlife, as expressed by

participant 9:

“… Life is only temporary, bad or good house is only temporary. I want a good

home in the afterlife by doing worship” (P9).

Taking wisdom from disaster to become a better human being

Almost all participants in this study consider that the earthquake was a warning from

God that humans need to try to be better than before, as expressed by participant 2:

“… I consider this disaster as a warning to be more trustworthy and devoted to

Allah” (P2).

Although believing in the disaster was a warning and reprimand due to any unpleased

action, it did not make the participants feel punished or hated by God. On the contrary,

for most participants, the condition of surviving a disaster was considered an

opportunity to improve. The following was the expression of participant 7:

“… Yes, we are self-conscious; we must not judge people in this area as a sinner.

If we feel ourselves are not good enough, then try to improve ourselves” (P7).

A slightly different statement was expressed by participant 9. According to him, after

the disaster, everyone became equal; there were no rich and poor people, no luxurious

homes, and ugly houses. Everything became equal. According to participant 9, there

were things they could learn from the disaster.

Nurse Media Journal of Nursing, 10(1), 2020, 29

“… House. Before the disaster, some houses were ugly; others were large and

luxurious. After the disaster, all the houses were flat. There were no longer the

rich and the poor, all the same; the houses were equally flat.” (P9).

DISCUSSION

In this study, each participant provided different information despite having the same

experience. This condition can occur because the life experiences that disaster survivors

have are subjective and individual so that they can produce different psychological

responses to each individual in dealing with traumatic experiences (Suryani, 2013).

Ability to overcome problems in a disaster situation

The ability of survivors to overcome problems is influenced by various factors,

including interpersonal relationships, internal and external resources that they have.

According to Ponizovsky, Finkelstein, Poliakova, Mostovoy, Goldberger, and Rosca

(2013), these factors affect the ability of individuals to deal with a problem. Most

survivors in this study tried to overcome the panic experienced by being calm.

According to participants, a calm attitude in stressful conditions when experiencing a

disaster was very effective in reducing feelings of fear, depression, and panic so that it

could save them from life-threatening conditions. It is in line with a study by Suryani

(2013), which stated that the experience of survivors in facing and overcoming

challenges every day is subjective. It means that individuals use all their strengths in

their limitations as sources of strength. Survivors can find their way of overcoming

problems.

Besides, some participants also made efforts to joke and laugh as a part of their sense of

humor. According to Eysenck (2012), individuals with a good sense of humor can look

at problems from a more positive perspective. It contributes to reducing anxiety and

feelings of helplessness. However, in this study, a sense of humor is not only a way to

overcome problems, but also a way to enjoy life during difficult conditions.

Another effort made by participants in overcoming their problems is by trying to think

positively in stressful situations. Positive thinking is closely related to emotions.

Survivors with positive thoughts are more likely to reduce stress (Phanichrat &

Townshend, 2010). The statement reinforces the findings of Mondal et al. (2013) that

the survivor’s ability to think positively will have an impact on the accuracy of making

decisions, the ability to control emotions, and being calm.

Survive in limitations and difficulties

Individuals who experience psychological problems after a disaster have a chance to

survive and overcome the problem. It is related to resilience that describes the ability of

survivors to overcome and adapt to an adverse event in life. It describes the effort made

by survivors to survive in a state of stress and deal with the traumatic experience they

have (Suryani, 2013).

Based on the results of the study, participants gained the strength to survive in

togetherness. This is following the results of a study by Oflaz, Hatipoğlu, and Aydin

(2008), which revealed that post-disaster psychological problems could be overcome by

Nurse Media Journal of Nursing, 10(1), 2020, 30

improving social and interpersonal relationships, especially among fellow disaster

victims. This study is also in line with Richardson, Cobham, McDermott, and Murray

(2013), reporting that feeling the same fate as having experienced the same incident can

strengthen self-confidence and alleviate feelings of distress. Besides, participants also

revealed their efforts to survive the threat of thieves and looters shortly after the

earthquake. This is a new phenomenon in Lombok and maybe in Indonesia because it is

due to natural disasters. There are no previous research results related to natural disaster

survivors regarding this theme. According to Goto, Wilson, Kahana, and Slane (2006),

cases such as theft and looting caused by the condition of people who have difficulty

getting food and drinks so that they decide to steal.

In this study, participants made efforts to survive through social cooperation such as

patrolling, cooperation, and mutual care. This condition shows a positive social

relationship with fellow disaster victims. Based on the results of a study by Yamamoto

(2011) on earthquake survivors in Japan, it was reported that individuals with positive

social relationships and social support from their communities tended to be more

capable to effectively overcome the difficulties and pressures of life.

Feeling accustomed to earthquakes

Based on the results of the study, there was a phenomenon where most participants were

able to overcome feelings of anxiety, panic, fear, and stress after feeling accustomed to

the earthquake. This phenomenon caused by the earthquake that occurred in Lombok

lasted continuously for a long time. Based on a review of various literature on natural

disaster survivors in Indonesia and abroad, no research discusses the theme of feeling

accustomed to earthquakes or other natural disasters.

The results of the study of Ma et al. (2011) for survivors in China found that post-

disaster psychological problems such as trauma is still felt by survivors after three years

of the earthquake disaster. Similarly, research by Shenk et al. (2010) in Peru showed

that three years after the disaster, most of the survivors still survived in the refugee

camp because they felt traumatized. From the results of the study, participants felt

accustomed after 11 days to 2 months after the disaster. It was further revealed that the

feeling of being accustomed to an earthquake is not an ability acquired through effort,

but arouse due to difficult conditions that forced them to adjust.

Difficult conditions that occur in a long period can encourage individuals to try to find

ways to reduce stress (Ponizovsky et al., 2013). Referring to the results of Yamamoto’s

study (2011), survivors have adapted to difficult situations characterized by reduced

psychosocial impacts in the aftermath of a disaster. In line with this statement, Christia

(2012), in her research, explained that survivors who have repeated similar experiences

would know better how to act to get out of stressful conditions after a disaster.

The emergence of the theme of feeling accustomed to earthquakes is a new insight in

this study as it is not reported in previous studies regarding the life experience of natural

disaster survivors. This could be due to the experience of survivors in dealing and

interpreting disasters as subjective to produce different psychological responses in each

survivor (Suryani, 2013).

Nurse Media Journal of Nursing, 10(1), 2020, 31

The presence of a family as a strong source to continue life

Life after a disaster is a state of stress and difficulty for survivors. This condition made

participants need tangible support from various sources to survive the difficulties caused

by the disaster. All participants in this study revealed the amount of support and

meaning of family presence. Participants became more eager to move on. This finding

is supported by the research of Musa et al. (2014) related to the experience of tsunami

survivors in Aceh that the presence of families is a source of strength and motivation

needed in living life during and after a disaster.

Various literature studies are carried out to find out why certain survivors have stronger

resilience than other individuals when facing difficulties. Studies by Warsini, Mills,

West, and Usher (2016), and Levine, Laufer, Stein, Hamama‐Raz, and Solomon (2009)

have identified factors that strengthen survivor resilience, namely the existence of the

family as a source of strength in facing and overcoming difficulties. The findings in this

study are consistent with the results of previous studies. Participants revealed that the

family is a source of strength to survive and move on.

Based on a study by Sharp (2010), survivors may not be able to overcome their

problems and need the role of other people around them, especially their families. The

importance of family presence is expressed by Shenk et al. (2010) in his study that

survivors displaced by disasters tended to feel worthless because they did not have

anything. The support of the family in the form of love and affection is very helpful in

increasing their confidence. It means that family is the most valuable and meaningful

for participants. Family presence is a source of strength and motivation in living a

difficult life.

Getting closer to God by performing worship rituals

The findings of this study indicated that most participants tried to gain peace of mind by

getting closer to God through rituals of worship such as prayer, dhikr, chanting, and

giving alms. There are also spiritual aspects, namely trusting (surrender to God),

sincerity by accepting the difficult conditions and having faith in destiny. Mohr et al.

(2011) explains that spirituality is a means for soul recovery to increase self-confidence

and relieve feelings of difficulty. Lukoff (2007) stated that spirituality is a part of soul

recovery through worship rituals such as praying and reading scriptures. Survivors can

gain peace, self-confidence, develop their self-worth as humans, and gain optimism in

living life.

The results of a study by Piyasil et al. (2011) about tsunami survivors in Thailand found

a strong influence of spiritual values such as acceptance of God’s will and belief in

destiny (faith) on the resilience of survivors. Spiritual values can be protective factors

that strengthen the resilience of survivors, so they are safe from more severe

psychological problems. Previous studies showed that protective factors in the form of

spirituality could increase the resilience of survivors (Hayward, & Krause, 2014; Uyun,

& Witruk, 2016).

Nurse Media Journal of Nursing, 10(1), 2020, 32

Taking wisdom from disaster to become a better human being

A phenomenon has meaning because someone experiences it and gives meaning to the

experience (Suryani, 2013). After the disaster, most of the participants felt they had

developed into stronger personalities through the experience and wisdom gained when

experiencing life difficulties. The lessons learned include being better at dealing with

stress, becoming more religious than before, trying to be a better human being, and

finally feeling more grateful for what they have. Raj and Subramony (2008) revealed

that the ability of survivors to take wisdom from an unpleasant event in life indicates

success in carrying out the process of adaptation to adversity. The study also showed

that the survivors had strong resilience. It supports a study by Irmansyah, Dharmono,

Maramis, and Minas (2010), that survivors with strong resilience can develop ways of

changing stressful situations into an opportunity to become a better personality.

Some participants believed that the disaster was a warning from God so that the wisdom

could be gained in the form of efforts to improve themselves to become a better human

being. The effort to take lessons from a disaster is motivated by the beliefs held by most

of the participants in this study. In the perspective of being a Muslim, participants

believe that there is always wisdom behind adversity. This is also reported by Musa et

al. (2014) in a study related to tsunami survivors in Aceh, Indonesia. Survivors with high

spirituality tend to take lessons from the difficulties experienced, especially after the

tsunami disaster. By taking lessons from the conditions of difficulties caused by

disasters, survivors gain peace and confidence in overcoming life’s difficulties.

This study has its limitations. The participants in this study were the survivors who

directly experienced the earthquake disaster in Lombok, and only a small number of

survivors were involved in this study. As a result, the findings of this study cannot be

generalized to the broader population. However, the findings of this study have the

potential to fill a “blind spot” in knowledge about the lived experience of earthquake

disaster survivors.

CONCLUSION

In this study, four new insights found, namely the ability to deal with stress through the

effort to joke and laugh, feeling accustomed to earthquakes, surviving the threat of

thieves and looters, and taking lessons from disaster to become a better human being. In

conclusion, the life experience of a natural disaster survivor is a long journey where

survivors try to survive and adapt to difficult conditions. Therefore, they can turn a

stressful state into an opportunity to develop themselves into better personalities than

before. The results of this study are expected to be a reference for nurses in making

greater contributions to overcome psychological problems after a disaster by enhancing

the spiritual aspects of victims, trauma healing, playing therapy, and peer support

groups.

ACKNOWLEDGEMENT

The authors would like to thank all participants and other parties who have supported

and facilitated the study.

Nurse Media Journal of Nursing, 10(1), 2020, 33

CONFLICT OF INTEREST

The authors declare no conflict of interest.

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Nurse Media Journal of Nursing, 10(1), 2020, 36-45 Available online at http://ejournal.undip.ac.id/index.php/medianers

DOI: 10.14710/nmjn.v10i1.25770

Determinants of Stunting in Children Aged 12-59 Months

Erna Julianti1, Elni1

1Department of Child Nursing, Pangkalpinang Nursing Academy, Bangka Belitung, Indonesia

Corresponding Author: Erna Julianti (adex_erna90@yahoo.com)

Received: 6 October 2019 Revised: 24 April 2020 Accepted: 27 April 2020

ABSTRACT

Background: Stunting is one of the priorities of nutritional issues in Indonesia. It is one

of the chronic malnutrition effects in children, which will have a long-term impact on

the growth and cross-generation of mothers through the cycle of stunting syndrome.

Purpose: This study aimed to identify the determinant factors of stunting in children

aged 12-59 months.

Methods: Quantitative research with a cross-sectional approach was employed in this

study, involving 205 respondents recruited using a consecutive sampling technique.

Data were collected using the z scores and questionnaires for children aged 12-59

months, food trust questionnaire, feeding practice questionnaire, and child eating habits

questionnaire. The Chi-Square test and multivariable logistic regression were performed

for the data analysis.

Results: Children who were not exclusively breastfed and had major infectious disease

had a higher risk of stunting for 53.8% and 40.9%, respectively. There was a significant

relationship between the history of exclusive breastfeeding (p=0.001, OR=2.28), the

history of infection (p=0.013, OR= 2.27), and eating habits (p=0.04, OR=1.55) with

stunting in children.

Conclusion: There is a relationship between the history of exclusive breastfeeding, the

history of infection, and the eating habits of children with stunting. The formation of a

peer group community of children aged 12-59 months is expected to prevent and

overcome stunting and improve nutritional status and optimal development of the

children.

Keywords: Children aged 12-59 months, stunting, breastfeeding, infection, eating habit

How to cite: Julianti, E., & Elni. (2020). Determinants of stunting in children aged 12-5

months. Nurse Media Journal of Nursing, 10(1), 36-45. doi:10.14710/nmjn.v10i1.25770

Permalink/DOI: https://doi.org/10.14710/nmjn.v10i1.25770

BACKGROUND

Nutritional status has a significant influence on a child’s growth and development. The

efforts to meet the good nutritional status are given to a mother since the pregnant

period until the phase after the baby is born (United Nations Children’s Fund

[UNICEF], 2017). Complete and varied nutrition during the first 1000 days of life can

help brain development, promote proportional growth, and reduce the risk of disease

(Saavedra & Dattilo, 2016). The inability to fulfill nutrition for the children during this

http://ejournal.undip.ac.id/index.php/medianers

Nurse Media Journal of Nursing, 10(1), 2020, 37

period can cause growth failure or growth retardation (Williams & Suchdev, 2017). One

of the growth disturbances is stunting, which can affect the development of cognitive

and non-cognitive abilities that will be felt in the pre-school to adolescence (Himaz,

2018).

The prevalence of stunting in the world has decreased from 32.6% in 2000 to 22.2% in

2017. Likewise, the prevalence of stunting in Southeast Asia has decreased from 51.3%

in 2000 to 35.8% in 2016 (UNICEF, WHO, World Bank Group, 2017). Indonesia is

included in the third country with the highest prevalence in the Southeast Asian or

South-East Asia Regional (SEAR) region. The prevalence of stunting children aged 12-

59 months in Indonesia in 2013 was 37.2%, and in 2018 was 30.8% (Ministry of Health

Republic of Indonesia [MoHRI], 2018). The prevalence of short children aged 12-59

months in Bangka Belitung Islands Province in 2016 was 21.9%, which increased by

27.3% in 2017. Similarly, in Pangkalpinang, a city in Bangka Belitung, the prevalence

of short children aged 12-59 months in 2016 was 21.7% and increased to 26.7% in 2017

(Public Health Office of Bangka Belitung Islands Province, 2017).

Referring to the high number of stunting and the impact it takes, a comprehensive effort

is needed. One of the efforts that have been successfully carried out is to control the

factors that cause stunting (Zanello, Srinivasan, & Shankar, 2016). Kismul, Acharya,

Mapatano, & Hatløy (2017) grouped three factors related to stunting: distal factors,

intermediate factors, and proximal factors. Distal factors cover mothers’ education,

ethnicity, economic status, location, and type of settlement. Intermediate factors include

environmental factors and maternal factors. Proximal factors include the birth order of

children, the child’s health status, and early breastfeeding initiation. Moreover, eating

habits can also affect stunting, one of which is due to the way parents give their children

food that is not yet diverse and balanced (Ban, Guo, Scherpbier, Wang, Zhou, & Tata,

2017).

The cultures are also influencing factors of stunting. Such cultures may include belief

against food, practices of child feeding according to mother’s tradition, and children’s

eating habits. The culture that exists in society is also one of the factors that influence

how parents feed their children (Batiro, Demissie, Halala, & Anjulo, 2017). There is a

culture of prelacteal feeding of newborns and complementary feeding for children aged

12-59 months (Illahi & Muniroh, 2016). The culture that influences the feeding also

indirectly influences the nutritional adequacy of children, which affects the emergence

of stunting (Pokhrel, Nanishi, Poudel, Pokhrel, Tiwari, & Jimba, 2016).

Cultural and tradition factors have not been the focus of research in Indonesia, even

though they are one of the main factors of stunting. Due to the diverse factors which

cause stunting, the high incidence, and the impact of stunting, the researchers are

interested in finding out the determinants of stunting in children aged 12-59 months.

PURPOSE

This study aimed to identify the determinant factors of stunting in children aged 12-56

months.

Nurse Media Journal of Nursing, 10(1), 2020, 38

METHODS

Design and samples

This study used a cross-sectional research design and was conducted in Pangkalpinang,

Bangka Belitung. The samples were 205 respondents of children aged 12-59 months

selected from seven districts. Proportional sampling, which refers to the sampling

process based on the area or unit by taking into account the proportion of the

population, was used to recruit the samples. The number of samples in each district

based on the calculation of proportion is listed as follows: Rangkui = 37, Bukit Intan =

40, Grimaya = 19, Pangkalbalam = 22, Taman Sari = 21, and Gerunggang = 38, and

Selindung = 28. After the number of samples in each district was determined, the

sampling in this study was carried out using a non-probability sampling method of

consecutive sampling. The inclusion criteria were: children aged 12-59 months, mothers

and children aged 12-59 months were residents living in Pangkalpinang, the mothers

were able to read and write, and willing to be respondents after receiving the research

explanation. The exclusion criteria were parents who were sick and unable to continue

filling out the questionnaire, and the level of children’s intelligence was <105.

Ethical consideration

This study was approved by the health research ethics committee of Yogyakarta

Aisyiyah University as an effort to protect the welfare of the respondents in the form of

an ethical statement No. 393/KEP-UNISA/XII/2018.

Measurement

Data collection tools in this study were a height meter to measure a child’s height and

height chart according to the age by WHO 2006 to determine stunting in children aged

12-59 months by looking at the z score and questionnaire. Four questionnaires were

used in the study. The questionnaires were derived from Birch, Fisher, Grimm-Thomas,

Markey, Sawyer, & Johnson (2001), and tested for validity and reliability. The first

questionnaire is the child characteristic questionnaire, which consisted of gender, age,

history of exclusive breastfeeding, history of early breastfeeding initiation, history of

immunization, and history of infectious diseases. The second questionnaire is the Belief

or Tradition Questionnaire towards Food that is measured using a 1-10 Likert scale (1 =

do not agree, and 10 = strongly agree), and the validity was 0.425-0.933. The third

questionnaire is the Child Feeding Questionnaire to find out how parents feel in feeding

their children in terms of responsibilities and monitoring measured by using a Likert

scale of 1-5 (1 = never, 2 = rarely, 3 = several times, 4 = mostly, 5 = always) and the

validity is 0.58-0.841. The fourth questionnaire is the Child Eating Habit Questionnaire

to find out children’s eating habits measured by using a Likert scale of 1-5 (1 = never, 2

= rarely, 3 = several times, 4 = mostly, 5 = always) and the validity is 0.439-0.929. The

second, third, and fourth questionnaires have obtained the r results (corrected item-total

correlation) more than the r table (0.361), so it can be concluded that the statements in

the questionnaire are valid.

The results of the reliability test showed that the Cronbach’s alpha values of the second,

third, and fourth questionnaires were 0.962, 0.938, and 0.976, respectively. Therefore, it

could be concluded that the instruments were reliable since the value was more or equal

to 0.8.

Nurse Media Journal of Nursing, 10(1), 2020, 39

Data analysis

The data analysis in this study was performed using univariate and bivariate analyses.

The univariate analysis described the characteristics of children and the culture of

feeding children, which were expressed in frequency and percentage distribution since

the data were categorical. The bivariate analysis described the relationship between the

characteristics of children, feeding culture, and the incidence of stunting. The statistical

test utilized the chi-square and multivariable logistic regression for the analysis process.

RESULTS

Demographic characteristics of respondents

The majority of children aged 12-59 months were males (51.2%). The children with a

history of exclusive breastfeeding and a history of early breastfeeding initiation were

68.3% and 73.2%, respectively. Furthermore, those children with a history of complete

immunization and a history of infection were 77.6%, and 56.1%, respectively (Table 1).

Table 1. The Characteristic of respondents

Characteristics of Respondents f %

Sex

Male

Female

105

100

51.2

48.8 Exclusive breastfeeding history

Exclusive breastfeeding

Non-exclusive breastfeeding

140

68.3

31.7 History of early breastfeeding initiation

Early breastfeeding initiation

Non-early breastfeeding initiation

150

73.2

26.8

Immunization history Complete

Incomplete

159

77.6

22.4

Infection history Had an infection

Never had an infection

115

56.1

43.9

Relationship between gender, breastfeeding, immunization and infectious disease

with stunting

The results indicated that there was no significant relationship between gender, history

of early breastfeeding initiation, and history of immunization with stunting (p-value

0.62; 0.93; 0.66) (Table 2). However, the proportion of children aged 12-59 months

who were not exclusively breastfed had a higher stinting risk of 53.8%. Based on the

results of the analysis, it is reported that there was a significant relationship between

exclusive breastfeeding and stunting with a p-value of 0.001 (p<0.005). In addition, the

OR (Odds Ratio) value is 2.28 (95% CI: 1.57-3.32), which shows that children aged 12-

59 months who were not given exclusively breastfed have 2.28 times stunting chance

compared to exclusive breastfeeding.

The proportion of the children aged 12-59 months with the majority of infectious

disease had a higher stunting risk of 40.9%. The analysis found that there was a

Nurse Media Journal of Nursing, 10(1), 2020, 40

significant relationship between infectious disease status and the incidence of stunting

in Pangkalpinang with p-value = 0.013 (p<0.05). It is also obtained an OR (Odds Ratio)

value of 2.27 (95% CI:1.22-4.19), which shows that children aged 12-59 months

suffering from infectious diseases have 2.27 times chance of stunting compared to those

who did not (Table 2).

Table 2. Relationship between gender, history of exclusive breastfeeding, history of

early breastfeeding initiation, history of basic immunization, history of infectious

diseases, and stunting

Variable Stunting classification P OR

Stunting Non-stunting value (CI 95%)

n % n %

Gender

Male (ref) 37 35.2 68 64.8 0.620 0.83

Female 31 31 69 69 (0.46-1.48)

Exclusive breastfeeding history

Exclusive breastfeeding (ref) 33 23.6 107 76.4 0.001* 2.28

Non-exclusive breastfeeding 35 53.8 30 46.2 (1.57-3.32)

History of early breastfeeding initiation

Early breastfeeding initiation (ref) 49 32.7 101 67.3 0.930 0.92

Non-early breastfeeding initiation 19 34.5 36 65.5 (0.48-1.76) History of basic immunizations

Complete, age-appropriate (ref) 51 32.1 108 67.9 0.660 0.82

Incomplete 17 37 29 63 (0.41-1.59)

History of infectious diseases

Positive 47 40.9 68 59.1 0.013* 2.27

Negative (ref) 21 23.3 69 78.7 (1.22-4.19) * p-value <0.05

Relationship between mothers’ belief, feeding practice, and eating habits, and

stunting

The results of this study indicated that there was no relationship between mothers’

belief in food and the feeding practice with the incidence of stunting. Children with low

eating habits tended to experience more stunting, which was 39.6%. The results of the

analysis found that there was a significant relationship between children’s eating habits

and stunting with p-value = 0.04 (p<0.05). In addition, an OR (Odds Ratio) value was

1.55 (95% CI:1.03-2.35), which showed that the children aged 12-59 months with low

eating habits hadve 1.55 times chance of stunting compared to those with high eating

habits (Table 3).

Nurse Media Journal of Nursing, 10(1), 2020, 41

Table 3. Relationship between mothers’ belief against food, practices of child feeding

according to mothers’ tradition, the practice of child feeding, children’s eating habits

with stunting

Variable Stunting Classification p OR

Stunting Non Stunting value (CI 95%)

n % n %

Mother’s Belief in Feeding

Low confidence 40 38.8 63 61.2 0.1 0.59

High confidence (ref) 28 27.5 74 72.5 (0.33-1.07)

The Practice of Child Feeding

Low control 35 32.4 73 67.6 0.92 1.07

High control (ref) 33 34 64 64 (0.6-1.9)

Children’s Eating Habits

Low 44 39.6 67 60.4 0.04* 1.55

High (ref) 24 25.5 70 74.5 (1.03-2.35) * p-value <0.05

DISCUSSION

The characteristics of the children in this study included gender, age of the child, history

of exclusive breastfeeding, history of early breastfeeding initiation, history of basic

immunization, and history of infectious diseases. There is no relationship between the

gender of the children aged 12-59 months in this study and stunting. Both males and

females have a similar possibility to experience stunting. Other things that have a

similar possibility are the history of early breastfeeding initiation and the history of

basic immunizations. On the other hand, the history of non-exclusive breastfeeding and

the history of infectious diseases experienced by children aged 12-59 months have a

chance to cause stunting.

A study by Setiawan, Machmud, and Masrul (2019) showed that there were significant

relationships between energy intake level, history of infectious disease duration with the

incidence of stunting. Non-exclusive breastfeeding has an influence on the incidence of

stunting in children aged 12-59 months. It is in line with the results of the previous

study, which points out that exclusive breastfeeding is strongly associated with reducing

the risk of stunting (Victora et al., 2008). The result of another research indicates the

same result; one of the main factors causing stunting in the village of Petobo, Palu is

that the mothers do not give exclusive breastfeeding (Rahman, Napirah, Nadila, &

Bohari, 2017). This finding is also supported by the results of another research which

states that exclusive breastfeeding during the first six months and appropriate

complementary foods are the efforts to reduce short growth rates and improve the

children’s survival. The survey result from eight countries in Africa and Asia revealed

that two countries (Ethiopia and Kenya) showed significant results in the relationship

between stunting and exclusive breastfeeding (Bove, Miranda, Campoy, Uauy, &

Napol, 2012). Breast milk contains nutrients and bioactive factors that can prevent

infection and inflammation and support the body’s immunity and organ maturity

(Ballard & Morrow, 2013). It confirms that exclusive breastfeeding is very important in

supporting optimal child growth. The benefits may be due to the nutritional content of

Nurse Media Journal of Nursing, 10(1), 2020, 42

breastfeeding, like long-chain fatty acids such as docosahexaenoic acid (DHA) and

arachidonic acid (AA) and their influence on brain development. Breastfeeding might

exert an effect through the physical and emotional contact between mother and infant

during breastfeeding (Pang et al., 2019).

Based on the results of this study, infectious disease is one of the contributors to the

occurrence of stunting. Infectious diseases can be caused by several things, such as the

environment and poor sanitation. More than one-fifth of the world’s population lives in

inadequate environments and lack of clean water which allow high rates of enteric

infections like diarrhea. The enteric infection will disrupt the function of absorption of

nutrients in the intestine, causing up to 43% of growth to be stunted, which affects one-

fifth of children worldwide and one-third of children in developing countries (Guerrant,

DeBoer, Moore, Scharf, & Lima, 2013). When during the first two years, a child has an

infectious disease, he/she can experience an average growth reduction of 8 cm and IQ

decrease of 10 points when they are 7-9 years old. It shows that infectious diseases in

children can result in stunted growth (Guerrant et al., 2013).

Culture in child feeding covers the mothers’ belief in feeding, child feeding practices,

and child’s eating habits. The mothers’’ belief in feeding will affect child feeding

practices. It is related to the habits that the mother believes regarding the prohibition or

abstinence of nutritious food in her family. Most mothers have beliefs in particular food

and the application of feeding practices is done according to low maternal confidence

(Ma, 2015). It means that few people believe in culture and rarely apply the belief

according to it. Koini, Ochola, and Ogada (2019) stated that socio-cultural practices and

beliefs had been shown to influence the feeding of children, thus determining their

nutritional status. Socio-cultural beliefs and practices which are basically contrary to the

principle of fulfilling nutrition are the existence of dietary restrictions on pregnant

women and children, mistakes in providing complimentary food to children, as well as

the existence of negative views that prohibit immunization and exclusive breastfeeding.

The variable of child feeding illustrates how parents provide supervision, pressure, and

restrictions on feeding their children. Ek et al., (2016) elaborate that the variable of

child feeding is the way parents control and regulate the child’s feeding. The variable

also aims to see the beliefs, attitudes, and application of feeding by parents to children

(Birch et al., 2001). Feeding a child is one of the factors that will affect a child’s

nutrition. This is partly because the child’s food intake at pre-school age depends on the

feeding. It is in line with the research of Birch et al., (2001) that parents who have

babies and preschool children play an important role in deciding food for their children,

responding to children’s desire to eat, and deciding on adequate food limits for their

children. In this study, child feeding is largely low, which shows that the efforts to

control and regulate food intake for children are also low. Birch et al., (2001) explained

that if the feeding given by parents is low, the food intake received by children is also

low. Therefore, it can be concluded that low feeding contributes to the adequacy of

nutrition received by children.

The variable of children’s eating habits consists of two domains: the rejection of food

and acceptance of food. In this study, most of the eating habits in children are low.

Nurse Media Journal of Nursing, 10(1), 2020, 43

Children eating habits can affect food intake, which can affect the nutrition of children,

one of which is stunting (Biondi, 2007). Birch et al. (2001) affirm that children have

begun the ability to choose which foods they like or dislike. It confirms that the

children’s desire to choose allows them to form the eating habits which are possibly not

appropriate with the efforts to fulfill optimal nutrition. On the other hand, parents must

have a good ability to control food consumption. It is in line with research conducted by

Birch et al. (2001), which explains that feeding the children has a close relationship with

eating habits. Another research finding states that the initiation of inappropriate

complementary feeding is directly related to stunting (Abeway, Gebremichael,

Murugan, Assefa, & Adinew, 2018). The variables explained in some of the results of

these studies are the factors that have a relationship in assessing the nutritional status of

children related to their physical growth.

One of the factors that can influence stunting is eating habits, one of which is due to the

way parents give their children food that is not yet diverse and balanced (Ban, Guo,

Scherpbier, Wang, Zhou, & Tata, 2017). The culture that exists in the community is one

of the factors that influence how parents feed their children (Batiro et al., 2017). The

existence of a culture that is contrary to the principle of fulfilling nutrition in children is

one of the predisposing factors for the occurrence of stunting (Nurbaiti, Adi, Devi, &

Harthana, 2014).

CONCLUSION

This study showed that there was a significant relationship between the history of

exclusive breastfeeding, the history of infection, eating habits, and stunting in children

aged 12-59 months. The findings are expected to help the formation of peer groups in

the children aged 12-59 months’ family community to prevent and overcome stunting

and to improve nutritional status and optimal children aged 12-59 months’ development.

ACKNOWLEDGEMENT

The researchers would like to thank Yayasan Pendidikan Pangkapinang (YPK) and

Akper Pangkalpinang for funding support to this study. We also thank the parents and

children aged 12-59 months in the city of Pangkalpinang who participated in this study.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

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Nurse Media Journal of Nursing, 10(1), 2020, 46-56 Available online at http://ejournal.undip.ac.id/index.php/medianers

DOI: 10.14710/nmjn.v10i1.28564

English Language Proficiency and Its Relationship with

Academic Performance and the Nurse Licensure Examination

Ryan Michael F. Oducado1, Marianne G. Sotelo1, Liza Marie M. Ramirez1,

Maylin P. Habaña1, Rosana Grace Belo-Delariarte1

1 College of Nursing, West Visayas State University, Philippines

Corresponding Author: Ryan Michael F. Oducado (rmoducado@wvsu.edu.ph)

Received: 14 February 2020 Revised: 11 April 2020 Accepted: 13 April 2020

ABSTRACT

Background: Studies have shown that various factors influence students’ success in

nursing school and the Nurse Licensure Examination (NLE). Such factors should be

studied as foundations of the nursing programs. Problems with proficiency in the

language used by the instructor to teach curricular courses may be considered a barrier

to effective learning and academic success.

Purpose: This study ascertained the influence of English language proficiency on the

academic performance of students in professional nursing courses and the NLE.

Methods: This study employed a retrospective descriptive correlational study design.

Secondary analysis of existing research data sets of 141 nursing students in one nursing

school in the Philippines was performed. Pearson’s r was used to determine the

correlation between variables.

Results: Findings showed that there were significant correlations between academic

performance and the Verbal Ability subscale of the Nursing Aptitude Test (p=0.003)

and the three English courses included in the nursing curriculum (p=0.000). There were

also significant correlations between the NLE ratings and Verbal Ability (p=0.000) and

the three English courses (p=0.000).

Conclusion: English language proficiency is an important factor in determining the

academic and licensure success of nursing students. Nursing schools must ensure that

approaches in improving students’ English language proficiency must be well integrated

into the undergraduate nursing program.

Keywords: Academic performance; English language proficiency; English

competency; licensure exam; nursing

How to cite: Oducado, R. M. F., Sotelo, M. G., Ramirez, L. M. M., Habaña, M. P., &

Belo-Delariarte, R. C. (2020). English Language Proficiency and Its Relationship with

Academic Performance and the Nurse Licensure Examination. Nurse Media Journal of

Nursing, 10(1), 46-56. doi:10.14710/nmjn.v10i1.28564

Permalink/DOI: https://doi.org/10.14710/nmjn.v10i1.28564

BACKGROUND

English is the ‘operating system’ of the global conversation spoken by a quarter of the

world’s population (British Council, 2013). It is the language of diplomacy, business,

http://ejournal.undip.ac.id/index.php/medianers

mailto:rmoducado@wvsu.edu.ph

Nurse Media Journal of Nursing, 10(1), 2020, 47

education, engineering, law, and healthcare (Cabigon, 2015; Nishanti, 2018). With the

impact of globalization and economic development, command in the English language

is vital for those who work in the global workforce.

The Philippines is acknowledged globally as one of the biggest English-speaking

nations. Proficiency in the English language is also one of the country’s assets that

helped the country’s economy (Cabigon, 2015). The Philippines is considered one of

the top outsourcing destinations of foreign healthcare workers worldwide (Ubas-

Sumagaysay & Oducado, 2020; Yeates & Pillinger, 2018). However, concern on the

narrowing competitive advantage of the country was raised despite that the country is

doing fine in terms of English competency (Cabigon, 2015). Recent studies are showing

that the Filipinos’ grasp of the English language requires an area of concern. Results of

an online Standard English Test (SET) revealed a declining trend in the English

language skills of Filipinos (Education First, 2019). A Philippine Senate Resolution 622

(2018) was filed in 2018 calling for an inquiry into the declining proficiency in English

among Filipino students citing reports from Hopkins International Partners and the

Common European Framework of Reference for Languages. The Hopkins International

Partners study revealed that college graduates in the Philippines had lower English

proficiency level than the proficiency target set for high school students in Thailand and

the taxi drivers in Dubai. Moreover, the Common European Framework of Reference

for Languages reported that the median score of Filipino university graduates was

comparable only to the proficiency level of 5th and 6th graders in countries wherein

English is the native language. There was also news that reported that many Filipino

nurses failed the English proficiency test required to qualify for employment in a

hospital in London (Byrne, 2017).

Internationally educated nurses or nurses from countries outside of the United States of

America (USA), United Kingdom (UK), and Australia, to name a few, are required to

take an English test or provide proof of English language skills prior to employment. It

has been established that the tests used for estimating future job performance should be

administered in the language used in the job because those with inadequate competence

in that language may also perform poorly either on the test, on the job, or both (O’Neill,

Marks, & Liu, 2006). In other words, the low English proficiency of Filipino nurses

may negatively affect their future job performance or employment when they work in

English-speaking countries.

The value of the English language in the Philippine educational system cannot be

overemphasized. While Filipino is considered as the national language, the official

languages of the country for purposes of communication and instruction are Filipino and

English, as stated in the 1987 Philippine Constitution. Globally, in developing and even

in some developed countries, a language other than the students’ mother tongue is used

in all levels of the educational system (Civan & Coşkun, 2016). The English language is

widely used in the field of education, especially in highly technical fields like nursing.

English as a medium of instruction has been adopted for decades by Philippine nursing

schools. Published academic research and major references used in nursing schools in

the country are written mostly in English. It is said that the language of instruction plays

Nurse Media Journal of Nursing, 10(1), 2020, 48

an essential role in facilitating learning of course contents and in teaching the subject

(Ibrahim, Shafaatu, & Yabo, 2017).

Understanding the performance of students in nursing school and the licensure

examination are important to identify students who are at risk of not performing well

(Oducado, 2019). Past researches have shown that various factors influence nursing

students’ academic performance (Belo-Delariarte, Oducado, & Penuela, 2018;

Mthimunye & Daniels, 2019; Mthimunye & Daniels, 2020) and success in the licensure

examination in countries like Kenya (Okanga, Ogur, & Arudo, 2017), Ghana

(Amankwaa, Agyemang-Dankwah, & Boateng, 2015), USA (Kim, Nikstaitis, Park,

Armstrong, & Mark, 2019) and the Philippines (Oducado, Cendaña, & Belo-Delariarte,

2019b). Prior studies indicated that English language proficiency influences the

academic performance of nursing students in the Philippines (Oducado & Penuela,

2014) and Kuwait (Vidal, Labeeb, Wu, & Alhajraf, 2017). Students who had high self-

reported English language proficiency were also found to have the highest GPA in a

study among international university students in the USA (Martirosyan, Hwang, &

Wanjohi, 2015). It was also established that performance in academic influences

performance in the NLE (De Leon, 2016; Oducado et al., 2019b; Soriano, 2016).

However, despite the positive impact of English language proficiency on academic

success, there are reported concerns on the potential negative effects on the learning

process and students’ academic achievement when the medium of instruction or

language used to teach the subject is a language different from the mother or native

tongue of the learners or students (Civan & Coşkun, 2016). This may be true within the

multi-lingual context of the Philippines and in the setting of this study wherein English

is the medium of instruction, and Hiligaynon is the local dialect spoken by most of the

study sample. Nursing students with English as an additional language or English as a

second language (ESL) may experience more learning challenges and may not perform

well academically (Glew, Hillege, Salamonson, Dixon, Good, & Lombardo, 2015;

Salamonson, Everett, Koch, Andrew, & Davidson, 2008). The study of Green (2015)

relayed that ethnicity and English proficiency were predictors of academic performance

and progress. Language barriers were also identified as a significant barrier faced by

ESL nursing students in a critical review of the literature (Olson, 2012).

While a number of scholars have investigated the association between English language

proficiency and academic performance, literature is scarce on the relationship between

English proficiency and NLE in the Philippines. Lack of English proficiency may be an

impediment to students’ academic success and in acquiring nursing knowledge and

skills to produce globally competitive nursing graduates. Understanding the influence of

English language proficiency on the academic performance in professional nursing

courses and the NLE is thereby necessary.

PURPOSE

The purpose of this study was to investigate the influence of English language

proficiency on nursing students’ academic performance in professional nursing courses

and the NLE at one baccalaureate nursing program.

Nurse Media Journal of Nursing, 10(1), 2020, 49

METHODS

Research design

This study utilized a retrospective, descriptive-correlational design. A secondary

analysis of existing data sets was performed. Secondary analysis “refers to the use of

existing research data to find answer to a question that was different from the original

work” (Tripathy, 2013).

Participants

The researchers analyzed secondary data of 141 nursing graduates at one baccalaureate

nursing program in the Philippines. Power analysis using G*Power 3.1 software

revealed that 115 is the required sample size given an alpha of .05, power of .95, and

medium effect size of .3. The researchers, however, decided to include all 141 students

in the analysis since data were readily available to the researchers. Students with

complete records of the variables of the research and took the NLE in May 2015 were

included. Those who repeated any of their courses in the program were excluded from

the analysis.

Research instrument and data collection

Two measures were used to determine the English language proficiency of students:

Verbal Ability and grades in English courses. The Verbal Ability subscale of the

Nursing Aptitude Test (NAT) was used to measure the pre-admission English language

proficiency of students. The result of the NAT was obtained from the Center for

Educational Measurement, Inc. (CEM), the center that administered the NAT, as part of

the qualifying admission requirements to incoming first-year nursing students in the

college. In general, the NAT, a standardized test, gives an estimate of the student’s

mental abilities in the areas of Verbal Ability, Numerical Facility, Science, and Health

Information (CEM, n.d.; Oducado & Penuela, 2014). The Verbal Ability subtest is

composed of 60 items in a multiple-choice format measures proficiency or ability in the

English language with content areas of verbal analogies and vocabulary and has a

reported reliability coefficient of greater than .70 (CEM, n.d.). The Verbal Ability

standard scores were interpreted as follows: 676-800 = Excellent; 626-675 = Superior;

576-625 = Above average; 526-575 = High average; 476-525 = Average; 426-475 =

Low average; 376-425 = Below average; 326-375 = Poor; 200-325 = Very poor. Grades

in the three (3) English courses (ENG 101, ENG 102, & ENG 103) included in the

Bachelor of Science in Nursing (BSN) curriculum were used to measure the English

proficiency of students in nursing school. The grades on English subjects and

professional nursing courses were obtained from the Transcript of Records of the

students originally taken from the University Registrar. The nursing curriculum in the

Philippines comprises both general education courses and professional courses. A total

of 21 professional nursing courses reflected in the Commission on Higher Education

Memorandum Order 14 series of 2009 BSN curriculum (Commission on Higher

Education, 2009) were analyzed. For this study, only the average grades obtained by the

students in both theoretical classroom instructions and Related Learning Experiences

(RLEs) (Oducado, Amboy, Penuela, & Belo-Delariarte, 2019a) in all professional

nursing courses were used as a measure of academic performance. To interpret the

grades in English subjects and professional nursing courses, the following were used:

1.50-1.74 = Outstanding; 1.75 – 1.99 = Very good; 2.00-2.24 = Good; 2.25-2.49 = Very

Nurse Media Journal of Nursing, 10(1), 2020, 50

satisfactory; 2.50-2.74 = Satisfactory. Data on the NLE ratings of the students were

originally requested from the Philippine Professional Regulatory Commission and were

interpreted as: 79.99 and below = low; 80-84.99 = average; 85 and above = high.

Statistical data analysis

Data analysis was aided by IBM SPSS version 23. Percentage, mean, and standard

deviation (SD) were used to describe the data. Pearson product-moment correlation

coefficient tested for the relationship between variables since data was found to be

normally distributed with sig. value of Kolmogorov-Smirnov Test greater than .05. The

level of significance was set at 0.05 alpha.

Ethical considerations

All secondary data remained confidential, were kept safe from unauthorized access, and

were only made available to the researchers. The original research where the data were

taken was granted an exemption by the ethics review committee of the University.

Administrative clearance from the Dean of the College of Nursing was secured to

conduct this secondary analysis.

RESULTS

Participants’ profile

Nursing students who participated in this study were graduates of the four-year

baccalaureate nursing degree program in one state-funded public university in the

Philippines. The majority of subjects of the study were females (f=123; 87.2%). They

were typically between 20 to 21 years old when they took the NLE.

English language proficiency of nursing students

Table 1 shows that the majority of nursing students had an above-average (M=612.68;

SD=60.65) English language proficiency in the Verbal Ability subscale of the NAT. In

terms of English language proficiency in nursing school, nursing students had a very

good performance in ENG 101 or Intensive English Grammar (M=1.76; SD=0.29) and

had an outstanding performance in ENG 102 or Study and Thinking Skills in English

(M=1.58; SD=0.21) and ENG 103 or Speech Communication (M=1.51; SD=0.25)

respectively.

Table 1. English language proficiency of nursing students

English language proficiency Mean SD Interpretation

Pre-admission

Verbal Ability 612.68 60.65 Above average

Performance in English courses ENG 101 (Intensive English Grammar) 1.76 0.29 Very Good

ENG 102 (Study and Thinking Skills in English) 1.58 0.21 Outstanding

ENG 103 (Speech Communication) 1.51 0.25 Outstanding

Academic performance in professional nursing courses and the NLE

Table 2 displays the academic performance of nursing students in 21 professional

nursing courses outlined the BSN curriculum and their performance in the NLE. It is

Nurse Media Journal of Nursing, 10(1), 2020, 51

shown in Table 2 that nursing students had a good (M=2.13; SD=21) performance in

professional nursing courses and had an average (M=80.74; SD=1.95) performance in

the NLE.

Table 2. Academic performance in professional nursing courses and the NLE

Variables Mean SD Interpretation

Academic performance in nursing courses 2.13 0.21 Good

Performance in the NLE 80.74 1.95 Average

Relationship of English language proficiency to academic performance and NLE

Table 3 reflects the correlation between English language proficiency and nursing

students’ academic performance in professional nursing courses and NLE. Table 3

shows that Verbal Ability (p=0.003), ENG 101 (p=0.000), ENG 102 (p=0.000), ENG

103 (p=0.000) were significantly related to academic performance in professional

nursing courses. It can also be gleaned in Table 3 that Verbal Ability (p=.0000), ENG

101 (p=0.000), ENG 102 (p=0.000), ENG 103 (p=0.000) were significantly related to

performance or rating in the NLE.

Table 3. Correlation between study variables

English language proficiency Academic performance NLE performance

r p r p

Verbal Ability -0.252 0.003* 0.366 0.000*

ENG 101 0.692 0.000* -0.541 0.000*

ENG 102 0.558 0.000* -0.340 0.000*

ENG 103 0.538 0.000* -0.362 0.000*

*significant if <0.05

DISCUSSION

This research determined the influence of English language proficiency on academic

performance and the NLE. This study found that nursing students in this study generally

have good English language proficiency prior to admission in the college and while in

nursing school. Additionally, this study revealed improvement in the English

proficiency of students as reflected in their very good to outstanding grades from one

English language course to another. Students having good command in the English

language in this study may probably be due to the highly competitive admission policy

of the college. As a state or government-funded university, only a limited number of

students are admitted to the BSN program. Generally, the college is able to attract the

best students within the region. Within the context of nursing, a high degree of English

language proficiency is essential for effective communication to provide safe nursing

care, to establish therapeutic relationships with clients, and to collaborate effectively as

a member of the healthcare team (Alinezhad & Gholami, 2012; Garone & Van de

Craen, 2017). The English language plays an important role and is useful in students’

academic life. The use of English language for classroom instruction and in the students’

RLEs requirements such as in case presentations, class reporting, and in documenting

Nurse Media Journal of Nursing, 10(1), 2020, 52

nurses’ work may have contributed to the improvement of the verbal and written

communication skills of student nurses in the English language.

Interestingly, the finding of this study and that of Racca & Lasaten (2016), which also

found satisfactory English proficiency among Philippine Science High school students,

are in contrast to the reports regarding the declining ability of Filipinos in the English

language. The authors cannot be conclusive about the general or overall English

proficiency of Filipino students. Bias in the sample may have been introduced,

influencing the results of the study.

Moreover, this study demonstrated that English language proficiency is significantly

correlated with academic performance. It must be noted that 1.0 is the highest grade

obtained by the student in the grading system of the college. Hence, a low number or

grade in academic performance indicates better performance or achievement. The

finding of the study is generally consistent with other research findings among nursing

students in the Philippines (Oducado & Penuela, 2014), nursing (Alharbi & Yakuot,

2018; Vidal et al., 2017) and medical (Kaliyadan, Thalamkandathil, Parupalli, Amin,

Balaha, & Al Bu Ali, 2015) students in Saudi Arabia, medical students in Iran (Sadeghi,

Kashanian, Maleki, & Haghdoost, 2013), and with pharmacy students (Green, 2015)

among others. English‐language acculturation was found to influence academic

performance among first-year ESL nursing students (Salamonson et al., 2008). English

reading comprehension ability was also found to positively influence academic

achievement among Indian nursing students (Ponkshe, 2013). Students with better

command in the English language were more likely to do better in their nursing courses.

Since English is the medium of instruction, students who were more proficient in

English were able to do better in writing, speaking, grasping and understanding the

instructions and lessons given to them in professional nursing courses. Teaching the

curricular content and having proficiency in the language used for instruction increases

the learner’s amount of exposure and opportunities to understand the content of

instruction hence students develop greater control over what is taught in class (British

Council, n.d.) resulting to positive outcomes on students’ academic success.

This study also disclosed a significant relationship between English language

proficiency and the NLE. Miñoza (2016) likewise found an association between

English proficiency and licensure examination among agriculturists in the Philippines.

Similarly, O’Neill et al. (2006) found a link between English proficiency and nursing

licensure examination performance. The authors found that ESL examinees had a lower

passing rate than English only candidates. This result suggests that an obvious issue in

language competency may create an impact on the performance in the licensure

examination. It also highlights the importance of proficiency in the language used in the

target examination. Not having good ability in the language used in the examination

may impede a better understanding of test item questions. Soriano and Lupdag-Padama

(2009) found that reading proficiency was a factor influencing the performance of

nursing graduates in the NLE. The findings of this study suggest that it is vital to take

into consideration that students who are admitted into the BSN program have good

English language competency. Likewise, academic nursing institutions should promote

students’ skills in the English language in both academic and clinical settings to

Nurse Media Journal of Nursing, 10(1), 2020, 53

safeguard students’ academic success in nursing school and the licensure examination.

Providing students with academic guidance remains a vital aspect of nursing education

(Oducado, Frigillano, Gunce, Jover, Meliton, & Pangilinan, 2017).

This study has its limitations. The data used were only secondary data in one college of

nursing, thus limits the generalizability of the findings. Another limitation is that the

English proficiency measure used in this study did not specifically assess English skills

in the dimensions of reading, writing, listening, and speaking. Language proficiency in

English is usually defined by a combination of these four skills (Sadiku, 2015). Future

studies may be conducted on a larger scale using standardized English tests to validate

the results of the investigation. Also, a qualitative component was missing, which could

have explored students’ views on the influence of the English language on their

academic and licensure success. Nonetheless, this study has addressed the paucity of

research on the influence of proficiency in the English language has on licensure

examination within the local context. Additionally, this study has provided support on

prior studies affirming the impact of English language proficiency on students’

academic performance where English is the medium of instruction in a non-native

English speaking country.

CONCLUSION

English language proficiency significantly influences students’ performance in

professional nursing courses and the NLE. Enhancing students’ English language

proficiency is considered beneficial in promoting students’ academic and licensure

examination success in a country where the language used by the teacher or instructor to

teach the language is English. The result of this study can be utilized in developing

strategies to enhance students’ English language proficiency to support students’

academic and licensure examination success. Nursing schools must ensure that

approaches in improving students’ English language proficiency must be well integrated

into the undergraduate nursing program.

CONFLICT OF INTEREST

None.

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DOI: 10.14710/nmjn.v10i1.25318

Deep Breathing Exercise and Active Range of Motion

Influence Physiological Response of Congestive Heart

Failure Patients

Novita Nirmalasari1, Mardiyono Mardiyono2, Edi Dharmana 3, Thohar Arifin3

1Department of Nursing, Faculty of Health, Jenderal Achmad Yani Yogyakarta University, Indonesia

2Department of Nursing, Health Polytechnic of Semarang, Indonesia

3Faculty of Medicine , Universitas Diponegoro, Indonesia Corresponding Author: Novita Nirmalasari (novitanirmalasari@gmail.com)

Received: 6 September 2019 Revised: 9 March 2020 Accepted: 12 April 2020

ABSTRACT

Background: Dyspnea and physiological changes are clinical manifestations of

Congestive Heart Failure (CHF) due to respiratory failure. Deep breathing exercise

combined with active range of motion increases respiratory muscles and blood

circulation. As a result, it reduces breathing effort and decreases blood pressure. Purpose: This research aimed to analyze the influence of deep breathing exercise and

active range of motion (ROM) on the physiological response of CHF patients.

Methods: This study used a quasi-experiment with pretest-posttest control group design

recruiting 32 respondents by stratified random sampling technique. The intervention

was done three times a day for three days. Deep breathing exercise for thirty times and

continued with active range of motion for five times each movement. Digital

sphygmomanometer and digital watch were used as measuring instruments. Data were

analyzed using independent and paired t-tests.

Result: The results showed that there were significant differences in the systole

(p=0.000), diastole (p=0.000) and respiratory rates (p=0.003) after the intervention

compared to the control group. There was also a significant difference in systolic blood

pressure between the intervention and the control group (p=0.003). However, no

significant difference in diastole and respiratory rates was found.

Conclusion: Deep breathing exercise combined with active range of motion decreases

the systole in CHF patients. Further research is expected to lengthen the time of

intervention to allow better significance.

Keywords: Active range of motion; CHF; deep breathing exercise; physiological

response

How to Cite: Nirmalasari, N., Mardiyono, M., Dharmana, E., & Arifin, T. (2020). Deep

breathing exercise and active range of motion influence physiological response of

congestive heart failure patients. Nurse Media Journal of Nursing, 10(1), 57-65. doi:

doi:10.14710/nmjn.v10i1.25318

Permalink/DOI: https://doi.org/10.14710/nmjn.v10i1.25318

Nurse Media Journal of Nursing, 10(1), 2020, 58

BACKGROUND

Heart and blood vessel diseases are one of the major health problems in both developed

and developing countries. This disease is the first leading cause of death in the world,

and the prevalence is estimated to continually increase up to 23.3 million in 2030

(Ministry of Health Republic of Indonesia [MoHRI], 2014; Yancy et al., 2013). Similar

phenomena also occur in Indonesia. The result of Basic Health Research (Riskesdas) by

the Ministry of Health, Republic of Indonesia in 2013 reported that the prevalence of

heart failure in Indonesia reached 0.3% (MoHRI, 2013). The highest prevalence in Java

island occurs in Yogyakarta Province, with the percentage of 0.25 % (MoHRI, 2014).

The increasing prevalence will cause problems for diseases, disabilities, and socio-

economic problems for family, communities, and the state (MoHRI, 2014; Ziaeian &

Fonarow, 2016). Therefore, comprehensive management for heart failure, especially

symptom management, needs to be addressed.

Dyspnea is a hallmark symptom of Congestive Heart Failure (CHF). Dyspnea impairs

functional capacity and quality of life. Dyspnea caused by ventricular dysfunction

causes decreased cardiac output and increased pulmonary venous pressure resulting in

pulmonary congestion. This ultimately leads to extravasation of fluid into the interstitial

space and lung alveoli, which reduces pulmonary compliance and impairs the ease of

breathing. Patients who have the NYHA functional class of III-IV will be having high

levels of dyspnea complaints (Kupper, Bonhof, Westerhuis, Widdershoven & Denollet,

2016). Patients with NYHA IV will be panting every day, even during mild activity or

at rest. This is because dyspnea affects the decrease in tissue oxygenation and energy

production, so that patient’s daily activity will also decrease, which can lower the

quality of patients’ life (Sepdianto & Maria, 2013). The pharmacological management

provided for these patients includes cardiac glycoside, diuretic therapy, and vasodilator

therapy (Shah, Gandhi, Srivastava, Shah, & Mansukhani, 2017). However, studies in

the form of systematic review and meta-analysis revealed that heart failure

rehabilitation is recommended for low and moderate risk of heart failure (NYHA II and

III) (Sagar et al., 2015).

Cardiac rehabilitation can be useful in clinically stable patients with heart failure

(Yancy et al., 2013). The American Heart Association recommends physical exercise to

be performed in patients with stable CHF. Physical exercise is done 20-30 minutes with

a frequency of 3-5 times each week. Before beginning physical exercise, patients with

CHF require a comprehensive assessment of risk stratification and are recommended to

rest due to fatigue. This exercise is one of the hospitalized exercises (inpatient) that can

be performed to the patients with NYHA II and III. Gradual activity management in

such patients is a mild and regular physical activity so that peripheral blood circulation

and tissue perfusion conditions can be improved (Adsett, Hons & Robbie, 2010;

Alvarez, Hannawi & Guha, 2016). Moreover, giving position and breathing exercises

can be done to reduce effort and improve respiratory muscle function. Tolerable

exercise can be managed to improve tissue perfusion and facilitate circulation. Exercise

training or regular physical activity is recommended as safe and effective for patients

with heart failure (Yancy et al., 2013).

Nurse Media Journal of Nursing, 10(1), 2020, 59

Breathing exercise is an exercise to improve breathing and functional performance

(Cahalin & Arena, 2015). One of the breathing exercises that can be done is a deep

breathing exercise, a nursing activity, that serves to increase the function of respiratory

muscles resulting in ventilation and oxygenation improvement (Bulechek, Butcher,

Dochterman, & Wagner, 2013; Herdman, Kamitsuru, & North American Nursing

Diagnosis Association, 2014; Kupper et al., 2016). Sepdianto and Maria (2013), in their

study, reported that breathing exercise in patients with heart failure for 15 minutes as

many as three times a day within 14 days reduces dyspnea. A systematic review of 27

studies also showed that physical exercise could increase oxygen saturation and quality

of life of patients with heart failure (Jewiss, Ostman, & Smart, 2016). Therefore, it is

important to conduct a study to examine the influence of breathing exercise and active

range of motion in CHF patients.

The use of deep breathing exercises and active range of motion as a nursing intervention

in CHF patients has not been widely studied in Indonesia. There are no studies that

combine the two interventions. This encourages researchers to study the effect of deep

breathing exercise and active range of motion on dyspnea in CHF patients.

PURPOSE

This research aimed to examine the effect of deep breathing exercises combined with an

active range of motion on physiological response in CHF patients.

METHODS

Research design and samples

The study used a pretest-posttest quasi-experimental research design with a control

group, and was conducted in two hospitals in Yogyakarta, Indonesia. A stratified

random sampling method was utilized to recruit the samples of NYHA II and III CHF

patients who met the inclusion criteria, which were stable hemodynamic status, no

weakness in both extremities, more than 17 years old, and receiving the same

pharmacological treatment. Whereas, the exclusion criteria included the patients with

neuro-musculoskeletal, severe systemic, mental and communication disorders, and

respiratory diseases. As many as thirty-two respondents who met the inclusion and

exclusion criteria were recruited. They were then divided into the equally same number

between the intervention and control groups.

Research instrument and data collection

The instruments used in this study were digital sphygmomanometer and digital watch to

measure blood pressure and respiratory rate. Pre-test and post-test on both groups were

conducted in the first and third days, respectively. All respondents in both groups were

measured their blood pressure and respiratory rates. The pre-test measurements were

performed 15 minutes before the intervention began, while the post-tests were done 15

minutes after the intervention ended. Interventions were initiated after 48 hours of

hospital admission. The intervention was started by deep breathing exercises for 30

times, followed by an active range of motion gradually on the hands, legs, hips, and

knees with each movement performed for five times. This intervention was done three

times a day for three days. On the other hand, the control group obtained standard

intervention, which was a semi-fowler position.

Nurse Media Journal of Nursing, 10(1), 2020, 60

Data analysis

A paired t-test was used to analyze the mean difference before and after the

intervention, while an independent t-test was used to compare the mean differences

between the intervention and the control groups.

Ethical consideration

Prior to the study, all respondents expressing agreement to participate in the study were

informed of the objectives, benefits, and procedures of the research. They were also

requested to sign informed consent. In terms of the privacy and confidentiality of

respondents, providing training fairly, benefits, and avoiding dangerous actions were

ensured during the study. This research had been reviewed and obtained ethical

permission from the ethics and research committee in the Faculty of Medicine,

Diponegoro University, Semarang, Indonesia, with the number of ethical approval of

202/EC/FK-RSDK/IV/2017.

RESULTS

Characteristics of respondents

The results of the study showed that more than half of the respondents in the

intervention and the control group were women and aged more than 60 years. A

majority of the respondents in both groups had common co-morbidities, which were

hypertension. The proportion of respondents who had NYHA II was the same as NYHA

III in both groups (50%), while most respondents in both groups obtained diuretic drugs

(Table 1).

Table 1. Characteristics of respondents (n=32)

Characteristic Intervention Control Total

p f (%) f (%) f (%)

Age

18 – 45 years old 2 (12.5) 2 (12.5) 4 (12.5)

0.132* 46 – 60 years old 3 (18.8) 6 (37.5) 9 (28.1)

> 60 years old 11 (68.7) 8 (50.0) 19 (59.4) Gender

Man 7 (43.8) 7 (43.8) 14 (43.8) 0.341**

Woman 9 (56.2) 9 (56.2) 18 (56.2) Co-morbidities

Hypertension 10 (62.4) 7 (43.7) 17 (53.1)

0.333* Diabetes mellitus 3 (18.7) 4 (25.0) 7 (21.9) Kidney failure 1 (6.3) 3 (18.7) 4 (12.6)

Anemia 1 (6.3) 1 (6.3) 2 (6.2)

Gastritis 1 (6.3) 1 (6.3) 2 (6.2)

NYHA class NYHA II 8 (50.0) 8 (50.0) 8 (50)

1.000** NYHA III 8 (50.0) 8 (50.0) 8 (50)

Pharmacological therapy Diuretic 6 (37.5) 8 (50.0) 14 (43.7)

0.242* Vasodilator 3 (18.8) 5 (31.3) 8 (25.0)

Diuretic and vasodilator 7 (43.8) 3 (18.8) 10 (31.3) *Mann-Whitney Test **Chi-Square

Nurse Media Journal of Nursing, 10(1), 2020, 61

Effects of deep breathing exercise and active range of motion on blood pressure in

CHF patients

The analyses of the effects of deep breathing exercise and active range of motion on

physiological responses, including systole and diastole in the intervention group and

control group, were shown in Table 2 and Table 3. There was a higher decrease in the

mean of systole and diastole after the intervention compared to the control group. There

were also significant differences in the systole (p=0.000) and diastole (p=0.000) in the

intervention group (Table 2).

Table 2. Differences in blood pressure of CHF patients (n=32)

Blood pressure Control Group Intervention Group

MeanSD t p MeanSD t p

Systole

Pre-test 128.3125.34 1.877 0.080*

128.2516.97 6.483 0.000*

Post-test 123.0033.31 110.1916.46

Diastole

Pre-test 74.8820.14 1.338 0.201*

73.5010.49 4.748 0.000*

Post-test 70.4416.57 65.0310.27

*paired t-test

As seen in Table 3, there was a significant difference in the mean difference of systolic

blood pressure between the intervention and the control group (p=0.003). However, the

mean difference of diastole was not significantly different between the groups

(p=0.296). It meant that deep breathing exercises combined with active range of motion

decreased the systole, yet the diastole compared with the hospital standard care.

Table 3. Effects of deep breathing exercise and active range of motion on blood

pressure of CHF patients (n=32)

Blood pressure Intervention Group Control Group

MeanSD MeanSD t p

Systole Pre-test – Post-test 18.0611.14 5.3111.32 3.210 0.003*

Diastole

Pre-test – Post-test 8.447.11 4.4413.26 1.063 0.296*

*independent t-test

Effects of deep breathing exercise and active range of motion on respiratory rate in

CHF patients

The analyses of the effect of deep breathing exercise and active range of motion on the

respiratory rate of CHF patients in the intervention group and control group can be seen

in Table 4 and Table 5. Table 4 shows that respiratory rates in the intervention group

decreased significantly (p=0.003) compared to the control group (p=0.417).

Nurse Media Journal of Nursing, 10(1), 2020, 62

Table 4. Differences in respiratory rates of CHF patients (n=32)

Respiratory Rate Control Group Intervention Group

MeanSD t p MeanSD t p

Pre-test 27.002.31 0.835 0.417

25.443.14 3.503 0.003*

Post-test 26.003.72 22.441.36

*paired t-test

The decrease in respiratory rates in the intervention group (3.00+3.43) was higher than

the control group (1.00+4.79). However, there was no significant difference in the

respiratory rates between the intervention and the control group (p=0.184). This meant

that deep breathing exercises and active range of motion were less effective at reducing

respiratory rates than the hospital-based interventions (Table 5).

Table 5. Effect of deep breathing exercise and active range of motion on the respiratory

rate in CHF patients (n=32)

Respiratory rates Intervention Group Control Group

MeanSD MeanSD t p

Pre-test – Post-test 3.003.43 1.004.79 1.359 0.184*

*independent t-test

DISCUSSION

Effects of deep breathing exercise and active range of motion interventions on

physiological response: Blood pressure in CHF patients

The results of this study showed that deep breathing exercises and active range of

motion significantly decreased the systole, but the diastole compared to the standard

care from the hospital. The results of previous studies also showed similar results that

breathing exercises were able to reduce systolic blood pressure by 3 mmHg (p=0.021)

and diastolic pressure by 6.2 mmHg (p=0.000) in patients with heart failure within 14

days (Sepdianto & Maria, 2013). Another research also revealed that three-week breath

exercises were capable of decreasing systolic 5.90.8 (p<0.001) and diastolic 1.40.8

(p<0.005) (Lee et al., 2003). A study conducted by Joseph et al. (2005) also showed that

controlled breathing decreased systolic and diastolic from 149.77±3.7 to 141.1±4 mm

Hg (p<0.05) and from 82.7±3 to 77.8±3.7 mm Hg (p<0.01). Futhermore, Jewiss et al.

(2016) also pointed out that physical exercise could increase oxygen saturation and

quality of life of patients with heart failure.

Deep breathing exercises in patients with heart failure can improve cardiac autonomic

regulation and decrease the sensitivity of chemoreceptors. This exercise will increase

left ventricular ejection fraction, decrease pulmonary pressure, and decrease pulmonary

edema. This may be due to an increased ventilator mechanism due to the regulation or

modulation of cardiopulmonary reflex (Parati et al., 2008). In addition, a range of

motion is a physical exercise that can affect blood pressure because the efficiency of the

heart or the ability of the heart will increase in accordance with the changes that occur

in the form of heart frequency, stroke contents, and bulk heart. Regular physical

exercise is done 3-5 times a week with a long exercise of 20-60 minutes once exercise,

Nurse Media Journal of Nursing, 10(1), 2020, 63

and it can lower blood pressure. The decrease in blood pressure, among others, occurs

because the blood vessels undergo dilation and relaxation (Arovah, 2010; Badriyah,

Kadarsih, & Yogyakarta, 2014). The finding showed that there was no significant

difference in the diastole between the intervention and the control group. This

insignificant difference might due to the small sample size.

Effects of deep breathing exercise and active range of motion interventions on

physiological response: Respiratory rate in CHF patients

The result shows that deep breathing exercises and active range of motion decreased

respiratory rates, although the decrease was not statistically significant compared to the

control group. This was consistent with previous studies. A study showed that breathing

exercise could decrease the frequency of breath (p<0.001) (Sepdianto & Maria, 2013).

Joseph et al. (2005) also reported that controlled breathing decreases respiratory rates

with p <0.05.

Respiratory exercises are performed to improve ventilation and oxygenation. Increased

lung compliance during respiratory exercise may cause the amount of air entering the

lungs to increase, resulting in lower respiratory frequency. Needs of oxygen are met

then the tolerance to the activity will increase. Decreased frequency of breathing after

intervention proves that there is an improvement in respiratory function. Breathing

exercises can optimize lung development and minimize the use of respiratory muscle.

By doing regular breathing exercises, the respiratory function will improve. It was

found to be optimal for improving alveolar ventilation in terms of increased arterial

oxygen saturation and ease and sustainability in terms of respiratory effort (Russo,

Santarelli, & O’Rourke, 2017).

Slow respiration in healthy humans reduces the chemoreflex response to hypercapnia

and hypoxia. Deep breathing can improve lung development capability and affect

perfusion and diffusion functions so that the oxygen supply to the tissues is adequate.

Lower pressure on the intrathorac will cause air to flow from the more atmospheric

pressure high entry into the lungs that have lower pressure as a gas exchange process or

lung ventilation (Cahalin & Arena, 2105).

Moreover, physical exercise will affect oxygen consumption and carbon dioxide

production. A large amount of oxygen will diffuse from the alveoli into the venous

blood back to the lungs. Conversely, the same levels of carbon dioxide enter from the

blood into the alveoli (Jewiss et al., 2016). Thus, ventilation will increase to maintain

appropriate alveolar gas concentrations to allow for increased exchange of oxygen and

carbon dioxide. As the exercise progresses, increased metabolic processes in the muscle

produce more heat, carbon dioxide, and hydrogen ions. This whole factor increases the

oxygen utilization in the muscle, which increases arterial oxygen as well. This results in

more carbon dioxide entering the blood, increasing the levels of carbon dioxide and

hydrogen ions in the blood. Chemoreceptor stimulates the inspiratory center resulting in

increased breathing and depth. Some researchers have suggested that chemoreceptor in

the muscle may also be involved that is by increasing ventilation by increasing tidal

volume. However, after the resting phase, the need for oxygen in the blood will be

Nurse Media Journal of Nursing, 10(1), 2020, 64

fulfilled to lower the frequency of breathing (Nagaya, Hayashi, Fujimoto, Maruoka, &

Kobayashi, 2015).

The result of the study showed an insignificant decrease in the respiratory rates between

the intervention and the control group. This might occur due to the short duration of the

intervention time and the affecting factors which could not be totally controlled. Despite

the limitations, this study could show the evidence that deep breathing exercises and

active range of motion decreased the systole, diastole, and respiratory rates.

CONCLUSION

The study found that deep breathing exercises and active range of motion reduced the

systole, diastole, and respiratory rates. However, the reduction in the systole was the

only statistically significant finding compared to the diastole and respiratory rates.

Although there was no significant difference in diastole and respiratory rates between

the intervention and the control group, the intervention group showed better value than

the control group. Further research on the effects of deep breathing exercise and active

range of motion is recommended to conduct by extending the intervention time and

utilizing a larger sample size.

ACKNOWLEDGMENT

The researchers would like to thank all those people and participants who were involved

in contributing to this study.

CONFLICT OF INTEREST

The authors declare that they have no conflict of interest.

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Nurse Media Journal of Nursing, 10(1), 2020, 66-75 Available online at http://ejournal.undip.ac.id/index.php/medianers

DOI: 10.14710/nmjn.v10i1.25231

A Comparison of Patient Safety Competencies between

Clinical and Classroom Settings among Nursing Students

Rizqi Amilia1, Devi Nurmalia2

1Student of Department of Nursing, Faculty of Medicine, Universitas Diponegoro, Indonesia

2Department of Nursing, Faculty of Medicine, Universitas Diponegoro, Indonesia

Corresponding Author: Devi Nurmalia (devinurmalia@lecturer.undip.ac.id)

Received: 14 February 2020 Revised: 26 April 2020 Accepted: 27 April 2020

ABSTRACT

Background: As nurses play an important role in the implementation of patient safety

in hospitals, competencies of patient safety should be developed and enhanced among

nursing students. Self-assessment is a method that can be used to assess patient safety

and its dimensions to help the students prepare themselves before entering the work life.

Purpose: This study aimed to investigate differences in patient safety competencies

between the classroom and clinical settings among nursing students using a self-

assessment method.

Methods: A descriptive study using the Health Professional Education in Patient Safety

Survey (H-PEPSS) questionnaire was conducted among 181 nursing students in a public

university in Indonesia. Paired t-test, ANOVA, and independent t-test were performed

to determine the comparison in the values of patient safety dimensions across the

classroom, clinical learning, and year of nursing course.

Results: Nursing students showed a higher mean value in the classroom setting than in

the clinical setting. Out of the seven dimensions of patient safety competencies,

“clinical safety” (M=4.36) and “communicate effectively” (M=4.29) obtained the

highest score in the classroom setting, while “adverse events” showed the lowest

(M=4.03). In the clinical setting, “clinical safety” (M=4.19) and “communicate

effectively” (M=4.12) obtained the highest score, while “working in teams” (M=3.82)

was the lowest. The third-year students showed a better score than the fourth year in

most dimensions.

Conclusion: In this study, the patient safety competencies among nursing students were

higher in the classroom setting than in the clinical setting. It is recommended to

investigate the factors that can increase the achievement of patient safety competence

among nursing students in the clinical setting.

Keywords: Patient safety competences; self-assessment; nursing students

How to Cite: Amilia, R., & Nurmalia, D. (2020). A comparison of patient safety

competencies between clinical and classroom settings among nursing students. Nurse

Media Journal of Nursing, 10(1), 66-75. doi:10.14710/nmjn.v10i1.25231

Permalink/DOI: https://doi.org/10.14710/nmjn.v10i1.25231

http://ejournal.undip.ac.id/index.php/medianers

Nurse Media Journal of Nursing, 10(1), 2020, 67

BACKGROUND

Patient safety is a significant health issue to discuss. It is an essential requirement in the

assessment of hospital accreditation nowadays. The Joint Commission International

(JCI) employs patient safety as one of the hospital’s international standards (The Joint

Commission, 2018). In addition to accreditation regulations, increased awareness of

patient safety is also applied by the World Health Organization to service providers as

well as health professional education institutions with the presence of a Patient Safety

Curriculum Guide (Usher et al., 2017; World Health Organization, 2011). The effort is

made to provide safe health services for patients.

Nurses, as a part of health workers, have an essential role in the implementation of

patient safety. Nurses are the most significant number of health workers so that their

roles in identifying, deciding, and correcting medical errors are significant (Attree,

Cooke, & Wakefield, 2008; da Costa, Santos, Junior, Vitor, de Oliveira Salvador, &

Alves, 2017; Kim, Jeong, & Kwon, 2018; Lukewich et al., 2015). A large number of

nurses also has direct implications on patient safety and error prevention strategies (da

Costa et al., 2017). Therefore, nurses are required to carry out the care that is safe for

patients. Due to the importance of implementing safety measures, patient safety

education is required to be organized for all health workers.

Education plays an important role in the efforts made to implement patient safety. As a

result, the health departments are triggered to collaborate with educational institutions in

the delivery of patient safety education (da Costa et al., 2017; Steven, Magnusson,

Smith, & Pearson, 2014). This collaboration is carried out as a preventive effort since

students who undertake clinical education will also provide services to patients. One of

the ways for educational institutions to improve the quality of the implementation of

patient safety is to develop competencies among the students. Competence is important

to learn and develop as students have not been fully exposed to patient safety behavior

(da Costa et al., 2017; Mansour, 2015; Tella, Liukka, Jamookeeah, Smith, Partanen, &

Turunen, 2013).

Delivering patient safety competencies in the classroom is very important for student

nurses, especially for the application in the practice area. Education in the classroom

will have a significant impact on behavior that will arise in the realm of the clinic

(Colet, Cruz, Otaibi, & Qubeilat, 2015; Mansour, 2015; Mansour, Skull, & Parker,

2015; Usher et al., 2017). Education provides not only theoretical knowledge but also

awareness related to actual practice areas (Pearson & Steven, 2009). One of the patient

safety competencies in health professional education is the Canadian Patient Safety

Institute (CPSI) framework (CPSI, 2009). The points in patient safety competencies are

taught in health education institutions in Indonesia. Patient safety competencies need to

be assessed even though they are not used as a graduation requirement.

One way to assess an individual’s competence is by using the self-assessment method.

Self-assessment can be useful as a way of identifying strengths and weaknesses to

achieve desired goals (Eva & Regehr, 2005; Wolff, Santen, Hopson, Hemphill, &

Farrell, 2017). Identification of strengths can lead to a sense of confidence to carry out

tasks and plannings without obstacles and doubts. Meanwhile, identification of

Nurse Media Journal of Nursing, 10(1), 2020, 68

deficiencies can help balance abilities and find ways to overcome deficiencies

(Kajander-Unkuri et al., 2014; Stan & Manea, 2015; Usher et al., 2018; Wolff et al.,

2017). Self-perception is affected by many things; one of them is a long time studying.

Research shows that the period of study in the classroom and clinical settings affect the

implementation of patient safety competence. A previous study showed that third-year

students have better self-perception of managing safety risks than the second-year ones

(Usher et al., 2017). Another study reported a different finding that lower year students

have better self-perceptions than higher year students regarding patient safety

competence (Lukewich et al., 2015).

Studies related to patient safety competence in Indonesia are rarely found. A few studies

investigated patient safety performance in general and not specific in the classroom or

clinical settings (Sari, 2015). A study investigating all aspects of patient safety

competencies (Julianto, Thiangchanya, & Boonyoung, 2014), as similar to the present

study, was conducted among hospital nurses, not students. Therefore, this study is

important to provide baseline data for informing and evaluating patient safety

competence concepts among nursing students in the classroom and clinical settings.

PURPOSE

The purpose of this study was to investigate the differences in patient safety

competencies between the classroom and clinical settings among nursing students.

METHODS

Design and samples

This study used a descriptive method with an online survey. The samples were nursing

students at the undergraduate program and professional program in a public university

in Indonesia who had undertaken clinical practices in the hospital for at least six months

and agreed to participate. The total samples were 181 students, consisting of 63 third-

year students, 69 fourth-year students, and 49 professional nursing students. Stratified

random sampling was used to select the samples.

Ethical consideration

This study was approved by the research ethics committee from the Faculty of Medicine

Diponegoro University and Dr. Kariadi Hospital (No. 538/EC/FK-RSDK/VII/2018).

Instrument and data collection

Data were collected using Google forms that were distributed to the students by the

assistance of students’ peer coordinators. The first page on the online form contained

information regarding the objectives and benefits of the study, as well as informed

consent and procedures on how to fill out the questionnaire.

This study used the 2012 version of the Health Professional Education in Patient Safety

Survey (H-PEPSS) developed by Dr. Liane Ginsburg from Canada. This instrument was

designed as a self-assessment tool to find out knowledge and self-assessment related to

six socio-cultural aspects of patient safety in classroom and clinical learning. The

domain includes working in teams (6 questions), communicating effectively (3

questions), management of safety risks (3 questions), human and environmental

Nurse Media Journal of Nursing, 10(1), 2020, 69

understanding (3 questions), adverse events (4 questions), and culture of safety (4

questions). In addition to these six domains, there is another domain, clinical safety,

which is a depiction of the daily clinical activities undertaken. Questions were assessed

using a Likert scale from 1 (strongly disagree) to 5 (strongly agree). This instrument

was chosen because of its wide scope in the healthcare profession for those who have

just graduated, nearing completion of the professional education process, or

undergraduate students (Usher et al., 2017).

This instrument is originally in English. A back-to-back translation was conducted from

English to Indonesian, and vice versa. The Cronbach’s alpha scores showed 0.81 for

classroom learning and 0.85 for clinical learning (Ginsburg, Castel, Tregunno, &

Norton, 2012). In 2017, Usher tested the questionnaire and obtained higher scores than

the original value of 0.885 for classroom learning and 0.892 for clinical learning (Usher

et al., 2017). Other questions in the questionnaire asked about demographic data which

include gender, age, and year of the study. The completion of the questionnaire took 10-

15 minutes.

Data analysis

Statistical analysis was performed using SPSS with p<0.05 as a significant value.

Demographic data were processed using descriptive statistical analysis. In addition, the

differences between study years and patient safety dimensions were analyzed using the

paired t-test, ANOVA test, and independent t-test.

RESULTS

Characteristics of respondents

The number of respondents who completed the questionnaire was 181 in total. A

majority of them were fourth-year students (38.1%) and females (91.2%) (Table 1).

Table 1. Characteristics of respondents

No Students’ characteristics f %

1 Student group:

Professional program students 49 27.1

4th

-year students (2014) 69 38.1 3

rd-year students (2015) 63 34.8

2 Gender

Female 165 91.2

Male 16 8.8

Dimensions of patient safety in the classroom and clinical learning

Table 2 shows that students have different scores of patient safety domains in the

classroom setting and the clinical setting for most domains. The results were significant

except for human and environmental factors and adverse events. The highest two mean

scores in the classroom and clinical setting were clinical safety and communicate

effectively. Besides, the lowest score, both in the classroom and clinical learning, was

the adverse events.

Nurse Media Journal of Nursing, 10(1), 2020, 70

Table 2. The comparison of the score in the classroom – clinical learning

Patient safety domain Setting N M SD p-value

Clinical safety Class 132 4.36 0.60 0.002*

Clinic 181 4.19 0.69

Working in teams Class 132 4.06 0.58 0.000*

Clinic 181 3.82 0.70

Communicating Class 132 4.29 0.51 0.000*

Clinic 181 4.12 0.65

Managing safety risks Class 132 4.08 0.59 0.010*

Clinic 181 3.97 0.63

Human and

environmental

Class 132 4.08 0.62 0.173

Clinic 181 4.01 0.69

Adverse events Class 132 4.03 0.56 0.003*

Clinic 181 3.87 0.65

Cultural safety Class 132 4.06 0.63 0.086

Clinic 181 3.98 0.69 *indicates a significant value

Table 3 shows that the third-year students’ classroom learning had a higher mean value

than the fourth-year ones except for the domains of clinical safety, managing safety risk,

and culture of safety. However, in classroom learning, the significant value was only in

the domains of managing safety risk and culture of safety.

Table 3. The comparison of the scores in classroom learnings among student groups

Patient safety Domain

Classroom Learning

3rd

year 4th year t-test

M (SD) M(SD) p

Clinical safety 4.3 (0.6) 4.4 (0.5) 0.659

Working in teams 4.1 (0.4) 3.9 (0.6) 0.077

Communicating 4.3 (0.5) 4.2 (0.5) 0.070

Managing safety risks 4.0 (0.6) 4.2 (0,5) 0.004* Human and environmental 4.1 (0.5) 4.0 (0.7) 0.118

Adverse events 4.1 (0.5) 4.0 (0.6) 0.102

Cultural safety 4.0 (0.7) 4.1 (0.5) 0.020* *indicates a significant value

Table 4 shows the difference in clinical learning between each student group. The

results showed that clinical students (professional program) had the highest mean values

in all domains, followed by third and fourth-year students. The results of self-

assessment in this clinical learning were found to be significant in all domains.

Nurse Media Journal of Nursing, 10(1), 2020, 71

Table 4. The comparison of the scores in clinical learnings among student groups

Patient safety domains

Clinical Learning

3rd

Year 4th Year

Clinical

students ANOVA

M(SD) M(SD) M(SD) F p

Clinical safety 4.2 (0.7) 4.1 (0.6) 4.5 (0.4) 5.66 0.004 Working in teams 4.0 (0.5) 3.6 (0.8) 4.1 (0.5) 9.29 0.000

Communicating 4.3 (0.5) 3.9 (0.7) 4.4 (0.5) 9.18 0.000

Managing safety risks 4.1 (0.6) 3.8 (0.6) 4.1 (0.6) 5.29 0.006 Human and environmental 4.1 (0.6) 3.9 (0.8) 4.2 (0.6) 3.89 0.022

Adverse events 4.0 (0.6) 3.8 (0.7) 4.1 (0.5) 5.70 0.004

Culture of safety 4.1 (0.6) 3.9 (0.8) 4.2 (0.5) 5.28 0.006

DISCUSSION

This study aimed to investigate the differences in patient safety competencies between

classroom and clinical settings among nursing students. The results of self-assessment

showed that differences between the classroom and clinical learning were evident. The

clinical safety and effective communication dimensions were the two highest scores in

the classroom-clinical learning. Meanwhile, dimensions of recognizing and responding

to adverse events, working in teams, and cultural safety showed low self-perceptions.

Academic education is organized to provide theoretical and skill preparations, while

clinical education helps students have direct experience to make decisions related to the

actual condition of patients according to the knowledge that has been learned in class

(Aktaş & Karabulut, 2016). Previous studies have shown that if the quality of clinical

learning increases, motivation in academic learning also increases (Aktaş & Karabulut,

2016; Arkan, Ordin, & Yılmaz, 2018). The success of clinical learning is influenced by

various factors such as individual factors, clinical instructors, academic instructors, and

physical environment (Günay & Kılınç, 2018). Personal experience is an individual

factor that affects the success of clinical learning. What might have happened is a

failure to connect the theoretical science taught in classroom learning to the clinical

realm (Arkan et al., 2018). Students may receive broad theoretical knowledge from the

school, but they cannot apply the knowledge obtained in actual practice (Günay &

Kılınç, 2018).

The study found that fourth-year students had lower self-ratings related to patient safety

competencies than the third-year students in all dimensions of patient safety. These

results indicated that lower year students have a higher rating than those students with a

higher academic year. The same case is also found in some studies reporting that lower

year students have higher self-assessment scores than the higher ones (Duhn, Karp, Oni,

Edge, Ginsburg, & VanDenKerkhof, 2012; Kajander-Unkuri et al., 2014). Such a

situation may happen due to a lack of students’ understanding related to patient safety,

causing ignorance when there is something missing from the understanding and actions

taken (Duhn et al., 2012; Ng et al., 2017; Sullivan, Hirst, & Cronenwett, 2009). Gaps

between academic and clinical knowledge also influence the way a person views patient

safety issues (Usher et al., 2017). These theories explain why third-year students have

Nurse Media Journal of Nursing, 10(1), 2020, 72

better self-assessments since they have not gone through clinical experiences as much as

fourth-year students.

This study also found that students had excellent results of self-assessment in the

clinical safety domain both in the classroom or clinical learning. This domain is a non-

sociocultural aspect that focuses on hand hygiene and infection control (Ginsburg,

Tregunno, & Norton, 2013). This result shows that students understand well every

aspect of clinical safety that they have learned since the beginning of their study.

Another reason is that this material is very popular in the health promotion programs

that students present as counseling materials in the community (Duhn et al., 2012).

The results also showed that effective communication was highly rated in this study.

This result is consistent with a previous study reporting that nursing students have a

good assessment of effective communication skills (Duhn et al., 2012; Ginsburg et al.,

2013). Students judged themselves to be able to carry out effective communication,

especially to patients. Previous research stated that new nurses have confidence in their

ability to communicate with doctors, patients, and families over time (between 6 – 12

months). In this study, students have previously gone through clinical practice for a

cumulative duration of six months (Pfaff, Baxter, Jack, & Ploeg, 2014).

Students showed a lack of self-assessment on recognizing and responding to adverse

events, working in teams, and cultural safety. The domain of working in team focuses

on managing inter-professional conflicts, power-sharing, and team dynamics (CPSI,

2009). This study showed similar results to previous research by Ginsburg, reporting

that nurses have the lowest self-assessment in clinical settings compared to other health

workers (pharmacy and doctor) (Ginsburg et al., 2013). One of the reasons causing a

decrease in self-assessment in clinics is the low self-assessment of students in managing

conflicts between professions. This conflict generally arises due to the paradigm of the

dominance of the medical profession in health organizations (Sollami, Caricati, &

Mancini, 2018). However, this paradigm can be slowly reduced by the existence of

interprofessional education programs that emphasize the alignment of the health

profession in dealing with patients (Labrague, McEnroe – Petitte, Fronda, & Obeidat,

2018; Sollami et al., 2018).

This study has limitations. Not all respondents in the study completed the questionnaire

for both classroom and clinical assessment due to time constraints. Further research

should consider longer period of time for data collection. A study about factors affecting

self-assessment patient safety competence could be taken into account to help identify

practical solutions to develop better learning programs/curricula.

CONCLUSION

This study revealed that the patient safety competencies of nursing students were higher

in the classroom setting than that in the clinical setting. The patient safety competencies

need to be improved in the education system through supervision and control. The

curriculum needs to consider more learning on other aspects of patient safety, such as

recognizing and responding unwanted events. Effective education and teaching should

also be promoted to enhance higher inter-professional skills and communication skills

Nurse Media Journal of Nursing, 10(1), 2020, 73

among nursing students. Future studies may consider to investigate the factors that

increase patient safety competence among nursing students in the clinical setting.

ACKNOWLEDGMENT

The researchers would like to thank the students for their participation in this study.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

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Nurse Media Journal of Nursing, 10(1), 2020, 76-85 Available online at http://ejournal.undip.ac.id/index.php/medianers

DOI: 10.14710/nmjn.v10i1.29056

Casey-Fink Graduate Experience Survey for Nurses and

Preceptors in the Kingdom of Saudi Arabia

Omar Ghazi Baker1, Musaad Salem Alghamdi2

1 Associate Professor, College of Nursing, King Saud University, Riyadh, Kingdom of Saudi Arabia

2 Quality and Patients Safety Director, Prince Mishari bin Saud Hospital, P.O. Box: 440,

Baljurashi 22888, Saudi Arabia

Corresponding Author: Omar Ghazi Baker (obaker70@gmail.com; obaker@ksu.edu.sa)

Received: 12 March 2020 Revised: 19 April 2020 Accepted: 22 April 2020

ABSTRACT

Background: Preceptors play an essential role in supporting new nurses during the

transitional period in professional roles. Moreover, graduated nurses experience several

challenges during their transitional role from students to professional nurses, despite of

the considerable relationship between nurses and preceptors.

Purpose: The study aims to evaluate the relationship between the experiences of nurses

using Casey-Fink Graduate Nurse Experience Survey and the number of preceptors in

Saudi hospitals.

Methods: A cross-sectional study design was adopted, and Casey-Fink Graduate Nurse

Experience Survey was used to collect data from 84 newly graduated nurses.

Descriptive and regression analysis was used for data analysis.

Results: Results showed that there was no statistically significant relationship between

the responses of 5 factors of Casey-Fink Graduate experience survey and the number of

preceptors. Based on the survey, (33.8%) had stress whereas significant causes of stress

were student loan (41.9%), personal relationships (13.5%), living situation (27%), and

finances (10.8%).

Conclusion: No statistically significant relationship was found between variables

including; support, patient safety, communication/leadership, professional satisfaction

and job satisfaction. The significance of preceptorship programs should be considered

by the primary health care corporation to support and prepare preceptors of newly

graduated and recruited nurses.

Keywords: Communication; learning; nurses; preceptors; Kingdom of Saudi Arabia

How to cite: Baker, O. G., & Alghamdi, M. S. (2020). Casey-Fink graduate experience

survey for nurses and preceptors in the Kingdom of Saudi Arabia. Nurse Media Journal

of Nursing, 10(1), 76-85. doi:10.14710/nmjn.v10i1.29056

Permalink/DOI: https://doi.org/10.14710/nmjn.v10i1.29056

BACKGROUND

Health and education programs rely on preceptors to facilitate preceptees’ transition

from students to professional nurses. The preceptorship relationship has a significant

caring component, even though proficiency and experience are essential. The

http://ejournal.undip.ac.id/index.php/medianers

mailto:obaker70@gmail.com;%20obaker@ksu.edu.sa

Nurse Media Journal of Nursing, 10(1), 2020, 77

relationship between nurses and preceptors reflects caring expressed through kind words

and actions. Supportive and caring preceptor workforce can help in the transition of

student nurses into experts by improving their sense of belonging in the nursing

profession (Omer & Moola, 2019). The transition of graduated nurses is importantly

handled in preceptorship programs that are able to provide safe and competent patient

care, leading towards the increase in retention of newly graduated nurses, and improve

the quality of care (Arbabi, Johnson, & Forgrave, 2018). Kim and Kim (2019) outlined

that the preceptor’s personality attributes such as self-efficacy, and leadership qualities

as significant characteristics that help in the successful transition of new nurses into

professional nurses.

The health sectors around the world are experiencing a shortage of healthcare workforce

(Haddad & Toney-Butler, 2019). This is evident from the report of the World Health

Organization (WHO) which estimated a shortage of 12.9 million by 2035 (World Health

Organization, 2013). Despite of significant relationship between nurses and preceptors,

graduated nurses experience several challenges during their transitional role from a

student to a professional nurse. Similar issues are encountered by experienced nurses

when entering to new workplace to be oriented to an unrecognized work environment. It

is assumed that the role of preceptors is vital to support new nurses during the

transitional period in professional roles (Borimnejad, Valizadeh, Rahmani, Shahbazi, &

Mazaheri, 2016).

Wong et al. (2018) conducted a study to identify the challenges encountered by the

nursing graduates during their transition period. Rush, Adamack, Gordon, Lilly, and

Janke (2013), on the other hand, highlighted that increased support from peers, mentors

and preceptors are significant in positively influencing the transition period of nurses.

Trained preceptors were also identified in creating a positive influence on the newly

graduated preceptor relationship. The role of the preceptor is expanding from

facilitation to support, coaching as well as positive role modeling for the formation of a

constructive environment. The corresponding relationship between nurses and their

preceptors provide them the opportunity to guide and encourage fresh nurses to

efficiently perform their respective roles and responsibilities, leading towards

improvement in skills and ultimate satisfaction in their jobs. Kamolo, Vernon, and

Toffoli (2017) outlined that team collaboration, communication, and an increase in

individual confidence are the ultimate benefits of preceptorship. The implementation of

the nursing preceptor has proved to be beneficial for the nurses’ retention, contributing

to the increased rate of 90% (Rush et al., 2013).

Certain factors such as the difference in focus, level of independence in practice, and

structure, and the experiences of the graduated nurses’ preceptors can be different from

those of experienced nurses, since most of the fresh nurses experience professional

isolation, lack of support from experienced staff and professional discrimination

(Alboliteeh, Magarey, & Wiechula, 2018). It has been suggested to assist students with

increased preceptorship and professional support, to make them confident enough for

their acquired knowledge along with decision-making skills.

Nurse Media Journal of Nursing, 10(1), 2020, 78

Recently, changes in the healthcare system are increasingly made, as new methods and

technology of care delivery are continuously developed. The burden of these changes on

staff, especially on nurses is observed by healthcare managers, along with the increased

safety risks to introduce new graduates (Schultze, 2017). Nursing schools fall upon

healthcare institutions for providing continuing education according to the need of new

graduates and fundamental skills of nursing care. They also provide a nurturing and

supportive environment to assure those newly graduated nurses become safe and

competent members of the healthcare team. This gives rise to the researchers’ interest in

investigating the topic concerning different domains.

Preceptorship needs to be explored as an essential phenomenon in the nursing

profession to improve their knowledge and perceptions regarding the preceptor’s roles.

According to Casey, Fink, Krugman, and Propst (2004), mostly graduated nurses do not

have the appropriate skills and competence which makes them incompetent in fulfilling

their responsibility to provide safe patient care based on several factors. These factors

include increasing turnover of the experienced graduated nurses, burnout, high-acuity

level, increasing workload demands, excessive use of contract labour, and decreasing

graduated nurses’ orientation. The overall discussion indicates that the problem is

highly critical and is associated with multiple factors. Therefore, investigation of the

topic concerning certain regions is crucial to improve healthcare quality.

Therefore, the study intends to evaluate the relationship between experiences of nurses

and preceptors using Casey-Fink Graduate Nurse Experience Survey in Saudi Arabian

hospitals. Rationale behind the selection of the region is based on its reported high

turnover rates. The study results are assumed to be helpful for nursing leaders in the

development of an effective transitional program, improving newly graduated nurse’s

satisfaction as well as providing a meaningful experience. One of the main contributions

of this study is the use of the Casey-Fink graduate experience questionnaire to

determine the relationship between nurses’ experience and preceptors in Saudi Arabian

hospitals. To the best of the author’s knowledge, this is the first study to explore this

objective using the Casey-Fink Graduate Experience questionnaire.

METHODS

Research design

The cross-sectional study design was employed to determine the relationship between

experiences of nurses and preceptors in the hospitals of Saudi Arabia. In this context, a

survey approach has been used to collect data prospectively from graduated nurses. The

study was conducted in 9 different hospitals of Al-Bahah region, Saudi Arabia.

Samples

The study targeted graduate nurses working with the experience of minimum 6 months

and a maximum of 2 years in Saudi Arabian hospitals. Since the researcher is a resident

of Al-Bahah region, the study was conducted in 9 general and public hospitals of Al-

Bahah region of Saudi Arabia. These hospitals include King Fahad Hospital, Prince

Mishari bin Saud Hospital, Almakwah Hospital and Al Mandaq General Hospital, Al

Aqiq General Hospital, Buljurshi Psychiatric, Gilwah General Hospital, Naqaha

Hospital, and Al Qara General Hospital. Limited nurses were working in these hospitals

Nurse Media Journal of Nursing, 10(1), 2020, 79

so a sample size of 80 was achieved based on 104 as population, 95% confidence level,

and 5% confidence interval. The selection of the graduated nurses was based on their

correspondence to the inclusion criteria.

Instrument

A prospective data collection approach was used to collect data from the targeted

graduated nurses. Casey-Fink Graduate Nurse Experience Survey was used in the study.

The selection of the tool is based on its utilization in previous research (Cline, La

Frentz, Fellman, Summers, & Brassil, 2017; Rush et al., 2013). This tool was originally

proposed by Kathy Casey and Regina Fink to measure newly licensed registered nurses’

comfort with skills over time (Casey et al., 2004). The Cronbach alpha coefficient for

the overall questionnaire (24 items) was 0.89. This questionnaire comprises of 5 factors,

which include support (α=0.90), communication/leadership (α=0.75), patient safety

(α=0.79), stress (α=0.71), and professional satisfaction (α=0.83). A 5-point Likert scale

was used to measure the factors from very unlikely to very likely.

Data analysis

Data collected were analyzed using the Statistical Package for Social Sciences (SPSS)

IBM version 20.0. Descriptive statistics such as mean, standard deviation, frequencies,

and percentages were employed for describing and categorizing the variables. Along

with it, regression analysis was applied for quantifying the relationship between Casey-

Fink Graduate Nurse experience survey factors and the number of preceptors. The p-

value of <0.05 was determined for demonstrating results’ significance statistically.

Ethical considerations

The deanship of postgraduate studies at King Saud University approved this study. The

Institutional Review Board (IRB) for the College of Medicine at King Saud University

granted the approval for conducting this study. Before the performance of the research,

a written letter and a copy of the sample were submitted to the clinical administration

for providing relevant information about the study. Along with it, study objectives,

confidentially and anonymity were also communicated to the participants followed by

the gathering of the written consent. One week’s time period was provided to the

participants for completing and submitting the survey to the nursing directors. The

completed surveys were then collected by the researchers.

RESULTS

Results showed that out of 80 participants, 41 were males and 39 were females with a

mean age of 26.48. Each nurse has mostly 1-2 preceptors (69%) during their orientation

(Table 1).

Table 1. Profile of participants

Characteristics f %

Age (M=26.48; SD=3.01)

Gender

Male 41 51.25 Female 39 48.75

Nurse Media Journal of Nursing, 10(1), 2020, 80

Characteristics f %

Nationality

Saudi 80 100

Number of preceptors 0 2 2.5

1-2 55 69

3-5 15 18.5

>5 8 10

The responses of nurses towards the five factors of Casey Fink Graduate Nurse Survey

which was measured on 5-point Likert scale response indicating that “1” represents

“very unlikely” and “5” is used for “very likely” showed the mean values ranges from

2.53 to the factor of organizing prioritizing patient safety and 3.27 to the factor of

professional satisfaction. The average number of preceptors in our study subjects was

almost 2 (Table 2).

Table 2. Descriptive statistics of different factors of Casey-Fink Graduate Nurse

Experience Survey and number of preceptors

Factors M SD

Support Organizing Prioritizing patient safely 3.43 0.43 Communication/Leadership Professional

Satisfaction

2.53 0.41

Job satisfaction 3.06 0.52 Number of preceptors 3.27 0.60

Towards the acceptance of experiencing stress in their life and its cause, 15 (15.8%)

agreed, 25 (33.8%) had strongly agreed, whereas, 49 (51.6%) were neutral, and 21

(22.1%) and 10 (10.5%) disagreed and strongly disagreed that they were experiencing

stress in their life. The significant causes of stress were student loans (41.9%), finances

(10.8%), living situation (27%), personal relationships (13.5%), and job performance

(8.1%) (Table 3).

Table 3. Distribution of responses towards level of stress and its causes among nurses

Stress and its causes f %

I am experiencing stress in my life

Strongly disagree 10 10.5

Disagree 21 22.1

Neutral 49 51.6

Agree 15 15.8

Strongly agree 25 33.8

Causes of stress

Finances 8 10.8

Child care 7 9.5

Student loans 31 41.9

Living situation 20 27

Personal relationships 10 13.5

Nurse Media Journal of Nursing, 10(1), 2020, 81

Stress and its causes f %

Job performance 6 8.1

Other 0 0

The relationship between the responses of 5 factors of Casey-Fink Graduate experience

survey by the nurses and the number of preceptors was assessed by using linear

regression analysis. The regression coefficients of each of the five factors (support,

patient safety, stress, communication/leadership, and professional satisfaction) indicate

no statistically significant linear relationship. The R-square values of these five factors

indicate no effect on the dependent variable (number of preceptors) (Table 4).

Table 4. Relationship between different factors of Casey-Fink Graduate Nurse

Experience Survey and number of preceptors

Dependent

variables

Independent variable Regression

coefficient

t-value R-square

value

Support Number of Preceptors -0.002 -0.079 0.000 0.938

Patient safety Number of Preceptors 0.013 0.603 0.004 0.548

Stress Number of Preceptors -0.002 -0.018 0.000 0.986

Communication/

Leadership

Number of Preceptors 0.044 1.395 0.021 0.166

Professional

Satisfaction

Number of Preceptors -0.023 -0.577 0.004 0.565

DISCUSSION

The present study has depicted the relationship between responses of 5 factors of Casey-

Fink Graduate experience survey by the newly graduated nurses and the number of

preceptors. Excessive work load, lack of basic as well as advance professional

knowledge, communication, individual expectations, change of role, work atmosphere,

support from peers and other professional training programs, blame or complaining

culture, and personal attitude are some common challenges faced by the nurses during

their period of transition.

The results depicted that there was no statistically significant relationship between the

responses of 5 factors of Casey-Fink Graduate experience survey by the newly

graduated nurses and the number of preceptors. The factors that support the newly

graduated nurses during their transition period include improved orientation, increased

support, unit socialization and improved work environment. Results also showed that

peer support, patient and families, ongoing learning, professional nursing role and

positive work environment increased their satisfaction with the work environment.

However, factors contributed to the least satisfaction in their working environment

include the nursing work environment, working system, interpersonal relationship, and

orientation.

More than half of the participants in the present study agreed towards experiencing

stress in their life that was caused due to financial issues, living situation, personal

relationships, and job performance. However, a previous study conducted by Hayes et

Nurse Media Journal of Nursing, 10(1), 2020, 82

al. (2006) stated that intention to leave was associated with dissatisfaction with the work

environment (including staffing, support, professional development, responsibility,

quality of care, and physical environment). These results are also consistent with the

study of D’ambra and Andrews (2014) stating that work environment factors play an

important role in experiencing stress and dissatisfaction among the newly graduated

nurses. Besides, work readiness (organizational acumen dimension) of newly graduated

nurses was associated with intention to remain in the current job and this relationship

was mediated by job satisfaction; though, the relationship has not been shown

quantitatively (Walker, 2013). Moreover, Osmo and Landau (2006) stated that job

satisfaction among newly graduated social workers was predicted by the extent to which

respondents felt their degree had prepared them for their job (measured after workforce

entry).

The relationship between preceptor and graduates is a two-way learning and growth

process. Moreover, the newly graduated nurses were expected to take on an active role

in their learning. Results depicted that the relationship between responses of the study

participants about five factors of Casey-Fink Graduate experience survey and the

number of preceptors was not statistically significant. A previous study conducted by

Carlson, Pilhammar, and Wann-Hansson (2010) stated that preceptorship is a strategy

that help in preparing the newly graduated nurses for the reality of practice, where the

integration of theory and practice occur to gain a sense of professional identity in

nursing. The role of preceptorship and preceptor is observed as dynamic, complex,

rewarding, engaging and consuming strategy. Preceptorship not only depends on

preceptors themselves, rather it depends on peers and managers that contribute to the

workplace environment.

The clinical learning among newly graduated nurses is likely to be perceived as a

process that takes place within the existing practices and social relations. Moreover, the

preceptors are responsible for inviting the newly graduated nurses into the community

of practice and help them in navigating these relations and practices. A similar study

was conducted by Yonge (2012) and stated that nurse preceptors serve as influencers,

role models, teachers, friends, assessors, evaluators and supervisors. Therefore, they

need to acknowledge the fact that nursing was their primary responsibility, while

precepting and patient safety was their foremost priority.

The findings of this study can influence academic and clinical education practice. The

level of support, feedback, and encouragement provided by preceptors can enable

educators to utilize these methods as a part of their curriculum. Feedback and

encouragement can be delivered through a pre-licensure curriculum to nursing students

as an approach to instill confidence and validation of practice accuracy. The graduated

nurses should be offered a training program to help them understand their important role

as an evaluator, educator, and role model. The short-term association established

between graduated nurses and preceptors provides attention on learning needs of the

graduated nurses and to develop their confidence in performing their expected roles.

The quality improvement project should be conducted in Saudi Arabian hospitals and

compared to all the graduated nurses’ responses for obtaining generalizability. The

clinical practice of the graduated nurses should be expanded in other clinical nurses of

Nurse Media Journal of Nursing, 10(1), 2020, 83

the hospitals such as the recovery room, wound care department, operating room, and

intensive care unit.

Findings of the present study can be implied to understand the difficulties of transition

for newly graduated nurses to reduce the turnover rate and to support the retention of a

qualified workforce to meet future healthcare needs. Moreover, developmental, role

transition, relational and organizational strategies are likely to enhance the critical

thinking ability, confidence and support of newly graduated nurses. It might also

contribute towards transition, relational and organizational components that are critical

to the transition. Moreover, newly graduated nurses, with their preceptor, should spend

time in the simulation lab putting their hands-on equipment and performing skills.

This study is limited since only certain factors were focused that are associated to the

relationship between nurses’ experience and preceptors. However, due to the small

number of participants, findings of this study cannot be generalized.

CONCLUSION

The results depicted the factors related to the difficulties experienced by the newly

graduated nurses, include role expectations, lack of confidence, workload, fear, and

orientation issues. In the transition period, these nurses must be prepared for the entry-

level practice. The results therefore, concluded that there was no statistically significant

relationship between the responses of 5 factors of Casey-Fink Graduate experience

survey by the newly graduated nurses and number of preceptors. Around half of the

study participants agreed towards experiencing stress in their life. Moreover, the leading

cause of stress among nurses was associated with financial issues, living situation,

personal relationships, and job performance.

Nurse educators and nurse managers have the opportunity for designing an orientation

program that fulfills the needs of the new graduate nurse. It might be essential for

considering how preceptors are used in the program as nursing leaders strive to explore

the most authentic way. Nursing administration must continue to develop competent

nurses as well as retain these nurses for several years of recruitment throughout the

organization.

Future studies should consider mixed-method or longitudinal designs for examining this

phenomenon further. New insights can be obtained through a discussion group with

fresh graduates after the initial interviews related to their experiences, as it may allow

them to share their observations and experiences with the preceptors. Future studies

should also explore the effectiveness of nursing educators to prepare newly graduated

nurses to enter the clinical environment.

ACKNOWLEDGMENT

The authors are thankful to all the associated personnel, who contributed for this study

by any means.

CONFLICT OF INTEREST

None

Nurse Media Journal of Nursing, 10(1), 2020, 84

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Nurse Media Journal of Nursing, 10(1), 2020, 86-95 Available online at http://ejournal.undip.ac.id/index.php/medianers

DOI: 10.14710/nmjn.v10i1.22722

The Experiences of Mothers with Intrauterine Fetal

Death/Demise (IUFD) in Indonesia

Alma Dormian Sinaga1, Justina Purwarini1, Lina Dewi Anggraeni1

1Sint Carolus School of Health Sciences, Jakarta, Indonesia

Corresponding Author: Justina Purwarini (justinearini@gmail.com)

Received: 6 April 2019 Revised: 22 April 2020 Accepted: 27 April 2020

ABSTRACT

Background: Intrauterine Fetal Death/Demise (IUFD) is a traumatic event for mothers.

Mothers with IUFD have the risk of experiencing depression, anxiety, sadness, and

sorrow in their lives. Research focusing on how mothers deal with such a traumatic

experience is therefore necessary.

Purpose: This study aimed to explore the experiences of mothers with Intrauterine Fetal

Death/Demise (IUFD) in Indonesia.

Methods: A descriptive qualitative study with a phenomenological approach was carried

out to seven informants who were recruited using a purposive sampling technique. Data

were collected through in-depth interviews and analyzed using the Colaizzi’s method.

Result: The results showed four major themes, including the mothers’ response to a loss

such as painful and traumatic experience; moral support received by mother; negative

behavior from others such as stigma and lack of support; and physical and psychological

changes that interfere with the role as wife and mother.

Conclusion: The history of IUFD was a very traumatic experience and had quite a high

emotional burden for mothers. Hence, it is necessary to integrate support and therapeutic

communication into practice.

Keywords: Intrauterine fetal death; mothers’ experiences; social support

How to cite: Sinaga, A. D, Purwarini, J, Anggraeni, L. D. (2020). The experiences of

mothers with intrauterine fetal death/demise (IUFD) in Indonesia. Nurse Media Journal

of Nursing, 10(1), 86-95. doi:10.14710/nmjn.v10i1.22722

Permalink/DOI: https://doi.org/10.14710/nmjn.v10i1.22722

BACKGROUND

One of the high risks of the pregnancy is mothers with intrauterine fetal death/demise

(IUFD). According to the American College of Physicians and Gynecologists (2002),

IUFD is a dead fetus in the uterus with a fetus weighing 500 grams that often occurs in

the twentieth week or more of the pregnancy. Furthermore, Cunningham et al. (2014)

stated that perinatal outcome statistics cover fetuses who die and neonates born weighing

500 grams or more.

Data from the World Health Organization (2015) shows that the infant mortality rate

(IMR) in ASEAN (Association of South East Asia Nations) countries such as in Indonesia

http://ejournal.undip.ac.id/index.php/medianers

Nurse Media Journal of Nursing, 10(1), 2020, 87

is 27/1000 live births. Furthermore, the results of the 2015 Interdental Population Survey

(SUPAS) in Indonesia also showed that the total IMR was 22.23/1000 live births, and this

statistic had reached the 2015 MDGs (Millennium Development Goals) target of 23/1000

live births (Depkes, 2015). This statistic should be a concern for not only the government

and health care facilities but also the community to take necessary actions for preventions.

A stillbirth – death or loss of a baby before or during delivery, is a grief event for parents.

Even with a high increase in quality of care in the health sector, there are still significant

cases of IUFD caused by several factors, including mother, fetus and placenta (Kary &

Oraif, 2017). Fetal death is shown by the fact that after separation, the fetus does not

indicate life such as heart rate, umbilical cord pulses, muscle movements, and attempts to

breathe (Patel, Thaker, Shah, & Majumder, 2014). IUFD often causes trauma to the

mother and family. A mother who experiences IUFD is at risk of experiencing depression

and feeling anxiety and sadness or grieving for more than six months. A study of 769

women who experienced IUFD reported that the women received support from families

(91.7%), nurses (90%), and doctors (53.4%). Such support can reduce the level of

depression and anxiety in mothers, while single women, divorced, and widows have a

higher level of depression after experiencing IUFD (Temple & Smith, 2014).

Furthermore, Brierley-Jones, Crawley, Lomax and Ayers (2015) reported that mothers

who experienced IUFD felt that they were still stigmatized and ignored by people around

them. Such condition becomes an emotional burden for the mothers which causes them

to feel depressed and traumatized by the event and result in the disruption of their roles

as mothers. Social stigma and loss of identity are commonly experienced by mothers with

IUFD (Cacciatore, Froen & Killian, 2013; Hill, Cacciatore, Shreffer & Pritchard, 2017;

Murphy, 2012;).

The phenomenon of stillbirth has been widely studied. Fewer studies, however, have been

undertaken on the sociocultural aspects of stillbirth (Cheer, 2016). The struggle of

whether to disclose the stillbirth or not is echoed in the literature by mothers who have

experienced guilt, shame, social isolation, and exclusion from family, friends, colleagues,

and strangers (Brierley-Jones et al., 2015; Cacciatore, 2010; Thompson, 2013). If the

opportunities to share memories of their stillborn babies increases maternal wellbeing, if

there was a social or perceived stigma surrounding stillbirth, and if there was a possibility

of an expected finite grieving period, and overcoming those barriers are necessary to

facilitate sharing opportunities (Keeble & Thorsteinsson, 2018). The mother and their

families perceived stillbirth to be a very sudden, unexpected, confusing, and frustrating

experience, as the exact cause was not explained to them clearly. They attributed various

explanations, including superstitions, biomedical explanations, and blamed various

persons in their lives for the occurrence (Gopichandran, Subramaniam & Kalsingh, 2018).

Additionally, parents report adverse long-term effects on their ability to manage their jobs

and their family life (Ryninks, Roberts-Collins, McKenzie-McHarg & Horsch, 2014).

There is necessity to do research that examines the psychological response of mothers

who experience IUFD, especially the cultures that greatly influences the lifestyle of

pregnant women in Indonesia. Therefore, it is important to conduct such a study and

understand this experience from all sides, including the changes that occur in mothers

with IUFD.

https://www.frontiersin.org/articles/10.3389/fpsyg.2018.01629/full#B9

https://www.frontiersin.org/articles/10.3389/fpsyg.2018.01629/full#B43

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https://www.frontiersin.org/articles/10.3389/fpsyg.2018.01629/full#B7

https://www.frontiersin.org/articles/10.3389/fpsyg.2018.01629/full#B8

https://www.frontiersin.org/articles/10.3389/fpsyg.2018.01629/full#B36

Nurse Media Journal of Nursing, 10(1), 2020, 88

PURPOSE

This study aimed to describe the experiences of mothers with Intrauterine Fetal Death/

Demise (IUFD) in Indonesia.

METHODS

A qualitative phenomenological research design was used in this study. The target

population was mothers who had experienced intrauterine fetal death (IUFD) in South

Lampung District, Indonesia. The participants were recruited using a purposed sampling

method with the most variant samples (Polit & Beck, 2012). They were screened for

eligibility to participate in this study based on the criteria of mothers who had experienced

IUFD for more than six months according to the time in the loss process stage (Videbeck,

2011). The method was suitable because it can see the perspective of the informants to be

interviewed, and through in-depth interviews, researchers can analyze the results of the

meaning developed by mothers who experience IUFD. From the interview results, several

similarities and differences in meaning were identified from some informants. The

interview guidelines to be asked to the mothers were also formulated. The interview guide

is generally more structured than informal conversation interviews, and there is still little

discussion in its composition (Turner, 2010). The questions used in the interview examine

more deeply the informants’ responses to retell what they felt from their experiences of

experiencing IUFD.

The interview was conducted in two cycles. The first cycle was carried out to find data in

full for approximately 45 minutes using the Indonesian language and recorded using a

tape recorder. In the second cycle, the participants were asked to validate the findings of

the interviews. During the interview process, everything encountered by the researchers

was noted. The informants’ expressions, attitudes, and facial expressions when

responding to the questions were included in the interview transcript. The Colaizzi’s

method was used to process and analyze the data assisted by software to obtain themes

and descriptions of the experiences of mother participants.

Prior to the study, the researchers explained the purpose of the study as well as the rights

and obligations as the participants. If they agreed, they signed informed consent. Their

identities were also kept confidential. A code name of I1to I7 was given to the participants

according to the time of participation. The ethical approval of this study was received

from the Ethical Committee of the Sint Carolus School of Health Sciences.

RESULTS

This study involved seven participants who had more than six months of IUFD experience

according to the time in the loss process stage. Most of them were primipara (57.2%) and

aged 26-40 (57.2%). Also, most of them lose their fetus at 8 – 9 months of pregnancy.

Table 1 shows the participant demographic profile of the study.

Table 1. Demographic profile of participants

Demographic profile n %

Age

18 – 25

42.8%

Nurse Media Journal of Nursing, 10(1), 2020, 89

Demographic profile n %

26 – 40 4 57.2%

Parity

Primipara

Multipara

57.2%

42.8%

Age of the fetus at death

6 – 7 months

8 – 9 months

42.8%

57.2%

From this study, four themes were found which presented various experiences of mothers

who experienced IUFD. These themes are discussed separately and interrelated with each

other to reveal the experiences of mothers who experience IUFD and have been identified

based on the research objectives.

Mothers’ response to loss

The first theme developed in this study was the mothers’ response to loss. In this theme,

the informants stated that they had a painful experience when they had an IUFD. They

stated that they felt a very deep sorrow and traumatic about the incident. The forms of

grief experienced by informants included sadness, crying, anger, disappointment, and in

time, the informants could accept the event. Some of the participants’ expressions are

quoted below:

“My reaction is immediately crying while looking at my baby, who had no hope. I

was sad and did not believe that my child had died. I was disappointed as well. I

wish someone had taken care of me at that time, but how else would it all be God’s

will.” (I1).

“I was shocked, and I immediately cried, I couldn’t take it anymore. I was very sad,

angry, and disappointed with myself and blamed myself (laughing in tears). I wish

I did not hear my mother’s words, but I also could not blame my mother. If I said I

was whole-hearted, what I would do, I was not whole-hearted. And I have to be

whole-hearted. Everything has happened, and indeed it is not my child’s fortune.”

(I6).

Furthermore, the informants also revealed a deep trauma to the event. Some of them even

refused and postponed their next pregnancy. Some participants expressed the following:

“When it happened, I was traumatized, Ma’am, I didn’t want to get pregnant again

because it had happened for the third time.” (I5).

“At that time, I was traumatized, whenever I heard baby’s voice, I could not be

happy, I immediately cried, especially when I was in the hospital when someone

next to me had a baby.” (I6).

Moral support received by mothers

The second theme raised the moral support received by the mothers. In this theme, it was

revealed that some informants received support from people closest to them, such as from

the family, medical teams, and community that could help informants’ health recovery.

Assistance received by the mothers can help them passed through the normal grieving

Nurse Media Journal of Nursing, 10(1), 2020, 90

process. Besides, the assistance provided by the medical team, especially nurses, could

help mothers find the meaning of the loss, and the family could understand the conditions

that occurred in mothers with IUFD so that mothers could undergo normal activities.

“The response of the nurses was concerned about my condition; they gave spirit

and hope.” (I1)

“The doctors and nurses are good, always give support to stay strong and not

stressed, and give hope and advice that I take part in the pregnancy program …” (I5)

A family is a group of person who is close to an informant who is always there at all times

in providing support. Support provided by the family was expressed by the informants,

as well as the support they received from the community:

“Husbands and parents are good with me; they are very patient in taking care of

me.” (I4)

“The great strength that I received was from my family …” (I5)

“For families, they are very attentive, especially my husband and child …” (I6)

“People like my neighbors and community are good, they visit me and give

encouragement, support, and prayer …” (I1)

“For good neighbors, I came home from the hospital, and they immediately visited

me to give me support …” (I4)

Negative behaviors from people around the mothers

This theme raised the negative behavior from people around the mothers. In this study,

the mothers perceived that the treatment they received was not good, including from the

family, medical team, and the community, such as getting a negative stigma, rejection,

and even a lack of communication delivered by the nurse.

“The response of the midwife/nurse is normal after the action is done; there is

nothing to say.” (I2, I3)

“The family of my husband (brothers) gave no care about me; instead, they are

becoming suspicious and stay away from me.” (I1)

“…there are people who talk about me, slamming compared to their

experiences….” (I5)

Physical and psychological changes that interfere with the role of wife and mother

This theme raises physical and psychological changes that interfere with the role of wife

and mother, which reveals the changes experienced by mothers after experiencing IUFD.

The informants revealed that many physical and psychological problems occurred so that

they experienced obstacles in carrying out daily activities that interfered with their role

as wife or mother.

“After the incident of fetal death that I experienced, I said I’m unconscious, dizzy,

and tense. I often get sick because I always think of my fetus.” (I1)

“All my needs were met by my husband; my job was replaced by him because I

must not have too much strength and a lot of thoughts because I was often dizzy

and tense.” (I4)

Nurse Media Journal of Nursing, 10(1), 2020, 91

“I often cry, daydream like crazy. I like being sensitive to people and not responding

to them. I often get angry with my husband.” (I1)

“I was traumatized until I didn’t want to see the baby’s clothes and hear the baby’s

voice. I cried myself, often had trouble sleeping, was nervous. I am not excited to

do activities and chat with neighbors …” (I6)

DISCUSSION

This study aimed to investigate the experiences of mothers with IUFD. Seven mothers

having the experience of IUFD for more than six months were interviewed in this study.

Four major themes were developed, including mothers’ response to a loss, moral support

received by mothers, negative behavior from others, and physical and psychological

changes that interfere with the role as wife and mother.

The first theme in this study was the mothers’ response to loss. This incident made some

participants experience a deep trauma so that they cried and felt sad when they recalled

the incident. The informant stated that the incident was so traumatizing that they were

afraid to get pregnant again, even though it had been more than two years. The trauma

response expressed by the informants included feeling guilty for all the actions they had

taken before IUFD, feeling that God had left them, and regretted the pregnancy. A

previous study reported that after one year of infant death, a woman will postpone her

pregnancy and have an excessive awareness of the next pregnancy (Daurgirdaite, Akker,

& Purewal, 2015). Another study found a difference in the loss response experienced by

mothers, from the age of mothers who are 18 years old with mothers over 30 years of age.

Informants aged 30 years and over have a deeper loss response, and expectations for

subsequent pregnancies are smaller than informants aged 18 or 20 years. At this age

difference, seen from maternal factors, mothers over 35 years old have a high risk of

developing IUFD (Cunningham et al., 2014).

The second theme described the support received by the mothers. This was expressed by

the participants that the support they received from those around them, such as family,

medical team, and community, could help their mental health recovery. Health

professionals face difficult choices about what issues should be raised with parents at this

sensitive time and the optimal timing to inform them of the decisions they will face (Sun,

Rei & Sheu, 2014). The support of the medical team, especially nurses, is highly needed

by mothers who experience IUFD. In this study, the mothers revealed the support

provided by nurses included enthusiasm, attention, and hope. According to Crawley,

Lomax, and Ayers (2013), the support received by mothers from a professional medical

team about mental health outcomes after the mother experiences fetal death while the

mother was at the hospital or after going home, it was something meaningful to motivate

mothers. Previous research conducted by Temple and Smith (2014) stated that support

from families, nurses, and doctors received by women with IUFD is very helpful in

reducing depression and anxiety in women with IUFD, compared to single, divorced, and

widowed women who have depression rates higher after experiencing IUFD. In this

research, there is also a form of social support provided by people around the mother.

Participants revealed that in addition to support from the medical team and their families,

they also received support from the community such as prayer and encouragement.

Allahdadian, Irajpour, Kazemi and Kheirabadi (2016) stated that the women expressed

Nurse Media Journal of Nursing, 10(1), 2020, 92

their need for family support during these hard times and mourn stages. Furthermore,

Mills, Ricklesford, Cooke, Heazell, Whitworth and Lavender (2014) also reported that

participation in tailored support programs was considered to have significant benefits, the

importance of emphasizing high-quality psychosocial support to parents who are

saddened in labor.

This study shows two forms of support received by participants, namely emotional

support and information support. Emotional and information support were shown in the

form of family assistance at the hospital or home, how long, and how easy it was for them

to talk or obtain information from health workers around them. The information given to

mother and family members was examined by asking whether their opinions were

appreciated if the information was adequate, and who had provided the information (Kirk,

Fallon, Fraser, Robinson, & Vassallo, 2015; Majasaari, Sarajarvi, Koskien, Autere &

Paavilainen, 2005). When care was not delivered well, mothers were further distressed,

on top of their grief for their baby, with unpredictable long-term consequences. However,

when this one chance was seized and used to its full capacity, the benefits appeared to be

significant and long term. Parents were particularly negative about perceived emotional

distance on the part of health professionals (Downe, Schmidt, Kingdon & Heazell, 2013).

The communication and openness look very important; the family and the closest person

become the biggest support system for the mother is facing uncomfortable conditions.

Thus, any support given by the health professional, family, and community to mothers

who experience IUFD can help mothers pass through the grieving process that is

experienced and can take mean from loss so that mothers can continue their normal

activities.

The third theme describes the negative behavior of people around the mother. This was

revealed by informants that they get negative behavior from people around like, negative

stigma even to accept rejection. In the study of Brierley-Jones et al. (2015), the mothers

who experience the stigma of infant mortality and stigma come from families,

professional medical personnel, friends, coworkers, and strangers, even from the mothers

themselves. They assume the mother deliberately did not maintain her pregnancy so that

IUFD occurred. Blame the mother for not doing regular pregnancy checks and

maintaining inadequate food. They recounted experiences that suggested that

relationships with others had been changed irrevocably and that other peoples’ attitudes

towards them had altered too (Murphy, 2012). Mother has an increasingly greater sense

of guilt because of that. Lack of knowledge and understanding of family or community

about IUFD causes negative stigma so that the behavior can slow down the recovery

process and worsen the mental condition of the mother.

The last theme reveals the physical and psychological changes that disrupted the role of

wife and mother. This can disturb the relationship between mother and family and the

surrounding community, both in terms of communication and socialization. Also, the

activities and role of informants as wives and mothers were disrupted due to delays in the

process of receiving IUFD incidents experienced by the informants. The previous study

by Huberty, Coleman, Rolfsmeyer, and Wu (2014) mentioned that women who had after

infant death have barriers to physical activity such as emotional symptoms, lack of

motivation, feeling tired, and feeling guilty. Psychological changes often occur in mothers

Nurse Media Journal of Nursing, 10(1), 2020, 93

who experience fetal death. This period occurs to the mother after experiencing the death

of the baby, and the mother has major consequences in showing the results of

psychological symptoms such as sadness, anxiety, fear, and suffering. According to

Heazell et al. (2016), mothers who experience IUFD often reported experiences of

negative psychological symptoms, including depression, anxiety, posttraumatic stress,

panic, phobia, and even with the idea of suicide. Because there were physical and

psychological changes, the mother cannot fulfill her normal role as a wife or mother. The

grief literature indicates that people expect there to be an endpoint to the period of grief,

and that grief symptoms should decrease over time (Penman, Breen, Hewitt & Prigerson,

2014). Some couples reported experiencing conflicting emotional reactions to sexual

relationships. Women, more frequently than men, reported guilt and disturbing images,

thoughts, and feelings that interfered with sex (Burden et al., 2016). Thus, the role of

health care providers in physical activity is needed by women who experience infant

mortality for the importance of physical activities such as working, exercising, and

maintaining a healthy body and their weight, and can help improve emotional and mental

health in mothers.

CONCLUSION

This study revealed four themes that described the experiences of mothers with IUFD,

including the mothers’ response to loss, moral support received by mothers, negative

behavior from people around the mothers, and physical and psychological changes that

affected mothers’ roles. The findings in this study are expected to increase the knowledge

of health/community cadres about mothers’ experiences of IUFD. It is hoped that the

community will not have a negative stigma and judge women with IUFD experiences,

and be more sensitive in providing support for maternal psychological conditions. It is

also expected that to improve healthcare services, nurses should increase their knowledge

and understanding of nursing in medical and psychological care with therapeutic

communication for mothers with IUFD, as well as increase their certifications to enhance

their competences.

ACKNOWLEDGMENT

The researchers would like to thank the participants of this study.

CONFLICT OF INTEREST

None

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Nurse Media Journal of Nursing, 10(1), 2020, 96-106 Available online at http://ejournal.undip.ac.id/index.php/medianers

DOI: 10.14710/nmjn.v10i1.28725

Family’s Experience: Nursing Care for Colorectal

Cancer Patients with Colostomy

Untung Sujianto1, Roland Billy1, Ani Margawati2

1Department of Nursing, Faculty of Medicine, Diponegoro University, Semarang, Indonesia 2Department of Nutrition, Faculty of Medicine, Diponegoro University, Indonesia

Corresponding Author: Untung Sujianto (untung71@yahoo.co.id; untung71@fk.undip.ac.id)

Received: 25 February 2020 Revised: 23 April 2020 Accepted: 24 April 2020

ABSTRACT

Background: Colorectal cancer patients with colostomy have various complaints about

changes in their life, including the need for comprehensive and personal care. Ostomy

nurses are responsible for managing people with a colostomy, and this particular nursing

practice continues to develop globally. Also, previous literature highlights the importance

of caregiver’s support, particularly family in colostomy patient care.

Purpose: This study aimed to explore the family experience of colorectal cancer patients

toward colostomy nursing care

Methods: The study design used was descriptive phenomenology to explore the

experience of ten participants through in-depth interviews The participants were selected

using purposive sampling with the inclusion criteria: family members of colorectal cancer

patients with colostomy, over 21 years old, and able to communicate verbally. The data

were analyzed using Colaizzi’s method.

Results: The results revealed three themes related to the family’s experience: (1) positive

and negative behavior in nursing care, (2) living with a colostomy, and (3) expectations

for nursing care. The findings showed that the families were happy with the ostomy

nursing care though some aspects need to be improved. However, colorectal cancer

patients experienced some difficulties in living with a colostomy.

Conclusion: The study concluded that the colostomy nursing care still needs to be

improved. This study recommends the ostomy nurses to improve their nursing care,

especially in terms of skills, responsiveness, and awareness.

Keywords: Colostomy; family experience; nursing care; colorectal cancer patients.

How to Cite: Sujianto, U., Billy, R., & Margawati, A. (2020). Family’s experience:

Nursing care for colorectal cancer patients with colostomy. Nurse Media Journal of

Nursing, 10(1), 96-107. doi:10.14710/nmjn.v10i1.28725

Permalink/DOI: https://doi.org/10.14710/nmjn.v10i1.28725

BACKGROUND

Colorectal cancer is one of the predominant cancers in the world. In 2018, this cancer

reached 16,000 deaths across Indonesia (WHO, 2018). Several studies stated that the

increase in colorectal malignancies significantly contributes to an increase in ostomy

procedure, leading to various effects on health-related quality of life (HRQOL) (Barreto

http://ejournal.undip.ac.id/index.php/medianers

mailto:untung71@yahoo.co.id

Nurse Media Journal of Nursing, 10(1), 2020, 97

& Valencia, 2013; Dabirian, Yaghmaei, Rassouli & Tafreshi, 2011). Nurses are health

care providers who have an important role in caring for patients with colostomy,

particularly in identifying their needs, preventing complications, and improving quality

of life (Adriana, 2010).

Danielsen, Soerensen, Burcharth, and Rosenberg (2013) stated that ostomy nurses are

responsible for managing persons with a stoma, and this specialty nursing practice

continues to evolve on a global basis. Ostomy nurses should be able to provide nursing

care not only on physiological problems but also other problems related to the ostomy.

Vonk-Klaassen, de Vocht, den Ouden, Eddes, and Schuurmans (2016), in their review,

identify some problems related to an ostomy. The problems include sexual problems,

depressive feelings, gas, constipation, dissatisfaction with appearance, changes in

clothing, travel difficulties, feeling tired, and worry about noises. Thus, comprehensive

and personalized nursing care is important in order to prevent or manage complications

and improve the physiological and psychosocial adjustments to ostomy patients

(Klingman, 2009). As a result, it will enhance the patients’ quality of life.

Living with colostomy causes negative impacts on the overall quality of life of the

patients (Von-Klaassen et al., 2016). This will affect their family or caregiver in providing

support. Caregiving is often a multi-faceted endeavor that can entail both instrumental

and affective support (Dumont, Jacobs, Turcotte, Anderson & Harel, 2010). Several

studies found that over the past decade, the cancer caregiving literature has grown as

patients’ and partners’ needs and quality of life (QoL) have become a focus of concern

(Berry, Dalwadi, & Jacobson, 2016; Bevans & Sternberg, 2012; Hawyer, Van, Wilson,

& Griffin, 2016). Existing research recognizes problems with collaboration between the

hospice major barrier in delivering high-quality care for patients in the nursing home

(Hwang, Teno, Clark, Shield, Williams, Casarett, & Spence, 2014). However, little

evidence was found related to the experience of a family on colorectal cancer-related

ostomy nursing care in the hospital setting. Therefore, it is fundamental to understand the

habits, perceptions, and attitudes, feelings, and emotions demonstrated in the most diverse

situations across the patients while trying to understand those who accompany and sustain

them in a patient’s life-changing experience.

PURPOSE

This study aimed to analyze the family’s experience of colorectal cancer related to

colostomy nursing care in the hospital.

METHODS

Research design

This study used a qualitative research method with a descriptive phenomenological

approach. This approach, which seeks to describe lived-experience, tries to find the

essence of these phenomena by remaining open to the meanings associated with those

who have experienced them (Polit & Beck, 2010).

Nurse Media Journal of Nursing, 10(1), 2020, 98

Setting and participants This study was carried out in a hospital in Semarang, Central Java, Indonesia. The

selection of the subject of this study was carried out using purposive or judgmental

sampling techniques, which was taking samples with certain considerations (Soegiono,

2011). The participants were the family members of colostomy patients due to colorectal

cancer in inpatient units, which met the inclusion criteria. In this study, the inclusion

criteria were patients who were able to communicate verbally, cooperative, and over 21

years old. As many as ten patient’s families participated in this study according to the

point of data saturation.

Data collection

Persons who agreed to participate in the study signed the free and informed consent form

after receiving detailed explanations of the proposed objectives and procedures. All

participants were recruited in the hospital. Permission to audiotape the interview session

was also sought from each participant. Confidentiality and anonymity were also

guaranteed. Data collection was conducted by semi-structured interviews and asking the

question to get deep information about their experiences recorded by voice recording. The

time and place of the interview were arranged in a calm environment within the hospitals,

which were according to the participant’s preferences. Each interview lasted for about

30-60 minutes. Data collection continued to the point of saturated data, where no new

information was obtained, and redundancy was achieved.

Data analysis

The initial stage of data analysis was carried out by documenting the results of the

interview in the form of interview transcripts. This process was carried out by playing the

recording repeatedly. Verbatim transcription was then done to all interview recordings,

and the data were grouped into the form of themes, sub-themes, and main categories.

Analysis of the data in this study used a method created by Colaizzi (Morrow, Rodriguez,

& King, 2015). The Colaizzi’s method has seven stages in analyzing data: (1)

familiarization, (2) identifying significant statements, (3) formulating meanings, (4)

clustering themes, (5) developing an exhaustive description, (6) producing the

fundamental structure, and (7) seeking verification of the fundamental structure. Many

factors were considered to ensure the validity of this research. This research ensured

dependability, credibility, confirmability, and transferability through some measures.

First, a good relationship with the patients and their families was established. Second,

member checking was done to clarify the transcripts, keywords, themes, and subthemes.

Ethical consideration

This research had obtained ethical approval from dr. Kariadi Hospital Health Research

Ethics Committee with the ethical number of 198/EC/KEPK-RSDK/2019. The ethical

considerations of this study were carried out based on the principle of the five rights of

human subjects in research. These five rights include the right to self-determination,

privacy, dignity, anonymity, and confidentiality.

Nurse Media Journal of Nursing, 10(1), 2020, 99

RESULTS

Participant characteristics

As seen in Table 1, the result showed that the majority of the participants were female

(60%), aged less than 40 years old (60%), had primary school as an educational

background (40%), and was the children of the patients (40%).

Table 1. Characteristics of participants (n=10)

Characteristics f %

Age

< 40 years old 6 60

> 40 years old 4 40

Gender

Male 4 40

Female 6 60

Education

Primary school 4 40

Junior high school 1 10

Senior high school 2 20

Diploma 1 10

Bachelor 2 20

Relationship

Children 4 40

Parent 2 20

Spouse 3 30

Brother 1 10

The study resulted in three themes related to the family’s experience: (1) positive and

negative behavior in nursing care, (2) living with colostomy, (3) expectations for nursing

care.

Positive and negative behaviour in nursing care

The participant expressed positive and negative behavior in ostomy nursing care,

especially nurses. However, the positive impression outweighed the negatives. The

participants stated that the nurses were friendly and had good communication.

“…The attitude of nurses in the hospital is all good. They already know my child.

If we met somewhere else, they recognized my child’s face and always greeted

first” (P.5).

“…Nothing is lacking in their attitude. The nurses here are subtle and polite. They

are also good and likes to joke” (P.6).

“…Nurses in the hospital are polite and respect the patient. The way they speak is

also nice and polite. There is nothing to say loudly like yelling or getting angry”

(P.10).

They also said that the ostomy nurses not only paid attention and supports to the patients

but also helped and taught the patients and families.

Nurse Media Journal of Nursing, 10(1), 2020, 100

“…I am grateful for my father being treated in this hospital; nurses always pay

attention to the condition of my father, such as asking how my father is doing and

ensuring that he feels comfortable” (P.4).

“…nurses give encouragement to patients. When the patient does not want to eat

hospital food, nurses encourage patients to be eager to eat a lot to recover quickly

… nurses give encouragement to patients. When the patient does not want to eat

hospital food, nurses encourage patients to be eager to eat a lot to recover quickly.”

(P.8).

“…when using a colostomy for the first time, the nurse teaches the family and

caregiver. They teach how to replace a colostomy” (P.1).

“…The nurse here is aware, every time there is a problem or when we ask for help,

they respond quickly” (P.7).

On the other hand, negative impressions were also expressed by the family, such as long

waits of nursing care, unresponsiveness, lack of skills, and being unreliable.

“…here to wait for a new colostomy bag can be one, three, even up to four days.

When moving to another room, the nurse also said that the bag had run out, so we

had to wait all the time … there is good work and bad work. There are nurses who

put up a colostomy bag, but only a few hours apart, the colostomy is already worn

off.” (P.8).

“…When my brother came for a biopsy, he felt in pain. Maybe the nurse thought

that it didn’t hurt so that it didn’t really matter even if the patient looked very weak”

(P.1).

“…I want the nurse to treat the patient well and clean. So far, it hasn’t been like

that. The nurse just told us to clean it up” (P.9).

Living with colostomy

The participants mentioned that colorectal cancer patients faced some challenges living

with a colostomy. The patients experienced some difficulties in living with colostomy

though many of them were able to cope with it. Some difficulties reported were feeling

of shame and dirty, physical complaints, activity disruption, and altered sleep.

“…only families know that the mother uses colostomy. If other people know and

see the poop suddenly out of the bag, maybe people can feel strange with it and

judge that it is dirty.” (P.10).

“…what he (patient) complained about his stomach, which was always tense. Just

eat a little bit, he had already felt full. Now he is also rather weak, maybe because

he can’t eat because when he eats even just a little, he feels like vomiting right

away. Now, his body also feels more pain.” (P.1).

“…according to him (patient), his waist is still in pain. Before there was a

colostomy, all activities could be carried out, since there is a colostomy the

activities have been limited, the activities cannot be done like before … it’s different

now because he can’t enjoy sleep anymore. Usually, he could sleep freely when

there was no colostomy. Now he is more careful when sleeping because there are

wounds (ostomy).” (P.5).

“…now, he is not fit anymore, so he cannot work and support the family.” (P.6).

Nurse Media Journal of Nursing, 10(1), 2020, 101

Although the patients experienced some problems, some participants also stated that the

patients had been able to adjust to the colostomy. As a result, the patients could return to

their jobs, enjoy their life, and improve their health.

“…for him, there are no problems when using a colostomy (to work)” (P.1)

“…Alhamdulillah no interference, he can still work as a driver smoothly. During

driving a bus back and forth to Jakarta, there is no big deal … he never told me

about complaints and problems. During this time, what I saw he seemed to enjoy

and relax with his current situation.” (P.7).

“…previously (the patient) is often nausea when eating, and no appetite, now (the

patient) can eat.” (P.8).

“…now since using colostomy, she looks healthy, she’s not like she used to be.

Mother said that she was healthier.” (P.10)

Expectations for nursing care

The family expected better nursing service, especially by the ostomy nurses. They

demanded the nurses to motivate and prioritize the patients.

“…our hope is that patient services can be prioritized because this hospital is a

central hospital, so the service must be better than the regional hospitals … patients

with colostomy have a lot of thoughts, so maybe nurses can encourage and motivate

patients to pass their life-changing experience.” (P.2).

“…I want my husband to be treated well and clean (by the nurses), not only told us

to do so (colostomy procedures).” (P.9).

DISCUSSION

Positive and negative behaviour in nursing care

The participant expressed positive and negative behavior in ostomy nursing care,

especially the nurses, though their positive impressions were more dominant. In addition,

to be attentive and supportive to the patients, the nurses helped and taught the patients

and families. These caring behaviors seem important to patients and families. This is

supported by Blacius and Setyowati (2016), who point out that caring has implications

for nursing practice, so that nurses who have caring behavior will show kindness and

politeness. Swanson (2007) also suggests that professional health workers have an

important role in nursing services in hospitals. Providing caring can improve and

influence the quality of service and improve the well-being of everyone.

Health professionals play an important role in meeting individual information needs

regarding colostomy care. Because of the trust in healthcare professionals, the informants

in this study had learned about the colostomy and its treatment largely from their surgeons

and nurses. Two systematic reviews by Danielsen, Burcharth and Rosenberg (2013), and

Phatak, Karanjawala, Chang and Kao (2014) identified that the impact of patient

education for patients with a stoma has potential benefits. The results of a systematic

review by Faury, Koleck, Foucaud, Bailare and Quintard (2017) also show that

educational interventions for patients with a colostomy can have a contrasting impact on

the quality of life and a positive impact on patients’ psychosocial as well as self-

management.

Nurse Media Journal of Nursing, 10(1), 2020, 102

The participants also stated that the nurses were friendly and had good communication.

Nurses, in this case, provide enthusiasm to the patients during their treatment in the

hospital. They give a good explanation to the patient, are easy to question, and to be asked

for consideration. Macdonald (2016) found that nurses are skilled in obtaining clinical

information to empower patients and establish therapeutic relationships. Taylor and

Morgan (2011) identified that providing quality support before, during, and after

colostomy care is needed to improve the quality of life of patients. Nurses in interacting

with patients and their families need communication skills. Another study by Chan,

Wong, Cheung and Lam (2018) revealed that good physical management and involving

effective nurse-patient communication in care add psychosocial comfort to patients.

However, the family identified that long waits of nursing care, as well as nurses being

unresponsive, lacking skills, and unreliable as the negative aspects. In this case, the

participants said that they were waiting too long for the new colostomy bag and the

intravenous fluid that was not immediately replaced. This is in accordance with the results

of Adriana’s (2010) study, which states that almost half of nurses have not provided

caring, especially in communicating with patients. Ostomy nurses need to improve their

nursing care, especially in terms of skills, responsiveness, and awareness.

Living with colostomy

The participants mentioned that colorectal cancer patients faced some challenges living

with a colostomy, such as activity disruption, and altered sleep. Changes in daily life

become the main thing in patients with a colostomy. Some participants said that their

families had limited activities such as housework; some even stopped working. The

findings of this problem are similar to those found by Dabirian et al. (2011), where most

patients revealed that they had to change or leave work after the onset of their disease and

ostomy, and that colostomy also affected their income. However, Dabirian’s finding was

quite different from the other results of this study, which found that some patients could

finally return to their jobs. Liao and Qin (2014) also found that patients with colostomy

experienced disturbances and difficulties at work and also in social situations, body

image, and stoma functions. These difficulties were similar to other categories of this

study, that feeling shame and dirty was reported by the participants. It included feelings

of discomfort or fear of others, and knowing the circumstances experienced by patients.

This was because the stool was clearly visible in the patient’s stomach so that patients

were afraid of people seeing them dirty. This finding is also consistent with the results of

research by Jansen, Koch, Brenner, and Arndt (2010), where they found that the discharge

from the colostomy bag that came out was considered dirty for others. This makes a

negative self-image for users of the colostomy so that embarrassment arises.

The existence of new devices in the body certainly has an impact on the daily use of

colostomies. Some participants said that the patients experienced difficulties when they

wanted to pray and sleep. Some had to use a chair during prayer because of difficulties

with a colostomy. This finding is in accordance with research conducted by Cengiz and

Bahar (2017) in their phenomenological study on 12 participants who were all Muslim.

They obtained a theme in the form of “limits on activities in daily life.” From this theme,

seven sub-themes were found, such as dressing, bathing, sleeping, sex, physical activity,

prayer, and social life. This finding is further strengthened by Akgül and Karadag’s

Nurse Media Journal of Nursing, 10(1), 2020, 103

(2016) research, where they found that the procedure for making colostomy gives

challenges for various religious practices in Islam, including those related to ablution,

prayer, fasting, and pilgrimage.

Although the use of colostomy is a therapeutic treatment for digestive problems, patients

still feel physical complaints, as for example, feeling sick, nausea, vomiting, weakness,

and having difficulty defecating. This is similar to research by Jansen et al. (2010), where

they explain that people with colostomies have many problems in physical function and

roles. Fatigue, dyspnea, and loss of appetite are some of the worst categories. This is also

significant with the findings of Zhang, Hu, Xu, Zheng and Liang (2013), where they

found significant values for physical disorders such as fatigue, pain, constipation, and

diarrhea.

Even though patients experienced some difficulties in living with a colostomy, many of

them were able to cope with it. As a result, the patients could enjoy their life and improve

their health after using colostomy. Some participants said that patients did not encounter

serious problems when using colostomy. They even felt physical comfort, including being

painless, gaining weight, being able to eat normally. This is similar to the research of

Szpilewska Juzwiszyn, Bolanowska, Milan and Chabowski (2018), in which a total of

43% of respondents stated that their health has no bad changes and some have even

improved since using a colostomy.

In addition to physical improvement, some participants said that patients did not mind the

situation they were experiencing. Despite physical impairments, these patients did not

think too much about the situation they were experiencing. This is in line with research

by Tao, Songwanthana and Isaramalai (2016) that informants’ perceptions of colostomy

are often associated with abnormalities, discomfort, difficulty in care, social isolation,

and limited job choices. Survival is the most important thing, allowing these informants

to accept the possibility of colostomy formation by following the surgeon’s advice and

embracing their destiny. A positive mood is also useful for individuals to deal with the

negative effects associated with a colostomy. Popek and Grant (2010) found that patients

who were optimistic and positive to receive their colostomy had a high quality of life. An

optimistic attitude can help people to successfully adapt to the disease.

Changes in the quality of life of patients with colostomy varied from negative and positive

responses. In this theme, negative sub-themes were more dominant than positive. This

finding is similar to the research of Kimura, Kamada, Guilhem, Modesto and de Abreu

(2016), which revealed that the obstacles faced by patients with colostomy significantly

affect their physical, psychological, social and spiritual well-being. From the analysis of

Kimura et al. (2016), it was found that there were more negative subcategories than

positive ones. This is also supported by Von Klaassen et al. (2016), who reported that

living with colostomy causes negative impacts on the overall quality of life of the patients

Expectations for nursing care

The family expected better nursing service, especially by the ostomy nurses. They

demanded the nurses to motivate and prioritize the patients. Some participants hoped that

Nurse Media Journal of Nursing, 10(1), 2020, 104

nurses could improve nursing services for patients and also support patients morally. The

role of nurses as health care providers in patients with colostomy needs to be improved

due to the low quality of life of colostomy patients (Liao & Qin, 2014). Other studies

have found that the expectations for nursing services were focused on the desire to be

treated humanely, assisting in the adaptation as a member of the household, restoring and

increasing patient strength, and help overcome the patient’s weakness (Ferreira-

umpiérrez & Fort-fort, 2014). The expectation is an important factor in the bio-psycho-

social-spiritual aspect. Expectations relate to how people’s beliefs affect their behavior.

Improved self-concept can be done by nurses by helping patients to shape their thinking

to be more positive, realistic, such as encouraging patients to do something for

themselves. Increasing the caring behavior of nurses is an ability to be dedicated to others,

showing concern, watching with caution, feeling empathy for others, and feelings of love

or love.

CONCLUSION

The findings showed that positive behaviors in nursing care outweighed the negative

things. The family was pleased with the ostomy nursing care though some aspects need

to be improved. Moreover, colorectal cancer patients experienced some difficulties in

living with colostomy, resulting in negative impacts on their quality of life. Therefore,

this study concluded that colostomy nursing care still needs to be improved. As a result,

it is recommended for ostomy nurses to improve their nursing care, especially in terms of

skills, responsiveness, and awareness, and for further research to get a deeper perspective

of colostomy patients with a diverse age group and gender.

ACKNOWLEDGEMENT

The authors would like to thank participants for their voluntary participation in this study.

CONFLICT OF INTEREST

The authors declare no conflicts of interest in this work.

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Authors submitting a manuscript do so on the understanding that if accepted for

publication, copyright of the article shall be assigned to Nurse Media Journal of Nursing

and Department of Nursing, Faculty of Medicine, Diponegoro University as the publisher

of this journal.

and media, including reprints, photographs, microfilms and any other similar

reproductions, as well as translations. The reproduction of any part of this journal, its

storage in databases and its transmission by any forms or media, such as electronic,

electrostatic and mechanical copies, photocopies, recordings, magnetic media, etc., will

be allowed only with a written permission from Nurse Media Journal of Nursing and

Department of Nursing, Faculty of Medicine, Diponegoro University.

Nurse Media Journal of Nursing and Department of Nursing, Faculty of Medicine,

Diponegoro University make every effort to ensure that no wrong or misleading data,

opinions or statements be published in the journal. In any way, the contents of the articles

and advertisements published in Nurse Media Journal of Nursing are sole and exclusive

responsibility of their respective authors and advertisers.

The Copyright Transfer Agreement Form can be downloaded at NMJN website

(http://ejournal.undip.ac.id/index.php/medianers). The copyright form should be filled

with respect to article and be signed originally and sent to the Editorial Office in the form

of original email, or scanned document file (softcopy) to:

Sri Padma Sari (Editor-in-Chief)

Department of Nursing, Faculty of Medicine, Diponegoro University

Jl. Prof. Soedarto, Tembalang, Semarang, Central Java, Indonesia 50275

Telp.: +62-24-76480919; Fax.: +62-24-76486849

E- mail: media_ners@undip.ac.id or media_ners@live.undip.ac.id (preferable)

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http://ejournal.undip.ac.id/index.php/medianers)

mailto:media_ners@undip.ac.id

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Name of Principal Author(s) :

Address of Principal Author(s) :

Phone Number / Fax Number :

Email :

Name of Author(s) :

Title of Manuscript :

1. I/We submit to the Nurse Media Journal of Nursing for the above manuscript.

I/We certify that the work reported here has not been published before and

contains no materials the publication of which would violate any copyright or

other personal or proprietary right of any person or entity.

2. I/We hereby agree to transfer all rights, title, interest, and copyright ownership to

Nurse Media Journal of Nursing, Faculty of Medicine, Diponegoro University for

the copyright of the above manuscript.

Date :

Signature (original) : (When there is more than one author, only one signature will suffice)

Author’s Name :

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Nurse Media Journal of Nursing (NMJN) is a peer-reviewed electronic international

journal. This statement clarifies ethical behavior of all parties involved in the act of

publishing an article in this journal, including the author, the chief editor, the Editorial

Board, the peer-reviewers and the publisher (Diponegoro University). This statement is

based on COPE’s Best Practice Guidelines for Journal Editors.

Ethical Guideline for Journal Publication

The publication of an article in a peer-reviewed NMJN journal is an essential building

block in the development of a coherent and respected network of knowledge. It is a direct

reflection of the quality of the work of the authors and the institutions that support them.

Peer-reviewed articles support and embody the scientific method. It is therefore important

to agree upon standards of expected ethical behavior for all parties involved in the act of

publishing: the author, the journal editor, the peer reviewer, the publisher and the society.

Diponegoro University as publisher of NMJN takes its duties of guardianship over all

stages of publishing extremely seriously and we recognize our ethical and other

responsibilities. We are committed to ensuring that advertising, reprint or other

commercial revenue has no impact or influence on editorial decisions. In addition, the

Department of Nursing Diponegoro University and Editorial Board will assist in

communications with other journals and/or publishers where this is useful and necessary.

Duties of Editor

Publication decisions

The editor of the NMJN journal is responsible for deciding which of the articles submitted

to the journal should be published. The validation of the work in question and its

importance to researchers and readers must always drive such decisions. The editors may

be guided by the policies of the journal’s editorial board and constrained by such legal

requirements as shall then be in force regarding libel, copyright infringement and

plagiarism. The editors may confer with other editors or reviewers in making this

decision.

Fair play

An editor at any time evaluate manuscripts for their intellectual content without regard to

race, gender, sexual orientation, religious belief, ethnic origin, citizenship, or political

philosophy of the authors.

Confidentiality

The editor and any editorial staff must not disclose any information about a submitted

manuscript to anyone other than the corresponding author, reviewers, potential reviewers,

other editorial advisers, and the publisher, as appropriate.

Publication Ethics and Malpractice Statement

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Disclosure and conflicts of interest

Unpublished materials disclosed in a submitted manuscript must not be used in an editor’s

own research without the express written consent of the author.

Duties of Reviewers

Contribution to editorial decisions

Peer review assists the editor in making editorial decisions and through the editorial

communications with the author may also assist the author in improving the paper.

Promptness

Any selected referee who feels unqualified to review the research reported in a manuscript

or knows that its prompt review will be impossible should notify the editor and excuse

himself from the review process.

Confidentiality

Any manuscripts received for review must be treated as confidential documents. They

must not be shown to or discussed with others except as authorized by the editor.

Standards of objectivity

Reviews should be conducted objectively. Personal criticism of the author is

inappropriate. Referees should express their views clearly with supporting arguments.

Acknowledgement of sources

Reviewers should identify relevant published work that has not been cited by the authors.

Any statement that an observation, derivation, or argument had been previously reported

should be accompanied by the relevant citation. A reviewer should also call to the editor’s

attention any substantial similarity or overlap between the manuscript under consideration

and any other published paper of which they have personal knowledge.

Disclosure and conflict of interest

Privileged information or ideas obtained through peer review must be kept confidential

and not used for personal advantage. Reviewers should not consider manuscripts in which

they have conflicts of interest resulting from competitive, collaborative, or other

relationships or connections with any of the authors, companies, or institutions connected

to the papers.

Duties of Authors

Reporting standards

Authors of reports of original research should present an accurate account of the work

performed as well as an objective discussion of its significance.

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Underlying data should be represented accurately in the paper. A paper should contain

sufficient detail and references to permit others to replicate the work. Fraudulent or

knowingly inaccurate statements constitute unethical behaviour and are unacceptable.

Data access and retention

Authors are asked to provide the raw data in connection with a paper for editorial review,

and should be prepared to provide public access to such data (consistent with the ALPSP-

STM Statement on Data and Databases), if practicable, and should in any event be

prepared to retain such data for a reasonable time after publication.

Originality and plagiarism

The authors should ensure that they have written entirely original works, and if the authors

have used the work and/or words of others that this has been appropriately cited or quoted.

Multiple, redundant or concurrent publication

An author should not in general publish manuscripts describing essentially the same

research in more than one journal or primary publication. Submitting the same manuscript

to more than one journal concurrently constitutes unethical publishing behaviour and is

unacceptable.

Acknowledgement of sources

Proper acknowledgment of the work of others must always be given. Authors should cite

publications that have been influential in determining the nature of the reported work.

Authorship of the paper

Authorship should be limited to those who have made a significant contribution to the

conception, design, execution, or interpretation of the reported study. All those who have

made significant contributions should be listed as co-authors. Where there are others who

have participated in certain substantive aspects of the research project, they should be

acknowledged or listed as contributors. The corresponding author should ensure that all

appropriate co-authors and no inappropriate co-authors are included on the paper, and

that all co-authors have seen and approved the final version of the paper and have agreed

to its submission for publication.

Hazards and human or animal subjects

If the work involves chemicals, procedures or equipment that have any unusual hazards

inherent in their use, the author must clearly identify these in the manuscript.

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Disclosure and conflicts of interest

All authors should disclose in their manuscript any financial or other substantive conflict

of interest that might be construed to influence the results or interpretation of their

manuscript. All sources of financial support for the project should be disclosed.

Fundamental Errors in Published Works

When an author discovers a significant error or inaccuracy in his/her own published work,

it is the author’s obligation to promptly notify the journal editor or publisher and

cooperate with the editor to retract or correct the paper.

Sri Padma Sari (Editor-in-Chief)

Nurse Media Journal of Nursing

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All manuscripts should be submitted to the NMJN Editorial Office by the Online

Submission and Tracking Interface at: http://ejournal.undip.ac.id/index.php/medianers.

The following materials should accompany the submitted manuscripts to the editorial

office:

(1) Signed Copyright Transfer Agreement Form (a copy reproduced from the website), (2) A Covering Letter, outlines the basic findings of the paper and their significance,

which are uploaded as Supplementary Materials (Step 4) in submission interface.

However, if for any reason authors are unable to use the above methods, authors may

also contact to the Editorial Office according to the following address:

Sri Padma Sari (Editor-in-Chief)

Nurse Media Journal of Nursing

Department of Nursing, Faculty of Medicine, Diponegoro University

Jl. Prof. Soedarto, Tembalang, Semarang, Central Java, Indonesia 50275

Telp. +62-24-76480919; Fax. +62-24-76486849

E-mail: media_ners@live.undip.ac.id

Three types of manuscripts are acceptable for publication in the NMJN: original research

articles, literature study, and case report.

Preparation of manuscripts

Manuscript of research article, case study or reviews should be prepared in the ‘camera

ready’ templates, according to the guidelines on the website:

http://ejournal.undip.ac.id/index.php/medianers/about/submissions

Reviewing of manuscripts

Every submitted paper is independently reviewed by at least two peers. Decision

for publication, amendment, or rejection is based upon their reports. If two or more

reviewers consider a manuscript unsuitable for publication in this journal, a statement

explaining the basis for the decision will be sent to the authors within three months of

the submission date. The rejected manuscripts will not be returned to the authors.

Revision of manuscripts

Manuscripts sent back to the authors for revision should be returned to the editor without

delay (not later than one month). The revised manuscripts should be sent to the Editorial

Office by e-mail (media_ners@live.undip.ac.id) or preferably through the Online

Submission Interface. The revised manuscripts returned later than three months will be

considered as new submissions.

Submission Information

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NMJN appreciates the reviewers who have commented the manuscripts for the current

issue:

Anggorowati : Department of Nursing, Faculty of Medicine,