Volume 7 Issue 3: May - June 2021
BELITUNG NURSING JOURNAL
E-ISSN: 2477 -4073 | P-ISSN: 2528-181X Edited by: Assoc. Prof. Dr. Yupin Aungsuroch & Dr. Joko Gunawan
DOI: https://doi.org/10.33546/bnj.v7i3
Review Article Implementation of nursing case management to improve community access to care: A scoping review Alenda Dwiadila Matra Putra, Ayyu Sandhi Theory and Concept Development Self-control in old age: A grounded theory study Laarni A. Caorong
The development of Spiritual Nursing Care Theory using deductive axiomatic approach Ashley A. Bangcola Original Research Article Barriers to exclusive breastfeeding: A cross-sectional study among mothers in Ho Chi Minh City, Vietnam Nhan Thi Nguyen, Huong Thi Do, Nhu Thi Van Pham
Influence of self-esteem, psychological empowerment, and empowering leader behaviors on assertive behaviors of staff nurses Ryan Michael F Oducado
Lived experiences of Overseas Filipino Worker (OFW) nurses working in COVID-19 intensive care units Jane Marnel Pogoy, Jezyl Cempron Cutamora
Symptom experience of adverse drug reaction among male and female patients with newly diagnosed pulmonary tuberculosis in Thailand Apichaya Thontham, Rapin Polsook
Knowledge, attitude, and practice towards COVID-19 among student nurses in Manila, Philippines: A cross-sectional study Earl Zedrick S Quisao, Raven Rose R Tayaba, Gil P Soriano
The effect of warm compresses on perineal tear and pain intensity during the second stage of labor: A randomized controlled trial Soumaya Modoor, Howieda Fouly, Hawazen Rawas
DAHAGA: An Islamic spiritual mindfulness-based application to reduce depression among nursing students during the COVID-19 pandemic Meidiana Dwidiyanti, Badrul Munif, Agus Santoso, Ashri Maulida Rahmawati, Rikhan Luhur Prasetya
“Accessibility”: A new narrative of healthcare services for people living with HIV in the capital city of Indonesia Mahathir Mahathir, Wiwin Wiarsih, Henny Permatasari Original Research: Research Methodology Paper
Psychometric properties of Quality-of-Life Index for Vietnamese women with breast cancer three weeks postmastectomy Xuan Thi Nhu Ha, Sureeporn Thanasilp Perspective
Common ethical dilemmas of family caregivers of palliative patients in Indonesia Martina Sinta Kristanti, Kusmaryanto Kusmaryanto, Christantie Effendy Case Study Developmental assessment and early intervention for children with developmental delays: A case study in South Australia Mardiyanti Mardiyanti, Amanda Case Letter to Editors Reflections on International Nurses Day: Current status, issues, and the future of nursing in Indonesia Feni Betriana, Tetsuya Tanioka, Rozzano Locsin, Nelwati Nelwati
T HE O FFICIAL P UBLICATION OF BELITUNG RAYA FOUNDATION Department of Publication, Indonesia
BELITUNG NURSING JOURNAL
Volume 7 Issue 3: May - June 2021
Launched in December 2015, Belitung Nursing Journal (BNJ) is a refereed international publication that provides a venue for the nursing scholarship with an Asian focus and perspectives from the region. We aim to highlight research on nursing science, nursing management, policy, education, and practice in the Asia-Pacific region and Asian communities worldwide to a broad international audience.
BNJ welcomes submissions of original research articles, review articles, concept analysis, perspectives, letter to editors, research methodology papers, study protocol, case studies, and guest editorials on various clinical and professional topics.
We also welcome "negative" results (i.e., studies which do not support a hypothesized difference or association) provided that the design was robust. Discussion papers that elaborate issues and challenges facing health care in one country are welcomed, provided the discussion is grounded in research-based evidence. The authors are addressing a global audience and a local one.
Nurses and midwives write most papers in BNJ, but there are no constraints on authorship as long as articles fit with the expressed aims and scope. BNJ's intended readership includes practicing nurses and midwives in all spheres and at all levels who are committed to advancing practice and professional development based on new knowledge and evidence; managers and senior members of the nursing and midwifery professions; nurse educators and nursing students; and researchers in other disciplines with interest in common issues and inter-disciplinary collaboration.
BNJ is an official publication of Department of Publication of Belitung Raya Foundation in Belitung Indonesia, jointly with Indonesian National Nurses Association of Belitung Indonesia (PPNI Belitung) and Prodi D3 Keperawatan Belitung Poltekkes Kemenkes RI Pangkal Pinang.
Belitung Raya Foundation is a non-profit organization that focuses on education, health, information technology, and the social and empowerment of the community. Belitung Raya Foundation is established in 2015 with an official license of establishment from the Ministry of Justice and Human Rights of the Republic of Indonesia (MENKUMHAM RI) with No: AHU- 0009599.AH.01.12.Year 2015 and Notarial Deed No: 12 on 06 July 2015 by SRI ARIYAWATI, SH.,M.KN.
BNJ has been accredited by the Ministry of Science, Research, Technology and Higher Education of Indonesia (RISTEKDIKTI RI) with No: 10/3/KPT/2019, valid until 2024.
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© 2021 The Authors. First published by Department of Publication of Belitung Raya Foundation Jalan Genayun, Komplek Perumahan Guru RT 06 RW 02, Dusun Urisan Jaya, Desa Padang, Kabupaten Belitung Timur, Manggar, Bangka Belitung, Indonesia 33512 | Mobile: +6281286251389 | Email: [email protected] and [email protected]
Volume 7 Issue 3: May - June 2021 Library of Congress Cataloging-in-Publication Data Belitung Nursing Journal Volume 7 Issue 3 E-ISSN: 2477-4073 | P-ISSN: 2528-181X
This issue is Open Access distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License which allows others to remix, tweak, and build upon the work non-commercially as long as the original work is properly cited. The new creations are not necessarily licensed under the identical terms.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
i EDITORIAL TEAM
EDITOR-IN-CHIEF
Assoc. Prof. Yupin Aungsuroch, PhD, RN Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand
INTERNATIONAL EDITORIAL ADVISORY BOARD
Prof. Mary L Fisher, PhD, RN The FINE Center, Indiana University School of Nursing, Indianapolis, IN USA College of Nursing, University of Florida, Gainesville, FL. USA
Prof. Josefina A Tuazon, RN, MN, DrPH College of Nursing, University of the Philippines Manila, Manila, Philippines
Prof. Rozzano C Locsin, RN, PhD, FAAN Florida Atlantic University, Boca Raton, FL 33431-0991 USA Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan 770-8509
Assoc. Prof. Colleen Marzilli, PhD, DNP, MBA, RN-BC, CCM, PHNA-BC, CNE, NEA-BC The University of Texas at Tyler, School of Nursing, 3900 University Blvd., Tyler, TX 75799, United States
MANAGING EDITOR
Joko Gunawan, S.Kep.Ners, PhD Belitung Raya Foundation, Belitung, Indonesia
EDITORIAL BOARD MEMBERS
Assist. Prof. Rapin Polsook, PhD, RN Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand
Assist. Prof. Ying Lie, PhD, RN School of Nursing, Dalian Medical University, Dalian, China
Barbara Lyn A. Galvez, MAN, RN, PhD Silliman University Hibbard Avenue, Dumaguete City, Negros Oriental Philippines, Philippines
Bayu Anggileo Pramesona, S.Kep, Ns, MMR, PhD RSD. Mayjend HM. Ryacudu Kotabumi, Lampung Utara, Indonesia
Dr. Khadizah H. Abdul Mumin, RN, RM, PhD Pengiran Anak Puteri Rashidah Sa’adatul Bolkiah, Institute of Health Sciences, University Brunei Darussalam, Brunei Darussalam
Feni Betriana, SKep, Ners, MNS Belitung Raya Foundation, Belitung, Indonesia
Ha Thi Nu Xuan, RN, MNS, PhD Nursing Department, The University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
Jed Ray Montayre, PhD, RN Western Sydney University, NZW, Australia
Le Thi Thanh Tuyen, RN, MNS, PhD Faculty of Nursing, Da Nang University of Medical Technology and Pharmacy, Da Nang, Viet Nam
Mohd Khairul Zul Hasymi Bin Firdaus, BHSc, MN Department of Medical Surgical Nursing, Faculty of Nursing, International Islamic University Malaysia, Malaysia
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
ii Souksavanh Phanpaseuth, MNS, RN University of Health Sciences, Lao PDR
Virya Koy, RN, SNA, MNSc, MHPEd, PhD Deputy Director of Department Hospital Services, Ministry of Health, Cambodia
COPYEDITOR & LAYOUT EDITOR
Anggie Amanda Belitung Raya Foundation, Indonesia
JOURNAL MANAGER
Joko Gunawan, S.Kep, Ners, PhD Belitung Raya Foundation, Belitung, Indonesia
TECHNICAL MANAGERS
Arief Hidayat Sutomo, S. Kom PT. Bejana Investidata Globalindo, Indonesia
Apriadi Belitung Raya Foundation, Belitung, Indonesia
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
iii TABLE OF CONTENTS
DOI: https://doi.org/10.33546/bnj.v7i3
Review Article Implementation of nursing case management to improve community access to care: A scoping review PDF Alenda Dwiadila Matra Putra, Ayyu Sandhi 141-150
Theory and Concept Development Self-control in old age: A grounded theory study PDF Laarni A. Caorong 151-162
The development of Spiritual Nursing Care Theory using deductive axiomatic approach PDF Ashley A. Bangcola 163-170
Original Research Article Barriers to exclusive breastfeeding: A cross-sectional study among mothers in Ho Chi Minh City, Vietnam PDF Nhan Thi Nguyen, Huong Thi Do, Nhu Thi Van Pham 171-178
Influence of self-esteem, psychological empowerment, and empowering leader behaviors on assertive PDF behaviors of staff nurses 179-185 Ryan Michael F Oducado
Lived experiences of Overseas Filipino Worker (OFW) nurses working in COVID-19 intensive care units PDF Jane Marnel Pogoy, Jezyl Cempron Cutamora 186-194
Symptom experience of adverse drug reaction among male and female patients with newly diagnosed PDF pulmonary tuberculosis in Thailand 195-202 Apichaya Thontham, Rapin Polsook
Knowledge, attitude, and practice towards COVID-19 among student nurses in Manila, Philippines: A cross- PDF sectional study 203-209 Earl Zedrick S Quisao, Raven Rose R Tayaba, Gil P Soriano
The effect of warm compresses on perineal tear and pain intensity during the second stage of labor: A PDF randomized controlled trial 210-218 Soumaya Modoor, Howieda Fouly, Hawazen Rawas
DAHAGA: An Islamic spiritual mindfulness-based application to reduce depression among nursing students PDF during the COVID-19 pandemic 219-226 Meidiana Dwidiyanti, Badrul Munif, Agus Santoso, Ashri Maulida Rahmawati, Rikhan Luhur Prasetya
“Accessibility”: A new narrative of healthcare services for people living with HIV in the capital city of PDF Indonesia 227-234 Mahathir Mahathir, Wiwin Wiarsih, Henny Permatasari
Original Research: Research Methodology Paper Psychometric properties of Quality-of-Life Index for Vietnamese women with breast cancer three weeks PDF postmastectomy 235-245 Xuan Thi Nhu Ha, Sureeporn Thanasilp
Perspective Common ethical dilemmas of family caregivers of palliative patients in Indonesia PDF Martina Sinta Kristanti, Kusmaryanto Kusmaryanto, Christantie Effendy 246-250
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
iv Case Study Developmental assessment and early intervention for children with developmental delays: A case study in PDF South Australia 251-259 Mardiyanti Mardiyanti, Amanda Case
Letter to Editors Reflections on International Nurses Day: Current status, issues, and the future of nursing in Indonesia PDF Feni Betriana, Tetsuya Tanioka, Rozzano Locsin, Nelwati Nelwati 260-261
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
v
Original Research BNJ
Implementation of nursing case Belitung Nursing Journal Volume 7(3), 141-150 © The Author(s) 2021 management to improve community https://doi.org/10.33546/bnj.1449 access to care: A scoping review
Alenda Dwiadila Matra Putra1 and Ayyu Sandhi2*
Abstract Background: Case management is an approach used to help patients locate and manage health resources as well as to enhance effective communication among patients, families, and health systems. Nurses’ role as case managers has been proven effective in reducing healthcare costs among patients with chronic diseases. However, little is known about its implementation in improving access to care in community-based settings. Objectives: This scoping review aimed to examine the components of nursing case management in improving access to care within community settings and to identify the issues of community-based nursing case management for future implications. Design: This study was conducted following the framework of scoping review. Data Sources: The authors systematically searched five electronic databases (CINAHL, PubMed, Science Direct, Scopus, and Google Scholar) for relevant studies published from January 2010 to February 2021. Only original studies involving nurses as one of the professions performing case management roles in the community-based settings, providing 'access to care' as the findings, were included. Review Methods: The article screening was guided by a PRISMA flowchart. Extraction was performed on Google Sheet, and synthesis was conducted from the extraction result. Results: A total of 19 studies were included. Five components of nursing case management to improve access to care were identified: 1) Bridging health systems into the community, 2) Providing the process of care, 3) Delivering individually-tailored health promotion and prevention, 4) Providing assistance in decision making, and 5) Providing holistic support. In addition, three issues of nursing case management were also identified: 1) Regulation ambiguity, 2) High caseloads, and 3) Lack of continuing case management training. Conclusion: Care coordination and care planning were the most frequent components of nursing case management associated with access to care. These findings are substantial to improve nurses' ability in performing the nursing process as well as to intensify nurses’ advocacy competence for future implications.
Keywords case management; care manager; nursing process; health service accessibility; health resources; nurses’ role
Access to health care is still a persistent challenge in the organizations have committed to eliminating the barriers to healthcare system around the world. Since the Alma Ata universal health coverage (UHC), thus providing accessible Declaration of 1978, 134 countries and 67 international health services for all populations (Pan American Health
1 Department of Nursing, Faculty of Medicine, Public Health and Nursing, Article Info: Universitas Gadjah Mada, Yogyakarta, Indonesia Received: 25 March 2021 Revised: 24 April 2021 2 Department of Pediatrics and Maternity Nursing, Faculty of Medicine, Accepted: 2 June 2021 Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia This is an Open Access article distributed under the terms of the Creative Corresponding author: Commons Attribution-NonCommercial 4.0 International License, which allows others to remix, tweak, and build upon the work non-commercially as long as Ayyu Sandhi, RN, MSc the original work is properly cited. The new creations are not necessarily Department of Pediatrics and Maternity Nursing, Faculty of Medicine, licensed under the identical terms. Public Health and Nursing, Universitas Gadjah Mada Jalan Farmako Sekip Utara, Sleman, Yogyakarta 55281, Indonesia E-ISSN: 2477-4073 | P-ISSN: 2528-181X Phone: +62-274-545674 | Fax: +62-274-631204 Email: [email protected]
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
141 Putra, A. D. M., & Sandhi, A. (2021)
Organization, 2019). One dimension indicating the UHC is This scoping review aimed to examine the components the proportion of people covered by the health system. of nursing case management in improving access to care Based on the report from the World Bank and World Health within community settings as well as the issues for future Organization (WHO), half of the global population could not implications. Two research questions were formulated: 1) obtain basic health services due to poor access (WHO, “What are the components of nursing case management 2017). Access to health care is defined as reaching a health interventions to necessarily improve access to health care service, provider, or institution to utilize appropriate care?” and 2) “What are the issues faced by nursing services in proportion to their need for care (Levesque et professions in delivering case management interventions?” al., 2013). It comprises three distinct components: 1) being This study is expected to provide existing information on able to gain entry into the healthcare system; 2) being able how nursing case management contributes to leaving no to locate provided health care services; and 3) being able one behind in the health system. to communicate with trusted health care providers (Agency for Healthcare Research and Quality, 2020). The Methods commitment to accelerate the UHC should be accompanied by efforts to strengthen community-based health care As the topic of community-based case management’s services and maintain appropriate healthcare financing impact on access to health care has not been systems. comprehensively reviewed, this study employed a scoping Case management is used as an approach to promote approach to evidence synthesis from existing literature better coordination of health care services and enable following the guidelines by Arksey and O'Malley (2005): 1) broader access to all populations. This intervention helps formulation of the research question(s), 2) identification of optimization of available resources; enhances relevant studies, 3) study selection, 4) charting the data, communication among health care providers, patients, and and 5) collating, summarizing, and reporting the results. A their families; and serves as patient advocates within the scoping review does not usually apply critical appraisal for health care system (Fabbri et al., 2017). As the largest selected studies as it includes a wide spectrum of studies occupational group in the health sector (WHO, 2020), the and aims to broadly sum up the research findings (Nam et nursing profession contributes to important roles in case al., 2015). management. Within nursing, a case manager is a nurse responsible for case finding, multidimensional assessment, Search Methods care delivery, monitoring, and evaluation of health Five electronic databases (CINAHL, PubMed, Science outcomes of a patient and their families (Bertuol et al., Direct, Scopus, and Google Scholar) had been searched to 2020). To deliver effective case management intervention, retrieve relevant references. Keywords of ((community) a nurse case manager should obtain clinical, managerial, AND ("case manage*")) AND (nurs*) AND (access) AND and financial skills. In addition, not only should a nurse case (care) were applied to identify original studies published manager be proficient in the health and well-being of between January 2010 and February 2021 with free full-text individuals across the lifespan, but also adept in availability in English or Bahasa Indonesia. communication (with patients, families, and health care team) and the health care system (Fabbri et al., 2017). Eligibility Criteria Currently, nurse case managers work in multiple References were included if those were original studies settings from hospitals, home health services, or patient employing quantitative, qualitative, or mixed methods; homes (Armold, 2019). It has been known as one strategy involving nurses as one of the professions performing case to reduce health care costs (van Voorst & Arnold, 2020). management roles; providing “access to health care” as the There was strong evidence of using case management to main finding; and published in peer-reviewed journals. significantly reduce the patients’ hospital use and improve Conversely, studies were excluded if they did not describe their quality of life (Joo & Liu, 2017; van Voorst & Arnold, case management intervention or roles of nurse case 2020). For individuals with chronic illnesses transitioning manager; only focused on other types of health workers between hospitals and their communities, case (i.e., community health workers, traditional healers); and in management is often cited as an effective intervention to the form of review, editorial, commentary, book, policy improve access to health care services (Joo & Liu, 2017). documents, or government document. According to the Commission for Case Management Certification (CCMC) in the United States, on average, two- Screening thirds of nurse case managers work within community Initially, 505 references were identified, of which 35 were settings (Armold, 2019). However, the majority of evidence duplicates. Two authors then independently screened 470 focused on improving patients' and families' quality of life, studies by title and abstract. After screening by title and cost-effectiveness, and reduced hospital readmission rates. abstract, the full texts of 34 studies were assessed for Information about community-based case management eligibility. After screening the full text, 15 studies were implementation in relation to its impact on access to health excluded. Six studies employed study designs that did not care is limited. fit into the inclusion criteria, five studies focused on other
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142 Putra, A. D. M., & Sandhi, A. (2021) types of health workers, and four studies provided no following information from selected studies: author, explanation about community case managers. Nineteen publication date (year), sample, design, research studies were found to meet the aim of this scoping review objectives, and findings. (Figure 1). Data Analysis Data Extraction Data analysis was conducted by two authors, who Narrative tables were used to chart, collate, and summarize summarized the major findings from selected studies to selected studies. The data charting table was created to draw themes and subthemes independently (Tricco et al., identify themes from research findings in accordance with 2016). Next step, the authors merged the data analysis and the research questions and purpose (Tricco et al., 2016). performed joint analysis to determine the sub-themes of The data extraction table was formulated to insert the research questions.
Figure 1 Flowchart of searching and screening strategy
Results are qualitative studies, while the remaining articles included quasi-experimental studies, analytical studies (cross- Search Results sectional, case study, and cohort study), mixed-method study, and a study utilizing grounded theory. Table 1 Characteristics of selected studies Analytical Findings Categories Details Total % As seen in Table 2, five components of nursing case Design of Qualitative studies 10 52.6 management interventions to improve access to health studies Quasi-experimental 3 15.8 care were deduced, namely: 1) bridging health systems into Analytical studies 4 21.1 the community, 2) providing the process of care, 3) Others 2 10.5 delivering individually-tailored health promotion and Year of 2010-2013 6 31.6 prevention, 4) providing assistance in decision making, and publication 2014-2017 6 31.6 5) providing holistic support. There were also three issues 2018-2020 7 36.8 of nursing case management identified, namely: 1)
regulation ambiguity, 2) high caseloads, and 3) lack of Table 1 presents the characteristics of selected studies continuing case management training. Table 3 presents a after the final full-text assessment. The majority of studies detailed summary of the final studies selected.
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143 Putra, A. D. M., & Sandhi, A. (2021)
Table 2 Themes and subthemes derived from the selected studies
Studies Components Issues
-
training systems into into systems prevention community High caseloads decision making decision Regulation ambiguity management Delivering individually Providing assistance in Lack of continuing case case continuing of Lack Providing holistic support Bridging health Providing the process of care tailored health promotion and and promotion health tailored Balard et al. (2016) V V V V You et al. (2016) V V Williams et al. (2011) V Uittenbroek et al. (2018) V V V V V V Tønnessen et al. (2017) V V Setiawan and Dawson (2018) V V Setiawan et al. (2016) V V Manthorpe et al. (2012) V V V V Klein and Evans‐Agnew (2019) V V V V Hudon et al. (2015) V V V V Hensley (2011) V V V V V Head et al. (2010) V V V V V V Gage et al. (2013) V Dhingra et al. (2016) V V V David et al. (2019) V V V V Cicutto et al. (2020) V V V Chapman et al. (2018) V V V V V Brown et al. (2011) V V V V V Borgès Da Silva et al. (2018) V V
Bridging Health Systems Into Community problem analysis, planning, implementation, and Nurse case managers should be able to engage clients and evaluation (Hudon et al., 2015; Klein & Evans‐Agnew, their families in the health system. This was the most 2019; Toney-Butler & Thayer, 2020). Following those common role, as mentioned in the 16 studies. Nurse case steps, a nurse case manager should determine the formulation of a care plan to meet clients’ needs (Head et managers are responsible for interpreting the information al., 2010; Brown et al., 2011; Manthorpe et al., 2012; Gage from the health system to clients and vice versa (Balard et et al., 2013; Balard et al., 2016; Dhingra et al., 2016; al., 2016). In one case, a nurse case manager becomes Borgès Da Silva et al., 2018; Chapman et al., 2018; David the only health worker in the designated area; thus, it is et al., 2019; Cicutto et al., 2020). The care plan should be important to obtain community trust (Setiawan & Dawson, shifted from traditionally task-oriented to person-centered 2018) so that initial treatment could be promptly delivered care (Uittenbroek et al., 2018) and involve family members (Setiawan et al., 2016). Service provided towards clients to maintain the continuity of care. and family members from the vulnerable population would Delivering Individually-Tailored Health Promotion and eventually help reduce delays in receiving medical care Prevention (Setiawan et al., 2016; Tønnessen et al., 2017). To ensure Six studies reported that nurse case managers provided the continuity of this role, a nurse case manager should personalized health promotion and disease prevention possess strong collaboration skills with other health along with case management itself. The development of professions (Borgès Da Silva et al., 2018; Uittenbroek et personalized service plans helped the patients and families al., 2018; Klein & Evans‐Agnew, 2019). Shared care could understand where they were leading (Hudon et al., 2015). be in the form of communicating with family physicians or Furthermore, it indicated that nurse case managers arranging schedules with general physicians, referrals, or prepare different approaches to each patients’ condition so other community health resources (Hensley, 2011; that the health information obtained would be completely in Williams et al., 2011; Hudon et al., 2015; Klein & Evans‐ accordance with the patients’ needs. For example, Cicutto Agnew, 2019). et al. (2020) presented that the nurse case managers
catered face-to-face visits to teach asthma management Providing the Process of Care (asthma control, inhaler utilization technique) for children As many as 13 studies emphasize the importance of a diagnosed with asthma, and Brown et al. (2011) provided nurse case manager in providing the process of care. The care process includes five essential steps: assessment, additional information besides regular diabetes self- management education sessions. Moreover, Uittenbroek
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144 Putra, A. D. M., & Sandhi, A. (2021) et al. (2018) showed flexible and creative personalities The second issue of nursing case management is were needed in terms of giving chronic care health about the high caseloads; as mentioned in one study, a education for the elderly into their daily routine. In general, nurse case manager should perform multiple roles, thus a nurse case manager should perform promotive and working overtime (Klein & Evans‐Agnew, 2019). The third preventive care to empower clients to be aware of lifestyle issue in nursing case management is the lack of continuing that might cause disturbance in health (Chapman et al., case management training. Experienced nurses should 2018; Uittenbroek et al., 2018); the goal is not only to serve as expert role models and consultants to the case improve patients’ understanding about one’s health but management staff and help to develop training curriculum also to change their health-seeking behavior (Setiawan et for case managers (Head et al., 2010). It is also mentioned al., 2016). that the understanding and recognition of a nurse case manager might depend on one’s adequate training, Providing Assistance in Decision Making although, so far, there is no consensual model of course or Five studies reported the nurse case manager’s role in training for nurse case managers (David et al., 2019). assisting patients and their families in making decisions regarding the treatment and health status. Patients who Discussion had easy access to nurse case managers were reported to have better communication with health professions, better This study provided evidence on components of participation in the process of improving their health and community-based nursing case management and related well-being, and better healthcare transition (Hensley, 2011; issues within the last ten years. To the best of our Hudon et al., 2015). To be able to do that, a nurse case knowledge, this is the first scoping review to describe the manager should own the leadership, articulation, and components and issues in the implementation of case mediation skills (David et al., 2019). management in improving community access to care. This study discovered that nurse case managers Providing Holistic Support connect, coordinate, collaborate, and care for the Seven studies reported that the nurse case manager patients/community with health care service providers contributed to provide holistic support towards patients and through holistic and personalized care provision. Also, it their families. As mentioned in one study focusing on the revealed that most of the nursing case management elderly, patients, and their families emphasized that nurse models cater to specific targeted populations. For example, case manager’s clinical expertise and psychological elderly (Manthorpe et al., 2012; Gage et al., 2013; Balard support contributed to the improvement of the continuum of et al., 2016; You et al., 2016), patients with long-term care provided (Manthorpe et al., 2012). In another study, illness (Hudon et al., 2015; Uittenbroek et al., 2018), elderly and caregivers saw a case manager as a person to palliative patients (Head et al., 2010; Dhingra et al., 2016), be “present”, “help others”, “respond to all the questions”, students/children (Setiawan et al., 2016; Setiawan & and to be “aware of everything”; thus, it is important for a Dawson, 2018; Klein & Evans‐Agnew, 2019; Cicutto et al., case manager to show caring behaviors (Balard et al., 2020) and people living with mental health problems 2016). A nurse case manager should also be aware of any (Chapman et al., 2018) are the populations reported as the cultural or environmental barriers that might hamper one’s beneficiaries in this study. In one study conducted in health status (Brown et al., 2011). Norway, Tønnessen et al. (2017) displayed nurse case managers as health providers to serve diverse populations Issues of Nursing Case Management with varied health conditions. Nurse case managers also Three sub-themes of issues of nursing case management play the same role towards adults under certain primary were identified. First, the regulation ambiguity issue was health care, as presented in a Canadian study (Borgès Da raised in terms of the roles and legal aspects. In one study Silva et al., 2018). This finding showed that nursing case conducted in Indonesia, the legal aspect for prescribing management could be implemented in bridging a broad becomes an issue since nurses are not allowed to range of cases and ages to improve access to care in prescribe medication, yet sometimes they are the only various populations. health provider in the rural areas (Setiawan & Dawson, Another highlighted finding of this review was related to 2018). In Australia, they consistently agreed that the issues that occurred during the implementation of gatekeeper and direct service provision were not the case nursing case management in the community settings. Case manager roles. This study suggests that case managers managers struggle with the ambiguity of the nurse case should just coordinate care service and plan (You et al., managers’ roles and deal with high caseloads as well as 2016). In Norway, case managers often found that limited case management training. A study by Joo and balancing their roles as a care-manager and a provider was Huber (2014), which reviewed nursing case management, a challenging task, also to set the limits between being also reported unclear and confusing roles for nurse case private and professional and consider between patients’ managers in the United States. Periodically nurse case needs and limited resources grant (Tønnessen et al., managers wished to set clear boundaries, but due to the 2017). patient’s condition, nurse case managers were still required
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145 Putra, A. D. M., & Sandhi, A. (2021) to provide direct care. It shows that the sense of caring There is a limitation to this scoping review. The remains a principle among nurse case managers. Advance terminology of community nursing management may vary training would be required for case managers to equip among countries. As a result, it is plausible that several themselves in dealing with these issues (Machini et al., essential articles might not be included in this study. 2020; Muscat, 2020). Therefore, future review studies should include more This review found the implementations of community- terminologies for the keywords in literature searching. based case management are different according to each country’s health care system requirements. Developed Implications for Nursing Management and Health countries like Australia, Norway, and Spain clearly divided Policy the roles and responsibilities between nurses and nurse In the era of UHC reform, many countries committed to case managers. Case managers are only expected to provide accessible health services for all populations perform their natural roles of the case manager. On the despite the consequences of high spending. This other hand, several countries' nurse case managers are commitment should be accompanied by efforts in also counted on to provide direct care services to the strengthening the community-based health care services. community besides performing their role as case This study showed that nurse case managers improve the managers. For example, in England, nurses can hold their access of care for different populations in the community in role as case managers while simultaneously working as both urban and rural areas. Besides, previous studies have practice nurses in the clinic (Iliffe et al., 2011), as district provided evidence on the implementation of case nurses providing visits towards housebound clients in the management to reduce health care spending and the community (Challis et al., 2011), and as disease-specific number of readmissions or rehospitalization (Joo, 2014; nurses in either secondary care settings or the community Duarte-Climents et al., 2019). This is the starting point for (Whittingham & Pearce, 2011). Also, in Indonesia, nurse the government to incorporate the implementation of case managers could be the only health professional in the community-based nursing case management into the particular area, so one should be familiar with disease policy level. In addition, the government still has to consider management and treatments. Differences in roles of nurse the needs and challenges in determining which case case managers among countries are seen as the result of management model is most suitable to the population. different health system issues and challenges in each nation.
Table 3 Detailed summary of the final studies selected
Study Sample Design Objectives Major findings Balard et al. Elderly, Qualitative, To explore the users’ Case managers delivered care to clients and (2016) caregivers, opened- (elderly and their subsequently helped patients and their families engage case ended, and informal caregivers) and with the health system, be familiarized with health France managers guided case managers’ first information and administrative processes, and make interviews experiences of case decisions. Case managers were also seen to perform management caring behavior such as responsive, helpful, present, and aware. You et al. Case Qualitative To explore the The study reported 16 essential roles of case manager (2016) managers study, semi- perceptions about case (CM) in Australia for community aged care. However, (with nursing, structured managers’ role in CM felt that the roles of broker, mediator, and counselor Australia social work, interview establishing community were ambivalent. Moreover, they consistently agreed Allied Health, aged care in Australia that gatekeeper and direct service provision were not the and other case manager roles. This study suggested that case backgrounds) managers coordinate care services and plans. Williams et al. Patients An inductive To explore patients' The study showed that community matrons (CMs) assist (2011) receiving or qualitative views and experiences the patients in the community to obtain easier and had recently design using a of the community shorter coordination and communication with general United Kingdom received care semi- matrons' roles in one physicians, including the referral to advanced health by community structured primary care provider facilities. matrons interview organization Uittenbroek et District A qualitative To explore how district The reflection of the case manager about providing case al. (2018) nurses study of in- nurses and social management was related to the central element of (nurses and depth workers experience new person-centered and integrated care, such as proactive The social interview professional roles as and preventive care delivery that includes monitoring, Netherlands workers) case managers within self-management support, care coordination, and embrace a person- network collaboration. Case management followed the centered and integrated nursing process framework. District nurses focused more care service for on healthcare and medical problems, while social community-living older workers focused more on psychosocial aspects. adults
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Table 3 (Cont.) Tønnessen et Group Qualitative To investigate the The study identified the responsibility of care managers al. (2017) meetings with conflicting expectations in providing services to vulnerable populations. However, care and ethical dilemmas balancing between the task of care manager and health Norway managers and to discuss future provider appears as a challenge. (nurses, clinical implications occupational therapists, physiotherapi sts, and social workers) Setiawan and Primary Interpretative To report on the Nurses and midwives gained confidence and trust from Dawson (2018) healthcare qualitative implementation of the community because they were often the only ones workers methodology community case who could administer medication in the village. CCM Indonesia (nurse, management (CCM) to reportedly thrived the primary health care workers midwives, reduce infant mortality in (PHCWs) clinical reasoning despite the confusion of their kader - cadre) a rural district prescription role. Setiawan et al. Mothers and Qualitative To investigate the Treatment provision could be initiated by primary health (2016) health implementation of care workers (PHCWs) in villages; therefore, it reduced workers community case delays in receiving medical help. Besides, participants Indonesia management (CCM) in were more likely to seek help from PHCWs than the Kutai Timur district traditional birth attendants since PHCWs were employed from the perspective of in the village. Moreover, under the CCM scheme, mothers who received families with sick babies were frequently visited by care PHCW. Manthorpe et Nurse case Case study To understand the The opinions of older people receiving nurse case al. (2012) managers, effects of nurse case management revealed the value of high-intensity older people, manager (NCMS) assistance to individuals with major health and social England family carers working in primary care needs. Older people or their carers reported the in the English national improvement of continuity of care provision and health service (NHS) psychosocial support. NCM supplemented social from multiple services by identifying unmet needs. perspectives and how this new role impacts social workers Klein and School Grounded To develop a theory Nurses provided direct nursing care in several forms for Evans‐Agnew nurses theory describing the processes children in the school. (2019) and actions for school case management United State of targeting children with America chronic conditions Hudon et al. Patients and Descriptive, To examine experience Easy access to the CM nurse facilitated communication. (2015) family qualitative, in- of patients and their This also allowed closer follow-up when needed. The members depth family members with privileged access to CM nurses fostered better Canada interview care integration as part communication with their family physicians. Participants of a primary care case reported improved access to personalized information, manager (CM) communication, coordination, and decision-making intervention assistance, as well as better healthcare transition. Hensley (2011) Case Qualitative, To explore the These managers saw themselves as an essential bridge managers focus group perceptions and in the process of medication utilization for their clients. United States of with nursing interview experiences of Case managers allocated their time to talk with clients by America background community-based phone and browse the Medicare websites, assisting the and mental health case client in understanding the information and making professionals managers in the field of decisions about Medicare benefits. from other Medicare prescription disciplines drug benefits Head et al. Users, nurses Quasi- To integrate palliative Provision of palliative care case management included (2010) experiment care principles and assessment of physical and psychosocial complications practices into the daily experienced by patients with serious illnesses, United States of routines of a Medicaid pharmaceutical interventions, identification of community America managed care provider resources to assist palliative care patients, and assistance in hospice referrals. Gage et al. Elderly, Case study To compare community The roles of case management were varied among (2013) nurses matrons in holding case nurses. Meanwhile, community matrons were working management roles for more intensively on the elderly and those taking more England impact on service medication than nurse case managers. utilization and costs
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Table 3 (Cont.) Dhingra et al. Adult users Retrospective To evaluate a diverse Case managers played roles in conducting a (2016) cohort study population served by an comprehensive assessment (medical evaluation and interdisciplinary model of mental health wellness of patients and their family), United States of community-based formulation of goals of care and advance care plans, America specialist palliative care evaluation of the need for home care, and evaluation of and the variation in the need for care coordination and hospice eligibility. In service delivery over delivering care, the duties were assigned to an time and identify interdisciplinary team including nurses, physicians, social subgroups with distinct workers, nurses who provided telephone support, and illness burden profiles chaplains. Individuals who received more home visits and telephone calls had greater health improvement. David et al. Nurses Literature To present and discuss As case managers, nurses should understand the (2019) review and the central aspects of health-illness process as a result of a complex qualitative the case manager nurse interaction of factors at various levels of life; perform Spain approach work process in three care beyond individual needs because the scope is including Spanish autonomous broad and include not only patients but also the individual communities caregivers; own the leadership, articulation and interviews mediation skills. Cicutto et al. Users, Quasi- To describe the A school nurse provided case management and case (2020) caregivers, experiment elements of asthma care coordination, including delivering care (asthma school nurses program and its management, asthma control, and medication United States of utilization by school management) and providing asthma education to both America nurses and school health clients and parents/guardians. Barriers in conducting teams in two urban case management, among others, are difficulty in school districts making contact with carers, restricted access to health- care records outside school settings, and time limitations experienced by school health teams. Chapman et al. Public county- Mixed To describe how A PMHNP provided case management services, (2018) based mental methods psychiatric mental health including formulating care plans (medication health approach, nurse practitioners management, crisis stabilization, and crisis intervention), United States of delivery including a (PMHNP) are made use assisting clients in administrative issues, and performing America system semi- of, determine obstacles promotive functions (empower clients to be aware of structured to full access, and lifestyles that might cause disturbance in health). interview evaluate PMHNP's economic contribution to public health systems Brown et al. Adult users Quasi- To explore the feasibility Roles of a nurse case manager, among others, are: (2011) experiment of adding a nurse case providing health education and consultation about manager to diabetes diabetes self-management, assisting patients in coping United States of self-management with cultural and environmental barriers, assisting America education to foster users' patients in locating and accessing health care facilities, attendance and increase as well as collaborating with health care teams. utilization of other Individuals who had higher contacts with nurse case available health care managers attended diabetes self-management services education sessions more often. In addition, participants expressed preference of having face-to-face contact with the nurse case managers than by telephone. Borgès Da Silva Adult users, Cross- To evaluate patients’ Patients experienced better access to primary health et al. (2018) primary sectional experience of care in facilities as nurses acted as case managers and health care primary care as it systematically followed patients. In addition, sharing care Canada organizations pertained to the nursing between nurses and general physicians could enhance role primary care access.
Conclusion consider the issues, needs, and challenges of each country in determining which case management model is most Care coordination and care planning were the most suitable to the population. Also, clear regulation and components of nursing case management frequently continuing training for case management should be associated with access to care. This scoping review provided by the authorities to reduce the occurrence of showed that nurse case managers improve the access of possible constraints during the implementation. Further care for different populations in the community, both urban research is needed to find a nursing case management and rural areas, besides reducing health care spending model according to primary health care to accelerate and the number of readmissions or rehospitalization. achieving UHC and develop validated measurement tools However, the initiation of implementation still has to to measure access to care based on the components of the community nursing case management model.
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Declaration of Conflicting Interest for asthma care program: A school-centered program The authors have no conflict of interest to declare. connecting schools, families, and community health-care providers. The Journal of School Nursing, 36(3), 168-180. Funding https://doi.org/10.1177/1059840518805824 This study did not obtain any grant from a funding agency. David, H. M. S. L., Riera, J. R. M., Mallebrera, A. H., & Costa, M. F. d. L. d. (2019). Case management nurse in Spain: Facing Authors’ Contribution the challenge of chronicity through a comprehensive practice. All authors contributed equally to the study conceptualization, Ciência & Saúde Coletiva, 25, 315-324. https://doi.org/10. methodology, article search, data analysis, writing, and editing of 1590/1413-81232020251.29272019 the manuscript. All authors approved the final version of the article. Dhingra, L., Dieckmann, N. F., Knotkova, H., Chen, J., Riggs, A., Breuer, B., . . . Portenoy, R. (2016). A high-touch model of Authors’ Biographies community-based specialist palliative care: Latent class Alenda Dwiadila Matra Putra, RN is an Assistant for Publication, analysis identifies distinct patient subgroups. Journal of Pain Research, and Collaboration at the Department of Nursing, and Symptom Management, 52(2), 178-186. Faculty of Medicine, Public Health, and Nursing, Universitas Duarte-Climents, G., Sánchez-Gómez, M. B., Rodríguez-Gómez, Gadjah Mada, Indonesia. J. Á., Rodríguez-Álvarez, C., Sierra-López, A., Aguirre-Jaime, Ayyu Sandhi, RN, MSc is a Lecturer at the Department of A., & Gómez-Salgado, J. (2019). Impact of the case Pediatric and Maternity Nursing, Faculty of Medicine, Public management model through community liaison nurses. Health, and Nursing, Universitas Gadjah Mada, Indonesia. International Journal of Environmental Research and Public Health, 16(11), 1894. https://doi.org/10.3390/ijerph16111894 References Fabbri, E., De Maria, M., & Bertolaccini, L. (2017). Case Agency for Healthcare Research and Quality. (2020). National management: An up-to-date review of literature and a healthcare quality & disparities report chartbooks. Retrieved proposal of a county utilization. Annals of Translational from https://www.ahrq.gov/research/findings/nhqrdr/chart Medicine, 5(20), 396. https://doi.org/10.21037/atm.2017. books/index.html 07.26 Arksey, H., & O'Malley, L. (2005). Scoping studies: Towards a Gage, H., Ting, S., Williams, P., Drennan, V., Goodman, C., Iliffe, methodological framework. International Journal of Social S., . . . Masey, H. (2013). Nurse‐led case management for Research Methodology, 8(1), 19-32. https://doi.org/10.1080/ community dwelling older people: An explorative study of 1364557032000119616 models and costs. Journal of Nursing Management, 21(1), Armold, S. (2019). Case management: An overview for nurses. 191-201. https://doi.org/10.1111/j.1365-2834.2012.01379.x Nursing2020, 49(9), 43-45. https://doi.org/10.1097/01.NUR Head, B. A., LaJoie, S., Augustine-Smith, L., Cantrell, M., SE.0000577708.49429.83 Hofmann, D., Keeney, C., & Pfeifer, M. (2010). Palliative care Balard, F., Gely-Nargeot, M.-C., Corvol, A., Saint-Jean, O., & case management: increasing access to community-based Somme, D. (2016). Case management for the elderly with palliative care for medicaid recipients. Professional Case complex needs: Cross-linking the views of their role held by Management, 15(4), 206-217. https://doi.org/10.1097/NCM. elderly people, their informal caregivers and the case 0b013e3181d18a9e managers. BMC Health Services Research, 16(1), 1-10. Hensley, M. A. (2011). Case managers and the use of Medicare, https://doi.org/10.1186/s12913-016-1892-6 part D. Professional Case Management, 16(6), 301-308. Bertuol, M., Di Niro, V., Tagliabue, C., Ventre, V., Cusenza, P., https://doi.org/10.1097/NCM.0b013e31821ee1f5 Taffurelli, C., . . . Artioli, G. (2020). The process of developing Hudon, C., Chouinard, M.-C., Diadiou, F., Lambert, M., & the professional identity of the nurse case care manager: A Bouliane, D. (2015). Case management in primary care for grounded theory study. Acta Bio-Medica: Atenei Parmensis, frequent users of health care services with chronic diseases: 91(6-S), 19-27. https://doi.org/10.23750/abm.v91i6-S.10019 A qualitative study of patient and family experience. The Borgès Da Silva, R., Brault, I., Pineault, R., Chouinard, M.-C., Annals of Family Medicine, 13(6), 523-528. https://doi.org/ Prud’homme, A., & D’Amour, D. (2018). Nursing practice in 10.1370/afm.1867 primary care and patients’ experience of care. Journal of Iliffe, S., Drennan, V., Manthorpe, J., Gage, H., Davies, S. L., Primary Care & Community Health, 9, 2150131917747186. Massey, H., . . . Goodman, C. (2011). Nurse case https://doi.org/10.1177/2150131917747186 management and general practice: Implications for GP Brown, S. A., García, A. A., Winter, M., Silva, L., Brown, A., & consortia. British Journal of General Practice, 61(591), e658- Hanis, C. L. (2011). Integrating education, group support, and e665. https://doi.org/10.3399/bjgp11X601370 case management for diabetic Hispanics. Ethnicity & Disease, Joo, J. Y. (2014). Community-based case management, hospital 21(1), 20-26. utilization, and patient-focused outcomes in Medicare Challis, D., Hughes, J., Berzins, K., Reilly, S., Abell, J., Stewart, beneficiaries. Western Journal of Nursing Research, 36(6), K., & Bowns, I. (2011). Implementation of case management 825-844. https://doi.org/10.1177/0193945913514140 in long-term conditions in England: Survey and case studies. Joo, J. Y., & Huber, D. L. (2014). An integrative review of nurse‐ Journal of Health Services Research & Policy, 16(1_suppl), 8- led community‐based case management effectiveness. 13. https://doi.org/10.1258/jhsrp.2010.010078 International Nursing Review, 61(1), 14-24. https://doi.org/ Chapman, S. A., Phoenix, B. J., Hahn, T. E., & Strod, D. C. (2018). 10.1111/inr.12068 Utilization and economic contribution of psychiatric mental Joo, J. Y., & Liu, M. F. (2017). Case management effectiveness in health nurse practitioners in public behavioral health services. reducing hospital use: A systematic review. International American Journal of Preventive Medicine, 54(6), S243-S249. Nursing Review, 64(2), 296-308. https://doi.org/10.1111/ https://doi.org/10.1016/j.amepre.2018.01.045 inr.12335 Cicutto, L., Gleason, M., Haas-Howard, C., White, M., Hollenbach, Klein, N. J., & Evans‐Agnew, R. (2019). Flying by the seat of their J. P., Williams, S., . . . Cloutier, M. M. (2020). Building Bridges pants: A grounded theory of school nurse case management.
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Journal of Advanced Nursing, 75(12), 3677-3688. https://doi. conflicting expectations. BMC Health Services Research, org/10.1111/jan.14204 17(1), 1-10. https://doi.org/10.1186/s12913-017-2578-4 Levesque, J.-F., Harris, M. F., & Russell, G. (2013). Patient- Tricco, A. C., Lillie, E., Zarin, W., O’Brien, K., Colquhoun, H., centred access to health care: Conceptualising access at the Kastner, M., . . . Wilson, K. (2016). A scoping review on the interface of health systems and populations. International conduct and reporting of scoping reviews. BMC Medical Journal for Equity in Health, 12(1), 1-9. https://doi.org/10. Research Methodology, 16(1), 1-10. https://doi.org/10.1186/ 1186/1475-9276-12-18 s12874-016-0116-4 Machini, B., Zurovac, D., Amboko, B., Malla, L., Snow, R. W., Uittenbroek, R. J., van der Mei, S. F., Slotman, K., Reijneveld, S. Kipruto, H., & Achia, T. N. O. (2020). Predictors of health A., & Wynia, K. (2018). Experiences of case managers in workers’ knowledge about artesunate-based severe malaria providing person-centered and integrated care based on the treatment recommendations in government and faith-based Chronic Care Model: A qualitative study on embrace. Plos hospitals in Kenya. Malaria Journal, 19(1), 1-10. One, 13(11), e0207109. https://doi.org/10.1371/journal.pone. https://doi.org/10.1186/s12936-020-03341-2 0207109 Manthorpe, J., Goodman, C., Drennan, V., Davies, S. L., Masey, van Voorst, H., & Arnold, A. E. R. (2020). Cost and health effects H., Gage, H., . . . Iliffe, S. (2012). Nurse-led case management of case management compared with outpatient clinic follow‐ in the National Health Service: Bridging clinical and social up in a Dutch heart failure cohort. ESC Heart Failure, 7(3), worlds. Primary Health Care Research & Development, 13(2), 1136-1144. https://doi.org/10.1002/ehf2.12692 153-164. https://doi.org/10.1017/S1463423611000533 Whittingham, K., & Pearce, D. E. (2011). Carer support from a Muscat, J. W. (2020). A case study evaluation of a community community-based heart specialist nurse service. British multidisciplinary team in South East England using a mixed- Journal of Nursing, 20(21), 1388-1393. https://doi.org/10. method approach. British Journal of General Practice, 12968/bjon.2011.20.21.1388 70(suppl 1). https://doi.org/10.3399/bjgp20X711569 WHO. (2017). World Bank and WHO: Half the world lacks access Nam, S., Redeker, N., & Whittemore, R. (2015). Social networks to essential health services, 100 million still pushed into and future direction for obesity research: A scoping review. extreme poverty because of health expenses. Retrieved from Nursing Outlook, 63(3), 299-317. https://www.worldbank.org/en/news/press-release/2017/12/ https://doi.org/10.1016/j.outlook.2014.11.001 13/world-bank-who-half-world-lacks-access-to-essential- Pan American Health Organization. (2019). Universal health in the health-services-100-million-still-pushed-into-extreme-poverty- 21st century: 40 years of Alma-Ata. Report of the High-Level because-of-health-expenses Commission. Retrieved from WHO. (2020). State of the world's nursing 2020: investing in https://www.paho.org/en/documents/universal-health-21st- education, jobs and leadership. Retrieved from https://apps. century-40-years-alma-ata-report-high-level-commission- who.int/iris/handle/10665/331677 revised Williams, V., Smith, A., Chapman, L., & Oliver, D. (2011). Setiawan, A., & Dawson, A. (2018). Strengthening the primary Community matrons–an exploratory study of patients’ views care workforce to deliver community case management for and experiences. Journal of Advanced Nursing, 67(1), 86-93. child health in rural Indonesia. Australian Health Review, https://doi.org/10.1111/j.1365-2648.2010.05458.x 42(5), 536-541. https://doi.org/10.1071/AH17092 You, E., Dunt, D., & Doyle, C. (2016). What is the role of a case Setiawan, A., Dignam, D., Waters, C., & Dawson, A. (2016). manager in community aged care? A qualitative study in Improving access to child health care in Indonesia through Australia. Health & Social Care in the Community, 24(4), 495- community case management. Maternal and Child Health 506. https://doi.org/10.1111/hsc.12238 Journal, 20(11), 2254-2260. https://doi.org/10.1007/s10995- 016-2149-z Cite this article as: Putra, A. D. M., & Sandhi, A. (2021). Toney-Butler, T. J., & Thayer, J. M. (2020). Nursing process. Implementation of nursing case management to improve Treasure Island, FL: StatPearls Publishing. community access to care: A scoping review. Belitung Nursing Tønnessen, S., Ursin, G., & Brinchmann, B. S. (2017). Care- Journal, 7(3), 141-150. https://doi.org/10.33546/bnj.1449 managers’ professional choices: Ethical dilemmas and
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150 Theory and Concept Development BNJ
Belitung Nursing Journal Self-control in old age: A Volume 7(3), 151-162 © The Author(s) 2021 grounded theory study https://doi.org/10.33546/bnj.1412
Laarni A. Caorong*
Abstract Background: Self-control is associated with multiple positive outcomes. There are several studies on self-control, yet no literature describing the mechanism of self-control in old age. Objective: This study aims to develop a substantive theory on the exercise of self-control in old age. Methods: Grounded Theory methodology developed by Glaser & Strauss was utilized in the conduct of this study with ten (10) older adults as participants following the set of inclusion and exclusion criteria. Individual in-depth interviews of 30-45 minutes were observed to gather the needed verbatim narrative responses from each participant after careful consideration of the ethical procedures approved by the University research ethics board. Major themes with their respective sub-themes were generated after rigorous analysis of the participants’ responses following the steps provided by Glasser & Strauss in conducting grounded theory studies. Results: This study resulted in the formulation of three propositions such as: (1) Older adults exercise self-control differently, (2) several personal motivations are involved in the exercise of self-control, and (3) the exercise of self- control leads to life satisfaction. From the propositions emerged the Theory of Self-control in Old age, which states that the process of self-control encompasses the human capability of exercising self-restraint to overrun different types of desires, passions, and temptations. The theory posits that older adults vary in their exercise of self-control depending upon their personal motivations. The theory also assumes that the exercise of self-control results in life satisfaction as displaying self-control is attributed to a host of positive life outcomes. Conclusion: The present study has important implications in the field of gerontology and health care services since the older population is growing, and so does the demand for health care services. The need to understand the choices and decisions of older adult clients is fundamental in individualizing the health care services that may be designed and provided for them.
Keywords self-control; grounded theory; old age; inductive approach; nursing
In life, human beings struggle to make optimal decisions so Late-life is often seen as a stage where there are often, which require the exertion of self-control. Self-control multiple losses in various life domains. Empirical evidence is crucial before making any personal decision or choice shows that a decrease in physical function and cognitive (De Ridder et al., 2012). The decisions may involve ability is prevalent in late life, attributed to the biological economic choices, decisions about lifestyle preferences, changes in aging (Baltes & Mayer, 2001; Sadang & moral choices, and personal predilections (Baumeister et Palompon, 2021; Salthouse, 1996; Schaie, 1989). al., 2007). Self-control is mainly the restraint that people Considerably, the decline of the physical function of old use on their desires and impulses (Baumeister, 2012). people as well as the older adults’ mental agility is linked More specifically, it is the capability to overrule or override with the aging changes at the biological level (Baumeister one’s response. Self-control is a self-initiated practice in & Alquist, 2009). Resultantly, there is a decrease and loss which the individual himself instigates the process of physical and cognitive functioning. As defined in this (Duckworth et al., 2014). study, self-control is a cognitive process governing one’s emotions, actions, and feelings. Notably, the exercise of
College of Health Sciences, Mindanao State University – Marawi, Article Info: Philippines Received: 28 February 2021 Revised: 29 March 2021 Accepted: 3 May 2021 Corresponding author: Dr. Laarni A. Caorong, RN, MAN This is an Open Access article distributed under the terms of the Creative College of Health Sciences, Mindanao State University – Marawi Commons Attribution-NonCommercial 4.0 International License which allows others to remix, tweak, and build upon the work non-commercially as long as 5th East Tubod, Iligan City 9200, Philippines the original work is properly cited. The new creations are not necessarily Mobile: +639-213-403-270 licensed under the identical terms. Email: [email protected] E-ISSN: 2477-4073 | P-ISSN: 2528-181X
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151 Caorong, L. A. (2021) self-control involves cognitive function. The link between understand the choices and decisions of older adult clients the cognitive decline in aging and the capacity to exercise is fundamental in individualizing the health care services self-control in old age remains largely unknown although that may be designed and provided for them. this might have a bearing on the older adults’ decisions affecting health, financial, social, and other life domains. Methods Self-control is consequential; thus, this essential concept needs further investigation (Baumeister et al., 2007). Design Population growth and longevity of older people mean The Grounded Theory method developed by Glaser and that the health care decisions they make, the investments Strauss (1967) was followed in undertaking this research they focus on, and the general choices they take in life will study with the main aim of generating a substantive theory become increasingly important to the society other than of self-control in old age. Systematic collection of themselves (Boals et al., 2011). The exercise of self-control qualitative data was employed to selected participants to comes into the picture when an older adult is faced with a gather datasets by carrying out a one-on-one in-depth decision to take. The decisions to control, restrain, interview to obtain a rich description of how people in old suppress or act out are but consequential and will affect the age exercise self-control. In this research study, the older adult himself and other people (Tangney et al., 2004). participants’ subjective experiences were explored to Remarkably, older adults display various life decisions in better understand their exercise of self-control in late life terms of their physical health, how they engage socially (Streubert & Carpenter, 2011). The purpose of Grounded with others, in financial matters, and others (Sadang & Theory is to explore and describe a phenomenon in Palompon, 2021). Varied life avenues require the naturalistic settings. The target of Grounded Theory is to demonstration of self-control. The practice, according to reach a conceptual theory that can explain and predict the many researchers, yields positive outcomes (Tangney et experiences of the interview persons in relation to their life al., 2004). Although this is common knowledge, yet many conditions (Glaser & Strauss, 1967). Moreover, an older adults come up with poor choices in terms of health inductive approach to theory development was utilized. practices, fail in financial management, and sometimes The process involved in this study included gathering have a strained relationship with other people as a result of qualitative data, analyzing the data collected, developing the poor exercise of self-control (De Ridder et al., 2012). hypotheses and propositions, and finally generating a This requires deeper understanding and investigation. substantive theory (Streubert & Carpenter, 2011). The Since the exercise of self-control is consequential, the idea theory develops and evolves during the actual research of delving deeper into this concept is not only vital but process as an interplay between data collection and relevant. analysis ensues. Existing literature states that self-control is an essential element for attaining one’s goals, being successful in one’s Participants undertaking, and resisting ones’ selfish and one’s The participants were selected following inclusion criteria, potentially harmful impulses. Since desires and which included the following: (a) willingness to participate temptations are ever-present, there is a need to exercise in the research study, (b) 60 years old and above, (c) self-control. Although there were studies on children’s self- resident of Iligan City, (d) no cognitive disabilities, and (e) control in relation to their success in later life (Mischel & able to articulate and express thoughts, ideas and Ebbesen, 1970; Mischel et al., 1989), the mechanism of experiences. The cognitive level was assessed through the self-control in old age has not been well documented. usage of a short portable mental questionnaire (Pfeiffer, Hence, the knowledge on the exercise of self-control in old 1975). Exclusion criteria were: (a) those who were age in terms of their health practices and behaviors and cognitively impaired, (b) physically and psychologically their social and financial dealings requires deep frail, and (c) those who were unwilling to participate in the elaboration. The foregoing clearly shows the need to study. investigate the mechanism of self-control in old age to provide an elaborate description of how it is exercised in Sampling later life and its impact on the various life aspects of older Theoretical sampling was employed in the study involving adults. Hence, the purpose of this study was to generate a ten (10) older adults from Iligan City, Philippines. substantive theory of self-control among older adults in old Theoretical sampling is the process of generating theory age. The knowledge thereof will provide a succinct idea from the data (Glaser & Strauss, 1967). In this study, and understanding about this human quality trait which is theoretical sampling was methodologically followed deemed essential before making optimal life decisions. throughout the interview process. The present study has important implications in the field of gerontology and also in health care services since the Data Gathering Process older population is growing over the past years. Hence, A face-to-face interview using an in-depth interview was there is an expectation obviously of a growing demand for conducted by the researcher in collecting qualitative data. health care services. So, there is a need for health care The interview session was carried out within 30-45 minutes professionals to understand elderly clients. The need to until data saturation was reached and theoretical sampling
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152 Caorong, L. A. (2021) was attained. The conversation was recorded in an audio commenting about the codes. Reflections and ideas about recorder, and permission was sought to record the codes and relationships between codes were made, which conversation explaining its necessity to capture every created the link between raw data and formal theorizing single detail of the dialogue. A semi-structured interview and hypothesis creation (Streubert & Carpenter, 2011). style was employed, and guide questions were used. The research participants’ perceptions, ideas, and experiences of self-control were explored and investigated Ethical Considerations using open ended-questions. The guide questions were Ethics approval of the protocol by the Cebu Normal primarily rooted from the main research question, which University- Research Ethics Committee (CNU-REC) with was ‘how do individuals in old-age exercise self-control’. CNU-REC code 229/2019-02 Caorong was secured as The idea was to ground the data which were systematically part of the research protocol. Permission and approval collected to describe self-control in old age. Moreover, from the Office of the Senior Citizens Affairs (OSCA) – probing questions or statements were used to prompt Iligan Chapter president was also observed prior to the answers and explanations. Statements such as ‘please conduct of this study. Each of the participants was given a elaborate or expound’, ‘tell me more’, ‘can you please copy of the informed consent duly approved by the CNU- clarify’, ‘what was the outcome’, ‘please, expound’, ‘I’d like REC. The researcher comprehensively explained the to hear more’, etc. were used. content of the informed consent in the dialect that the participant understood. After a thorough explanation and Results and Discussion discussion, the participants were asked to sign the informed consent form. The researcher assured that In this section, the basic description of the participants and participation is voluntary and that at any given rate if the their self-control process are presented. Ten older adults study participant should wish to stop participating, it should who were residents of Iligan City were recruited to join the be recognized and respected. research. All of the older adults who participated were within the age range of 62-92 years. Fifty percent (50%) of Analysis the participants were male. Table 1 indicates the basic After having gone through some initial analysis of the data information of the participants. gathered, the researcher made some notes on what key concepts needed elaboration. The research participants Table 1 Participants’ Profile were then asked about the concepts that needed elaboration until key and important concepts were Code Age Gender Religion Marital described, elaborated, and clarified. When there was a status redundancy of the information gathered from the research TOM 64 Male Islam Married participants, this signaled that there was already data ZEN 69 Female Iglesia ni Cristo Widowed saturation. Constant comparison was made by comparing ROB 63 Male Roman Catholic Widowed the findings with the existing findings. This method was REM 76 Female Roman Catholic Widowed DEB 64 Female Seventh Day Married essential in constructing theoretical categories which Adventist represented the core categories or concepts of the study DAN 92 Male Islam Married on self-control in old age (Streubert & Carpenter, 2011). MAX 78 Male Roman Catholic Married Grounded Theory involves several steps such as TEL 62 Female Protestant Widowed coding, memo writing, theoretical sampling, and the CEL 70 Female Islam Separated method of constant comparison (Glaser & Strauss, 1967). TED 78 Male Roman Catholic Married In this study, reading the qualitative data several times was done, and for chunks of data that had been gathered, Through constant comparative analysis, theoretical labels were then made. The labels were based on the categories emerged, which were essential in the meaning that emerged from the data. After open coding identification of the core theoretical categories which would one set of data, interconnections between categories and substantiate the theory of control in old age. Four codes were created. The process is called axial coding. At theoretical categories were formulated from the sixteen this stage of the data analysis, the researcher integrated sub-categories identified about the theory of self-control in the categories identified in the axial coding process. The old age, namely: (1) self-introspection and assessment, (2) selection of the core categories was made by decision and choice of action, (3) action, reaction and systematically relating the categories discovered. conduct as an indication of self-control, and (4) outcome Moreover, the categories were then validated through and impact of self-control. finding existing relationships. Further development was made by filling in categories that require more refinement Theoretical Category 1: Self-introspection and and development (Streubert & Carpenter, 2011). Assessment Memo writing was an essential aspect of the coding The process of self-control is initiated by an older adult who process (Glaser & Strauss, 1967). This was initiated as engages personally in self-introspection and assessment. soon as coding was started. It involved theorizing and By introspection, the cognitive thought process is activated
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153 Caorong, L. A. (2021) when a situation arises. This involves self-appraisal by an health-related changes as well as the current circumstance older adult concerning the advent of the situation or that the older adult is experiencing. The decision is also experience. Self-introspection primarily involves driven by outer and inner personal motives. examination or assessment of one’s thought and emotional Sub-category 1: Involvement of personal decision processes. The reflection involves looking into and and choice considering one’s experience, valuing one’s moral The exercise of self-control involves decision-making standards, and taking into consideration the lessons and choosing the next course of action or behavior to gained from the past experiences. employ. The individual himself does the exercise of self- Sub-category 1: Involvement of thinking and control. Older adults view self-control as a process assessment involving personal decisions and choices. The decision In exercising self-control, the older adults engaged the process includes weighing the pros and cons of a certain thought process through thinking and considering the next action or the negative or positive consequences of the course of action or response. The display of self-control by decision before coming up with a choice on what to take the older adults involves not only the concept of thinking and do as the next course of action. but also discerning in deep thought the possibilities and consequences of one’s action or response. This stage of “Self-control is a mental process. For instance, in a certain the process encompasses the process of assessment. situation, I choose not to get affected since I am afraid of another (heart) attack. In such a case, I really weigh things out. “You really have to engage in thinking. Thereafter, you can For example, I would not readily react to provocations to abate make a decision. It is really a personal decision and that you a situation because it could very well lead to conflict. Self- are aware that there are consequences of your choices and control is a cognitive process. It is a self-initiated process.” decision which would impact you.” ROB ROB
Sub-category 2: Valuing moral standards Sub-category 2: Thinking of the consequence of This pertains to the strong influence and consideration one’s decision of moral standards in self-control exercised by the older In the exercise of self-control, before the older adult participants. As many older adults have a strong sense of decides what to do next, he looks at the possible spirituality, their exercise of self-control is driven by a highly consequences of his decision and his choice of action. The personal motive of being afraid to commit sins and because older adult’s choice of action is in consideration of the of the fear of God and wanting to please Him. consequences both positive and negative of one’s decision and choice of action. “Well, the motivation for a religious person, for example, is avoidance of sin because the moment you don’t control “Before going to America, I was actually engaged in all sorts yourself, you transgress the criteria of moral… or you violate of vices. I was involved in drinking intoxicants and gambling. I the sharia (law). That’s the bottom line.” TOM did all those vices, but when I left the country, I also left those vices. I controlled myself to leave those vices so that I would not have any problems with my family and children. My family Sub-category 3: Knowledge and lessons gained remains intact after leaving those vices. I actually now live a through experience comfortable life.” TED The learnings gained from their past experiences gave them significant reasons to avoid experiencing the same Sub-category 3: Consideration of age and health- situation again, such as having experienced conflict within related changes the family as well as suffering due to poor health choices Older adults go through several changes in cognition, before. emotion, physical strength, and health, among other human aspects. The decision and choice of action by the “Hypothetically, you can control, or you can tame yourself to study participants were actually influenced by their current exercise self-control. You learn from exercising it. And you state of health as they now are keen on considering the develop already that kind of self-discipline. You can now internalize through yourself the virtue of discipline or the virtue different changes they are experiencing. Current changes of self-control how to attain self-control.” TOM in the aspect of health, for instance, had made them become motivated to demonstrate more self-control. They Theoretical Category 2: Decision and Choice of Action have changed their old practices to what now is necessary Self-control as a process involves the ability of an individual and recommended for them to do. to govern one’s actions, feelings, or emotions. The process also involves deciding and choosing the next course of “I usually do physical exercises every morning for 15-20 action. The choice of action comes out after having minutes. I usually force myself to get up so that I could expose my body to the sunlight before 8 am. This is so that I would be engaged in self-introspection or assessment. The decision exposed to the sunlight for Vitamin D.” REM is as well influenced by thinking of the positive and negative consequences of the actions. Furthermore, deciding the next course of action includes the consideration of the
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Sub-category 4: Consideration of current life Sub-category 1: Restraining self from acting out circumstance This sub-category reflects the manifestation of self- This category reflects that older adults go through restraint by an individual who exercises control in terms of varied life circumstances. Obligations and duties do not his actions. By restraining himself, he is engaged in a stop with aging. Certain responsibilities and obligations by deliberate action of his choosing. The choice of action is older adults need to be fulfilled and accomplished. Many processed within himself taking on different considerations older adults exercise self-control to carry through their such as the possible consequences. responsibilities in life. “Sometimes I get angry with my husband over minor things “If I won’t control my spending and just squander my money such as when our kitchen is messy. At home, I really like things carelessly, then for sure I will not have enough money for to be in their proper places, but my husband has this habit of future use. Although I wanted to eat rice, I restrain myself putting candy wrappers on my vases which I dislike. When that because eating rice could potentially cause my sugar to rise. I happens, I gently reprimand him. I now have self-restraint, but am also financially incapable of affording rice for myself and before, I usually throw things at him and sometimes even give my helper’s consumption.” REM him a smack.” DEB
Sub-category 5: Inner motivations of the exercise Sub-category 2: Resisting temptation and passion of self-control Human beings are surrounded by different and varying According to the participants, their exercise of self- types of desires, passions, and temptations. However, control includes inner motivations. Such inner motivation there are temptations and desires that need to be resisted included the want to avoid sin and to abide by moral because of the harm they could bring. This is where the standards. Fear of God also surfaced as an inner motive in exercise of self-control is needed. The exercise of self- self-control exercise as well as giving value to the Divine control against the desires and passion of an individual commands. entails struggle and effort.
“The number one reason why I exercise self-control is “Well, of course, with the basic control is fasting. It should also because of fear to commit sin to God. I also don’t like any be observed throughout your daily life. For example, if you can trouble, and I don’t want to experience a headache.” REM control partaking food like this one (points at the food on the table) … learning from this virtue for your daily life, you can Sub-category 6: Various outer motivations of the control not taking any food like taking any sweets, palatable food, cold drinks and all that. You can control yourself even if exercise of self-control it is palatable or satisfying through drinking cold water. I don’t Other than the inner motives of exercising self-control, even care for cold water or sweets or chocolate. I don’t care various outer motivations of the exercise thereof were also for those. I just take vegetable, and I cannot even finish a cup discovered. The various outer motivations in the exercise of rice. So that is the result of fasting.” TOM of self-control among the study participants included wanting to maintain social relationships intact, promoting Sub-category 3: Suppressing inner feelings health status, and managing financial resources well for Expressing emotions and feelings are inherent in a future use. man. There are constant engagements and interactions among people anytime and anywhere. The experience “If I would not control my spending and just squander my may often evoke the expression of feelings and emotions, money carelessly, I would not have enough funds for future yet, consequently, certain situations necessitate the use. There are really times that I suffer an asthma attack. exercise of self-control to keep the good social relationship During those times, there is really a need for me to purchase going and avoid unnecessary expressions of words that my asthma medication which costs over a thousand pesos. So, I really need to have some money on those times.” REM may not be received well by others.
Theoretical Category 3: Action, Reaction or Conduct “I know how to control myself. For instance, when provoked, I am aware that I should not get angry because it could cause as Indications of Self-control my blood pressure to rise. In such a case, what I do is restrain The third theoretical category reflects the decision and myself. When it comes to food prohibitions, I just eat a little to choice of the individual who exercises self-control. These ease my desire. That, I think is practicing self-control.” ROB are manifested or indicated in his or her actions, reactions, or conduct. Under this theoretical category are sub- Sub-category 4: The changing degrees of self- categories such as restraining the self from acting out, control resisting temptation and passion, and suppressing inner This subcategory entails the varying degrees and levels feeling, involving struggles to control the self as well as the of the display of self-control among older adults. There are changing degree of self-control. The third theoretical older adult participants who had more self-control, or their category is supported by the following subcategories level of self-control now had increased due to age. Yet, below: some older adults also are less able to control themselves by giving in to desires and whims. Hence the older
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155 Caorong, L. A. (2021) participants really have varying degrees or levels of self- Sub-category 2: Consequences of losing control control. The results of having less or no self-control are generally linked to negative consequences such as “There is actually a great impact that my self-control now has conflicts with other people, trouble, and strained increased. For instance, before I really wanted that those who relationships with others people. These occurrences were are indebted to me will really pay me back. Nowadays, I still experienced by the older adults themselves, as discovered allow other people to borrow money from me, yet I consider from the in-depth interview. lending people money like an act of charity.” REM
“I really cannot control my self especially when it comes to Sub-category 5: Struggles in controlling self reprimanding my children. I will not stop saying things until I For older people, exercising self-control involves the have said what I needed to say to my children, even if it is element of struggle. This occurs because there are hurtful to them. That is my weakness. I also am not able to outward and inward pressures of either satisfying one’s control myself when I am angry at my spouse.” DEB desire or refraining from doing something or acting out, which requires effort and conscientiousness. With the establishment of the core categories supported by the identified subcategories and the “For example, I am not in contact with my wife, and you are participants’ narrations, comes now the understanding of still an organism (me). What is the mechanism of self-control the process of self-control in old age. The process begins that you are not in contact with your wife? No cohabiting. No with the older adults engaging initially in what is called self- sexual pleasure. You cannot also commit Zina (adultery) introspection followed by the act of choosing and deciding. because that is haram (prohibited)…I don’t look at naked The decision and choice of the older adults will then be bodies. If it’s in front of me, I look away, and it’s very hard, reflected in their actions and conduct, which would then especially for the male. I turn away. I have interest, but I refrain. Who is not interested after all?” TOM yield some outcome and impact.
Theoretical Category 4: Outcome and Impact of Self- Hypotheses Derived from the Results control The generation of the substantive theory was derived The final theoretical category encompasses the different through employing the constant comparative analysis outcomes, results, and impact of exercising self-control. method of the qualitative data, which were systematically Many of the older adults expressed that exercising self- gathered. The analysis resulted in the identification and control led to positive outcomes. However, there are formulation of subcategories and theoretical categories negative outcomes as well of displaying low self-control. respectively, which in turn became the basis of developing Additionally, the results of displaying self-control as and generating the research hypotheses. The developed emphasized by the older adults do not only impact other hypotheses showcase the relationships between variables people but also relatively impact them. They even identified which emerged from grounding the qualitative conveyed that exercising self-control made them feel data sets. The exploration and analysis resulted in the happy and satisfied. following hypotheses: Sub-category 1: Feeling of satisfaction and Hypothesis 1: Self-control is a personal decision happiness which is self-initiated by an older adult driven by one’s This subcategory is the reflection of the ultimate result own personal motive of exercising self-control which is the feeling of happiness The hypothesis identified depicts that the exercise of and satisfaction. Several older adults who joined the study self-control by an older adult is self-initiated—each older stated when asked, ‘what do they feel upon exercising self- adult exercises self-control differently. The driving force for control?’, that they feel happy and satisfied. This may be the exercise and practice of self-control depends on one’s due to them doing actions they are so strongly motivated own personal motives or specific personal goals. This to act about or behave a certain way that they feel strong assumption was induced from the narratives of the about, giving them happiness and satisfaction. selected study participants. Some participants practice or Furthermore, not all older adults happen to have perfect exercise self-control in order to maintain good relations self-control. There are older people who display a lesser with other people, while others practice self-control to degree of self-control given a situation. The next follow moral standards or in consideration of the health- subcategory under this last theoretical category exhibits related changes they experience. the consequences of not practicing control or having less The different personal motivations of the older adults in self-control. their exercise of self-control are highly personal. They significantly vary in their personal motivations. The “I feel happy because I can please Allah. I can please the Lord, personal motivations to exercise self-control are influenced and Allah loves the people who exercise self-control. He loves by past experiences and the lessons gained from those people who renounce the world. So…you control, you fast, you experiences. renounce, you deprive yourself… that would make Allah very happy.” TOM
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Axial Coding Process The Self-Control Process in Old-Age
Involvement of thinking and assessment
SELF- Knowledge & lessons gained through INTROSPECTION & experience ASSESSMENT
Valuing moral standards
Involvement of personal decision & choice
Thinking of the consequences of one’s action
Consideration of current life circumstance DECISION & CHOICE OF ACTION Consideration of age & health related changes
Inner motivations of the exercise of self- control
Various outer motivations of the exercise of self-control SELF- CONTROL PROCESS Restraining self from acting out
ACTION, Resisting temptations and desires REACTION & CONDUCT AS INDICATORS OF Suppressing inner feeling SELF-CONTROL
Changing degree of self-control
Struggles in controlling self
Feeling of satisfaction & happiness OUTCOME & IMPACT OF SELF- CONTROL Consequence of losing control
Figure 1 The schematic diagram of the axial coding process
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Hypothesis 2: There is a relationship between Self-control, according to Vohs and Baumeister (2004), health status, interpersonal relationships, spirituality, is the ability of a person to suppress or inhibit behaviors or financial status, and the exercise of self-control among responses intentionally and consciously. Similarly, self- older adults control is seen as the capacity of an individual to alter It was established from the data collected one responses in terms of morals, values, ideals, and motivation of the older adults in their exercise of self- expectations of other people behind some long-term goals control is the consideration of the health-related changes (Baumeister et al., 2007). In the field of psychology and they now experience in late life. Some research philosophy, there is a contention that self-control is needed participants revealed that they are now more careful in to suppress an immediate urge to consume. Not smoking terms of their food intake. They avoid doing things that may cigarettes, not drinking alcoholic beverages, or not aggravate their current health condition or health issues. consuming fatty foods are just some examples of exhibiting They further revealed that they had to struggle to engage self-control. Those who claim to show self-control prefer in physical exercises to improve their health status and rewards or benefits in the future, such as longer lives and avoid foods not recommended for them to eat even if the better health (Henden, 2008). food is of their liking. The term self-control is often used in many disciplines, On the other hand, they are aware that they are already which may often also refer to self-regulation, conscience, in their sunset years, and this realization increases their willpower, and delayed satisfaction (Moffitt et al., 2011). As spiritual connection. Many participants said that they defined by Henden (2008), self-control refers to a person’s restrain themselves from giving in to some of their desires capacity in a lesser or larger degree. There are individuals since they are afraid of God and are therefore afraid to with a low level of self-control who may have distinct commit sins. When confronted with situations where giving characteristics in terms of attitude and behavior. These in would lead them to commit sin, they would readily individuals may also have the tendency to pursue exercise and practice self-control to avoid sinning. immediate gratification rather than delaying it. There are also explorations in the behavioral science that inspect Hypothesis 3: Older adults who have high self- self-control demonstration in early childhood and control have better life satisfaction determine the changes of the self-control practice during When asked what emotions they feel when they the life course (Jackson et al., 2009; Kochanska et al., exercise self-control in a given situation, several 2001). Persons with high self-control, on the other hand, participants answered that they feel happy and have are seen to be more successful in handling relationships personal satisfaction. As an example, they said that with other people as well as having more satisfying avoiding argumentation or refraining from speaking back ill relations with them (Finkel & Campbell, 2001). The impact words has preserved their good relationships with other of exercising self-control also to cope with stress and people, and as a result, they feel happy. Maintaining good maintain psychological health is also found to be positive relationships with loved ones, family, relatives, neighbors, (Englert & Bertrams, 2015). and other people are considerable factors for life Several researches consider self-control to range from satisfaction. poor to good behavioral control (Dick et al., 2010). Many investigators had the assumption which suggests that an Propositions Derived from the Hypotheses individual’s ability to regulate self or not differs in a The following are the propositions formulated from the qualitative sense (Friese & Hofmann, 2009; Hofmann et al., generated hypotheses grounded from the qualitative data 2009; Strack & Deutsch, 2004). Good self-control is said to obtained. involve a conscious regulatory process that includes Proposition 1: Older adults exercise self-control several subcomponents. They include one’s ability to differently adjust and monitor one’s behavior when anticipating The first proposition was derived from the first results, delaying gratification, suppressing problematic hypothesis, which states that self-control is a personal behavior, and being goal-directed. On the other side, decision which is self-initiated by an older adult driven by individuals who are unable to control themselves are more one’s own personal motive. People exert self-control on a spontaneous with their actions sidetracking the necessity daily basis across different life domains such as in health, of conscious planning. They are also unable to delay in their interpersonal relationships and dealings, in financial gratification or even appropriately modify responses matters, and others. Since human beings are in constant (Pearson et al., 2013). interaction with their environment, the exercise of self- In accomplishing daily-mundane tasks, which often control is vital. Human beings possess the capability of require decision-making, self-control is indeed needed. exercising self-control which involves the thought process However, many people find it extra challenging to exert of decision making and choosing which action or behavior self-control which leads to failure in accomplishing tasks to exercise, display or demonstrate. The exercise of self- such as eating healthy, doing exercise to saving money control differs from one older adult to another as individuals (Baumeister et al., 1998; Baumeister et al., 2007; Carver & have different personal motives and capabilities and are Scheier, 2001). unique in many ways.
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Proposition 2: There are various motivations feeling of happiness is associated with the positive involved in the exercise of self-control outcomes of the exercise of self-control, such as The next proposition was developed from the maintaining good interpersonal relationships. assumption that there is a relationship between health Self-control is a strong determining factor for success status, interpersonal relationships, spirituality, financial in life (De Ridder et al., 2012). There are a number of status, and the exercise of self-control among older adults. adaptive outcomes associated with the exercise of self- It could be argued that there are various motivations control which include better interpersonal relationships, behind the exercise of self-control by an individual. The better physical health, and better intellectual performance inner drives and motivations come in different forms as (Finkel & Campbell, 2001; Schmeichel et al., 2003; Will human beings inherently have different aspirations and life Crescioni et al., 2011). Exercising high self-control is a goals and aims. pertinent aspect of a person’s behavior for a person to Self-control is established as a person’s ability to have a successful and healthy life (De Ridder et al., 2012; regulate his own thoughts, actions, and feelings (De Ridder Tangney et al., 2004). It was found out that behaviors such et al., 2012). Moreover, the practice of self-control helps as minimized aggression, reduced criminality (Dewall et resolve motivational conflicts experienced by an individual al., 2007), better interactions (Finkel & Campbell, 2001), between short-term and long-term goals (Fujita, 2011). less abuse of alcohol, smoking, and other prohibited Persons who are good at controlling themselves easily substances (Sayette, 2004), and high self-esteem and resist temptations that would otherwise be in conflict with improved interpersonal skills were all related to the practice the valued long-term pursuits. Essentially, persons of this of high self-control. Moreover, Hofmann et al. (2014) stated type are certainly engaged in action and behaviors that that self-control is a person’s ability to override one’s inner help achieve or attain goals and motivations. response and to interrupt undesirable behavioral Motivations are classified as either intrinsic or extrinsic. inclinations or impulses. The reason behind the action or behavior of a person in a Additionally, greater self-control is also positively particular way is driven by his or her motivations. Intrinsic attributed to psychological adjustments and negatively motivation implies that an individual engages in activity predicts psychopathology (Tangney et al., 2004). It was because the person finds it enjoyable, satisfying, or also found out that the more self-control a person exhibits, interesting as his or her inner motivation. On the other the fewer are the experiences of symptoms and stress hand, extrinsic motivation means that a person is driven to while having better mental health (Boals et al., 2011). This do things that will lead him to achieve some personal gains finding was corroborated by the results of the study by such as money (Deci & Ryan, 1985; Ryan & Deci, 2000). Jensen-Campbell and Malcolm (2007) and Bogg and Henden (2008) suggested that self-control involves the Roberts (2004), that there is a link between self-control and notion of a person having the capacity to bring one’s action higher quality and satisfying relationships. The essence of in line with his intention in seemingly competing self-control in reaching significant life outcomes is widely motivations. This could be elucidated when a person has known. Empirical evidence shows that high self-control the intention to resist, for instance, another cigarette and practice positively predicts well-being, satisfaction with life, was able to resist it despite having a strong desire for it. and positive affect. High self-control here means the ability Edmund argues that self-control is a form of intentional of a person to regulate his thoughts, feelings, and control over one’s behavior; thus, self-control is a person’s behaviors (De Ridder et al., 2012; Hofmann et al., 2014). ability to control himself. There is a well-established relationship between self- According to Baumeister et al. (2007), there is a need control and optimal functioning (Tangney et al., 2004). to resist temptations as these may bring about long-term They also posited that people’s capacity to practice self- consequences. For instance, one must attempt to resist control displays their adaptive nature, which has some the temptation to eat unhealthy food, or to go to sleep for implications that they also live more happy and healthy extended hours or act in a violent manner since undeniably lives. Moreover, there is also evidence pointing out that failure to repel impulses and temptations may lead to people with a higher level of self-control are seen to feel crime, alcoholism, teen pregnancy, drug addiction, satisfied with their lives as well as experience positive venereal diseases or underachievement in education emotions more than those who have low levels of self- among other (Baumeister & Alquist, 2009; Baumeister et control (De Ridder et al., 2012; Hofmann et al., 2014). al., 2007). Additionally, self-control was seen by many researchers to be elemental in one’s personality trait. Having Proposition 3: The exercise of self-control leads to conscientiousness is attributed to longevity, physical life satisfaction health, and other relevant health behaviors (Bogg & The hypothesis that older adults who exercise self- Roberts, 2004; Friedman et al., 1993; Goodwin & control have better life satisfaction is the basis for the Friedman, 2006). Succinctly, self-control is a catchall above proposition. Findings of this current study show that essential human trait necessary for attaining a good life; older adults who exercise self-restraint on matters they feel thus, self-control demonstration is associated with a strong about and are motivated to do about find number of positive life outcomes. themselves feeling happy after exercising self-control. The
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The Theory of Self-control in Old age The theory generated could be classified as a middle- The theory of self-control in old age assumes that self- range theory since it addresses specific phenomena by control is a self-initiated process of governing one’s explaining what exercise of self-control is in old age, why it actions, emotions, and feelings driven by one’s own occurs, and how it occurs among older adults. This middle- personal motives. It is also assumed that older adults range theory on the exercise of self-control in old age exercise self-control differently as there are various suggests that older adults vary in their exercise of self- personal motivations involved in the exercise thereof. control. The degree of self-control is linked to one’s own Moreover, it is posited that the exercise of self-control personal motives and one’s attainment of specific aims and among older adults leads to life satisfaction. The theory life objectives. The theory further suggests that there are suggests that the ability to exercise self-control involves different factors and motivations involved in the exercise of introspection and assessment and the thought process of self-control among older adults. The display of self-control deciding and choosing what actions or behavior to display, presupposes various personal motives such as attaining and the individual himself does the exercise of self-control. personal interest and general well-being, maintaining The theory suggests that self-control involves deciding and social status or standing, having better interpersonal choosing an action or behavior that is highly grounded on relationships, accomplishing personal obligations and the person’s inner drive and personal motivations. It also responsibilities, and having better health. Furthermore, the involves weighing and assessing possible consequences theory assumes that the practice or exercise of self-control of one’s action before initiating a response or action. results in personal satisfaction as displaying self-control is attributed to a host of positive life outcomes.
Figure 2 Schematic diagram of the Theory of Self-control in Old age
The diagram shows that the exercise of self-control among in the field of gerontology and health care services since older adults entails the involvement of varying motivational the older population is growing, and so does the demand factors. It is assumed in the theory that the motivating for health care services. The need to understand the factors include the aspect of wanting to maintain health, choices and decisions of older adults is foundational in accomplishing obligations, maintaining social status, individualizing health care services. Further, the theory having better relationships, and attaining general well- also provides a broader view and a better perspective in being. As seen in the figure, attaining life satisfaction is an understanding older adults in their life choices and outcome for exercising self-control, as presented in Figure decisions. 2. Declaration of Conflicting Interest Conclusion There is no conflict of interest.
Funding The exercise of self-control in old age is a necessary This research work was supported by Mindanao State University aspect of any choices and decisions in life besides being – Marawi under the APDP Scholarship. consequential. The choices and decisions of older people in varied life avenues necessitate the practice of self- Acknowledgment control as outcomes will have an impact not only on them The author would like to acknowledge the support and contribution but also on other individuals and society in general. Older of the following organization and individuals: (1) Mindanao State University – Marawi headed by the System President, Dr. Habib people are not exempt but are also faced constantly with W. Macaayong, (2) Cebu Normal University in Cebu City, life decisions and choices in terms of their physical health, Philippines where she took up her terminal doctoral degree in social relationships, and economic choices as such the nursing, (3) the dean of her home College, Dr. Naima D. Mala, (4) practice of self-control is necessary as positive outcomes her dissertation adviser, Dr. Daisy R. Palompon, (4) her are expected. The present study has important implications dissertation panel members, (5) Dr. Jonaid M. Sadang for his
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160 Caorong, L. A. (2021) assistance during the processing of this publication, (6) family and Duckworth, A. L., Gendler, T. S., & Gross, J. J. (2014). Self-control friends, (7) BNJ editors & peer-reviewers for their great in school-age children. Educational Psychologist, 49(3), 199- contribution in refining this work, and of course (8) all the 217. https://doi.org/10.1080/00461520.2014.926225 participants who have been generous in sharing their respective Englert, C., & Bertrams, A. (2015). Integrating attentional control rich experiences during the data collection process. theory and the strength model of self-control. Frontiers in Psychology, 6, 824. https://doi.org/10.3389/fpsyg.2015.00824 Author Biography Finkel, E. J., & Campbell, W. K. (2001). Self-control and Dr. Laarni A. Caorong, RN, MAN is an Associate Professor V at accommodation in close relationships: An interdependence the College of Health Sciences, Mindanao State University – analysis. Journal of Personality and Social Psychology, 81(2), Marawi, Philippines. She is currently designated as BSN Program 263-277. https://doi.org/10.1037/0022-3514.81.2.263 Level – I Coordinator and a member of various working Friedman, H. S., Tucker, J. S., Tomlinson-Keasey, C., Schwartz, committees in the said College. J. E., Wingard, D. L., & Criqui, M. H. (1993). Does childhood personality predict longevity? Journal of Personality and Data Availability Statement Social Psychology, 65(1), 176-185. https://doi.org/10.1037/ The full transcribed verbatim responses of the participants were 0022-3514.65.1.176 kept in a password-protected computer during the analysis of this Friese, M., & Hofmann, W. (2009). Control me or I will control you: research work and was permanently deleted after the completion Impulses, trait self-control, and the guidance of behavior. of her dissertation paper for confidentiality and ethical purposes. Journal of Research in Personality, 43(5), 795-805. https://doi.org/10.1016/j.jrp.2009.07.004 References Fujita, K. (2011). On conceptualizing self-control as more than the Baltes, P. B., & Mayer, K. U. (2001). The Berlin aging study: Aging effortful inhibition of impulses. Personality and Social from 70 to 100. New York, NY, US: Cambridge University Psychology Review, 15(4), 352-366. https://doi.org/10.1177/ Press. 1088868311411165 Baumeister, R. F. (2012). Self-control—The moral muscle. The Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded Psychologist, 25(2), 112–115. theory: Strategies for qualitative research. Chicago: Aldine Baumeister, R. F., & Alquist, J. L. (2009). Is there a downside to Publishing. good self-control? Self and Identity, 8(2-3), 115-130. Goodwin, R. D., & Friedman, H. S. (2006). Health status and the https://doi.org/10.1080/15298860802501474 five-factor personality traits in a nationally representative Baumeister, R. F., Bratslavsky, E., Muraven, M., & Tice, D. M. sample. Journal of Health Psychology, 11(5), 643-654. (1998). Ego depletion: Is the active self a limited resource? https://doi.org/10.1177/1359105306066610 Journal of Personality and Social Psychology, 74(5), 1252- Henden, E. (2008). What is self-control? Philosophical 1265. https://doi.org/10.1037/0022-3514.74.5.1252 Psychology, 21(1), 69-90. https://doi.org/10.1080/09515080 Baumeister, R. F., Vohs, K. D., & Tice, D. M. (2007). The strength 701874092 model of self-control. Current Directions in Psychological Hofmann, W., Friese, M., & Strack, F. (2009). Impulse and self- Science, 16(6), 351-355. https://doi.org/10.1111/j.1467- control from a dual-systems perspective. Perspectives on 8721.2007.00534.x Psychological Science, 4(2), 162-176. https://doi.org/10.11 Boals, A., Vandellen, M. R., & Banks, J. B. (2011). The relationship 11/j.1745-6924.2009.01116.x between self-control and health: The mediating effect of Hofmann, W., Luhmann, M., Fisher, R. R., Vohs, K. D., & avoidant coping. Psychology & Health, 26(8), 1049-1062. Baumeister, R. F. (2014). Yes, but are they happy? Effects of https://doi.org/10.1080/08870446.2010.529139 trait self‐control on affective well‐being and life satisfaction. Bogg, T., & Roberts, B. W. (2004). Conscientiousness and health- Journal of Personality, 82(4), 265-277. https://doi.org/10.1111 related behaviors: A meta-analysis of the leading behavioral /jopy.12050 contributors to mortality. Psychological Bulletin, 130(6), 887- Jackson, J. J., Bogg, T., Walton, K. E., Wood, D., Harms, P. D., 919. https://doi.org/10.1037/0033-2909.130.6.887 Lodi-Smith, J., . . . Roberts, B. W. (2009). Not all Carver, C. S., & Scheier, M. F. (2001). On the self-regulation of conscientiousness scales change alike: A multimethod, behavior. New York, NY: Cambridge University Press. multisample study of age differences in the facets of De Ridder, D. T. D., Lensvelt-Mulders, G., Finkenauer, C., Stok, conscientiousness. Journal of Personality and Social F. M., & Baumeister, R. F. (2012). Taking stock of self-control: Psychology, 96(2), 446-459. https://doi.org/10.1037/a0014 A meta-analysis of how trait self-control relates to a wide range 156 of behaviors. Personality and Social Psychology Review, Jensen-Campbell, L. A., & Malcolm, K. T. (2007). The importance 16(1), 76-99. https://doi.org/10.1177/1088868311418749 of conscientiousness in adolescent interpersonal Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and self- relationships. Personality and Social Psychology Bulletin, determination in human behavior. New York: Plenum Press. 33(3), 368-383. https://doi.org/10.1177/0146167206296104 DeWall, C. N., Baumeister, R. F., Stillman, T. F., & Gailliot, M. T. Kochanska, G., Coy, K. C., & Murray, K. T. (2001). The (2007). Violence restrained: Effects of self-regulation and its development of self‐regulation in the first four years of life. depletion on aggression. Journal of Experimental Social Child Development, 72(4), 1091-1111. https://doi.org/10. Psychology, 43(1), 62-76. https://doi.org/10.1016/j.jesp.2005. 1111/1467-8624.00336 12.005 Mischel, W., & Ebbesen, E. B. (1970). Attention in delay of Dick, D. M., Smith, G., Olausson, P., Mitchell, S. H., Leeman, R. gratification. Journal of Personality and Social Psychology, F., O'Malley, S. S., & Sher, K. (2010). Understanding the 16(2), 329-337. https://doi.org/10.1037/h0029815 construct of impulsivity and its relationship to alcohol use Mischel, W., Shoda, Y., & Rodriguez, M. I. (1989). Delay of disorders. Addiction Biology, 15(2), 217-226. https://doi.org/ gratification in children. Science, 244(4907), 933-938. 10.1111/j.1369-1600.2009.00190.x https://doi.org/10.1126/science.2658056 Moffitt, T. E., Arseneault, L., Belsky, D., Dickson, N., Hancox, R. J., Harrington, H., . . . Ross, S. (2011). A gradient of childhood
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
161 Caorong, L. A. (2021)
self-control predicts health, wealth, and public safety. Schmeichel, B. J., Vohs, K. D., & Baumeister, R. F. (2003). Proceedings of the national Academy of Sciences, 108(7), Intellectual performance and ego depletion: Role of the self in 2693-2698. https://doi.org/10.1073/pnas.1010076108 logical reasoning and other information processing. Journal of Pearson, M. R., Kite, B. A., & Henson, J. M. (2013). Predictive Personality and Social Psychology, 85(1), 33-46. effects of good self-control and poor regulation on alcohol- https://doi.org/10.1037/0022-3514.85.1.33 related outcomes: Do protective behavioral strategies Strack, F., & Deutsch, R. (2004). Reflective and impulsive mediate? Psychology of Addictive Behaviors, 27(1), 81-89. determinants of social behavior. Personality and Social https://doi.org/10.1037/a0028818 Psychology Review, 8(3), 220-247. https://doi.org/10.1207/ Pfeiffer, E. (1975). A short portable mental status questionnaire for s15327957pspr0803_1 the assessment of organic brain deficit in elderly patients. Streubert, H. J., & Carpenter, D. R. (2011). Qualitative research in Journal of the American Geriatrics Society, 23(10), 433-441. nursing: Advancing the humanistic imperative (5th ed.). https://doi.org/10.1111/j.1532-5415.1975.tb00927.x Philadelpia: Lippincott Williams & Wilkins. Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and Tangney, J. P., Baumeister, R. F., & Boone, A. L. (2004). High self‐ the facilitation of intrinsic motivation, social development, and control predicts good adjustment, less pathology, better well-being. American Psychologist, 55(1), 68-78. https://doi. grades, and interpersonal success. Journal of Personality, org/10.1037//0003-066x.55.1.68 72(2), 271-324. https://doi.org/10.1111/j.0022-3506.2004.00 Sadang, J. M., & Palompon, D. R. (2021). The development of 263.x Need–Threat Internal Resiliency Theory in COVID-19 crisis Vohs, K. D., & Baumeister, R. F. (2004). Self-Control. In C. D. utilizing deductive axiomatic approach. Belitung Nursing Spielberger (Ed.), Encyclopedia of Applied Psychology (pp. Journal, 7(2), 72-77. https://doi.org/10.33546/bnj.1300 369-373). New York: Elsevier. Salthouse, T. A. (1996). The processing-speed theory of adult age Will Crescioni, A., Ehrlinger, J., Alquist, J. L., Conlon, K. E., differences in cognition. Psychological Review, 103(3), 403- Baumeister, R. F., Schatschneider, C., & Dutton, G. R. (2011). 428. https://doi.org/10.1037/0033-295X.103.3.403 High trait self-control predicts positive health behaviors and Sayette, M. A. (2004). Self-regulatory failure and addiction. In R. success in weight loss. Journal of Health Psychology, 16(5), F. Baumeister & K. D. Vohs (Eds.), Handbook of self- 750-759. https://doi.org/10.1177/1359105310390247 regulation (pp. 447-465). New York: Guilford Press. Schaie, K. W. (1989). The hazards of cognitive aging. The Cite this article as: Caorong, L. A. (2021). Self-control in old Gerontologist, 29(4), 484-493. https://doi.org/10.1093/geront/ age: A grounded theory study. Belitung Nursing Journal, 7(3), 29.4.484 151-162. https://doi.org/10.33546/bnj.1412
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162 Theory and Concept Development BNJ
Belitung Nursing Journal The development of Spiritual Volume 7(3), 163-170 © The Author(s) 2021 https://doi.org/10.33546/bnj.1456 Nursing Care Theory using deductive axiomatic approach
Ashley A. Bangcola*
Abstract The concepts of spirituality and spiritual well-being are not novel ideas as they have been subjects of scrutiny in several studies. However, there has yet to be a formalized framework of spiritual nursing in the Philippines despite its importance. Developing such a framework is significant, especially since holistic nursing believes in the relationships among body, mind, and spirit. Thus, the Spiritual Nursing Care theory was conceptualized, which states that every person has holistic needs, including spiritual needs that must be satisfied to attain spiritual well- being. It forwards that for the patient’s spiritual needs to be met, what is required is the triumvirate interconnection among the nurse, the external environment, and the spiritual nursing care which may be provided by the nurse as a healthcare provider and the significant others or family as part of the external environment. The theory has two propositions that were subjected to validation studies that either strengthened or repudiated the propositions presented: (1) the meaning of spirituality differs from person to person, and (2) the patient’s spiritual well-being is influenced by the nurse’s spiritual care competence, as well as the patient’s internal and external variables.
Keywords Spiritual Nursing Care Theory; spirituality; holistic nursing; health personnel; Philippines
Spirituality is an evolving concept that has significance in even in the past or ancient forms of nursing, patient care relation to bodily health. It is also considered an aspect of was always holistic, including both spiritual and religious health. Gone are the days when spirituality was limited to care. This may be because caring is an important the esoteric; it has now been deemed to have practical component of nursing practice. Although some measure of applications, such as in nursing care. There is extensive care is to be expected in other forms of healthcare, it can literature about the connection between spirituality and its be said that in nursing, the nurse takes a more active and influence on health and well-being (Puchalski, 2001; invested role in their patient’s well-being as their task is not Koenig & Cohen, 2002; Chaves & Gil, 2015; Ebrahimi et just to diagnose or dispense, but to provide holistic care. al., 2017). Furthermore, strong spirituality has been linked This is also an important factor to consider as to the to resilience (Koenig, 2012). Thus, it would be remiss not rationale of developing a Spiritual Nursing Care Theory. to incorporate the spiritual component in the practice of Spiritual care is compatible with nursing care as patient nursing care, which considers the holistic care of the care is more than just the medical aspect of nursing. The person to be its goal. Yousefi and Abedi (2011), in their nurse has to meet not just the medical needs of the patient study, posit that real and complete healthcare can only be but all aspects which deal with the patient’s well-being. Not possible through sensitivity to the patient’s spiritual needs. only is it demanded from nurses by nature of their The concept of spirituality has gained increasing profession, but studies would show that they are also well- interest from researchers. Although it has significance in suited for the task. the healthcare profession in general, the spiritual In a study that compared how doctors and nurses component is still most often associated with nursing care provided emotional care, it was found that the respondent (Timmins & McSherry, 2012). History would show that doctors would reassure their patients by continuing clinical
Mindanao State University – Marawi City, Philippines Article Info: Received: 20 March 2021 Revised: 30 April 2021 Corresponding author: Accepted: 21 May 2021 Dr. Ashley A. Bangcola, RN, MAN, DScN Mindanao State University – Marawi City This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which allows Block. 446 Zone 10 Purok 24 Brgy others to remix, tweak, and build upon the work non-commercially as long as Maria Christina Iligan City, Philippines 9200 the original work is properly cited. The new creations are not necessarily Mobile: +639-177-101-258 licensed under the identical terms.
Email: [email protected] E-ISSN: 2477-4073 | P-ISSN: 2528-181X
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163 Bangcola, A. A. (2021) care and explaining the curative nature of the treatment. framework is significant because compared to traditional Furthermore, they believed that they could not reassure forms of healthcare which make use of equipment and patients if they discussed the latter’s fear with them. In facilities that may not be available, spiritual nursing care contrast, nurses relied on psychological and social skills, requires only the competency of the healthcare provider, often being open and discussing patients’ concerns with specifically the nurse, in giving spiritual care. As of now, them, this being their way of providing reassurance and spiritual needs are considered only a small component of emotional support (Forsey et al., 2013). the holistic needs of a person. However, the author argues Furthermore, the majority of the international literature that the concepts of spirituality, spiritual needs, and and studies have supported the increasing importance of spiritual well-being, which have been studied in previous spiritual care and recognize it as an important component literature, can all be interconnected in one formal of nursing care that is well-rounded and holistic (Koenig, theoretical framework. One way of understanding 2012; Chaves & Gil, 2015; Ebrahimi et al., 2017). The spirituality is the perception of a person on the importance concepts of spirituality, spiritual needs, and spiritual well- of or how strong his or her spiritual practices or beliefs being have also been discussed and defined in various make up a part of his life. Spiritual needs are specific needs studies. Fisher defines spirituality as a “personal quest for that must be addressed by the healthcare provider, in this understanding answers to ultimate questions about life, case, the nurse, so that the patient can attain meaningful about the meaning and about relationships that are sacred well-being, or be more specific, spiritual well-being. When or transcendent” (Fisher, 2011). Meanwhile, according to a spiritual needs are satisfactorily addressed, spiritual well- study by Guerrero-Castaneda and Flores (2017) on being is achieved and contributes to holistic health care. spiritual nursing care as perceived by older persons, older The author posits that spiritual well-being is as important people make use of spirituality and religiosity to find a as physical, emotional, and mental health, which deserves sense of life amidst all of the radically developing due consideration. circumstances brought about by advancing age. This paper was meant to explore the patient’s (Narayanasamy et al., 2004) identified specific spiritual understanding and perception of the concept of spirituality, needs of older persons, including religious beliefs and the influence of the cultural elements of the patient’s practices, absolution, seeking connectedness and comfort, external environment on the practice of spiritual nursing and healing or looking for meaning and purpose. Spiritual care, as well as the competencies of the nurse in providing Well-Being was defined as the “ability to experience and spiritual care, and its link to attaining spiritual well-being for integrate meaning and purpose in life through a person's the patient. The eventual aim of this paper was to develop connectedness with self, others, their environment, or a a comprehensive, holistic, and spiritually inclusive nursing power greater than oneself and the totality of care framework, which values the importance of each circumstances that would lead a person to say that his life stakeholder. This paper can be of help to patients, the is going well” (Fisher, 2011). family, nursing practitioners, scholars, learners, and It can thus be inferred that studies generally agree that curriculum planners who may decide to incorporate spirituality is a state of being of a person; however, there is spiritual nursing care as a part of the curriculum and the still an evident lack of consistency in the definition of nursing profession as a whole. It would serve to add to the spirituality (Timmins et al., 2015). In addition, while there minimal knowledge of spiritual nursing care within the have been studies conducted to investigate the spiritual Philippine context. needs of aged persons in residential homes and those at the end of life stage in intensive care units (Erichsen & Methods Büssing, 2013), there is unexplored potential in studying their spiritual well-being. According to the National Health The theory proposed in this paper on spiritual nursing care Service Scotland (2009), all healthcare staff, caregivers, was conceptualized through the deductive form of and families could provide spiritual care. However, there is reasoning. Deductive reasoning is the systematic and also a significant lack of literature concerning the three-way logical process whereby a conclusion is reached based on relationship between the nurse, the patient, and his or her the concurrence of multiple premises that are generally family as current studies on spiritual nursing care tend to assumed to be true (Sternberg, 2009). According to be general and broad. In light of all of these, there seems Creswell and Plano Clark (2007), utilizing deductive to be a great need to address these huge gaps in nursing reasoning by the researcher would involve the researcher literature related to Spiritual Nursing Care. For these working from the ‘top down’ starting with a theory to reasons, the researcher wanted to develop a Spiritual hypothesis and then to data to add to or contradict the Nursing Care Theory. theory. In this study, the author wanted to explore another The deductive method is used to construct a deductive perspective that considers the interconnection of the axiomatic system or theory. The essence of an axiomatic healthcare provider, specifically the nurse, the family, and approach as used in the field of logic and mathematics is the patient himself or herself. There has yet to be a that a group of statements, called propositions, are derived formalized framework of Spiritual Nursing Care in the through the use of deductive logic applied to another more Philippines despite its importance. Developing such a fundamental set of statements serving as basic
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164 Bangcola, A. A. (2021) assumptions, also known as axioms. Axioms represent the Results and Discussion foundation statements in a deductive system. Meanwhile, a concept is defined as representing views or descriptions Five axioms were generated after thoroughly reviewing the of some aspect of the real world. A concept of something literature and studies and were used as a basis for is not the same as the thing itself (Lambert, 1973). generating the two propositions, which served as the Finally, a theory is a set of logically related statements, framework for the development of the Spiritual Nursing including some law-like basic assumptions having testable Care Theory. The connection between spirituality and implications, are an explanation and description of some health has been the subject of study since time concept. All theories are deductive systems. Kerlinger immemorial. In the past, and even until now, the caring for (1973) defines a theory as a set of interrelated constructs the body and the spirit was done by the same person acting or concepts, propositions, as well as a systemic view of as both therapist or counselor and religious leader phenomena through specifying relations among variables (Fradelos et al., 2014). Spirituality is linked to the human with the objective of explaining and predicting such spirit and is an important component of human existence phenomena. Theories are those which knit together (McKee & Chappel, 1992). Many people consider their observations (Thompson, 2005). spirituality and religion as a crucial part of their existence. The Spiritual Nursing Care Theory was developed Spirituality also serves as a source of support and following a deductive axiomatic approach. Within the contributes to people’s well-being, and helps them cope framework of nursing theories and models, the author also with everyday struggles (Purdy & Dupey, 2005). used an empirical quantitative approach in her theory Health professionals also recognize the part spirituality generation (Jacox, 1974) in developing the Spiritual plays in healthcare (Monareng, 2012). Monareng, in her Nursing Care Theory. The researcher identified the study, goes on to state that it is the holistic perspective on phenomena that she wanted to investigate within her field human functioning and in nursing which demands that of study, specified, then classified concepts used when nurses take into account aspects of spirituality when they describing these phenomena. A broad topic in the field of provide nursing care (Monareng, 2012). nursing was chosen, specifically in gerontology, which was Studies exploring spirituality from a holistic approach of interest to the researcher and which had the potential for revealed that patients use religious or spiritual beliefs and further study. The topic chosen was the role of spirituality practices to cope with suffering such as illness and stress in nursing care. The next step was to research and gather (Koenig, 2012). One of the findings from Koenig (2012) related literature on the selected topic. The researcher then was that religious people tend to spend less time in the developed propositions on how two or more concepts are hospital. He then claims in his study that healthcare related. To elaborate, by identifying patterns among the providers, including nurses, have an obligation to the studies made by prominent scholars in the field, the patient to include the patient’s religious beliefs in their care researcher was able to single out statements that were and incorporate their faith (spirituality) in promoting generally accepted to be true (axioms) to serve as a healing. The nature of nursing is to care, and thus it would starting point for deducing and inferring other truths which make sense for nurses to have a more direct hand in would be the building blocks of the theory (propositions). attending to the spiritual needs of patients. The researcher then linked propositions to each other in a Various studies also show that people who are more systematic way to come up with the theory. spiritual have better adaptive capabilities. They tend to Walker and Avant (1995) identified four levels of adapt more quickly to health complications compared to nursing theories, which include practice theories, mid- their counterparts, who are less spiritual (Strandberg et al., range theories, grand theory, and metatheory. The term 2007). Levin et al. (1996) meanwhile explored connections ‘grand theory’ is an alternative term to ‘model’. In contrast between spiritual beliefs and practices and health. His to grand theories, which do not easily find an application findings are corroborated by studies that revealed the and are furthermore broad and abstract, mid-range many ways spirituality can prevent illness and promote theories are more restricted in their focus. Mid-range well-being, such as by positively impacting physical health, theories are also abstract, but only moderately so. lessening the risk of disease, and influencing Moreover, they are composed of measurable variables. responsiveness to treatment (Baker et al., 2015). The Spiritual Nursing Care Theory developed is an Holistic approaches in healthcare take into example of a mid-range theory that specifies how the consideration all aspects of the individual, and his or her propositions, and the concepts of spirituality, spiritual needs, including mental, social, and spiritual needs. needs, spiritual well-being, and spiritual nursing care are Research regarding spirituality suggests that meeting related to each other, but which propositions remain patients’ spiritual needs has a positive contribution to their measurable. The Spiritual Nursing Care Theory may also adaptation to illness and improving rehabilitation (Levin et easily be applied in actual nursing practice. al., 1996). Based on the literature mentioned above (Purdy The related literature in the succeeding discussion was & Dupey, 2005; Strandberg et al., 2007; Koenig, 2012; gathered to formulate the premises to base the more Baker et al., 2015), it can be said that every person has specific propositions, which made up the foundation of the holistic needs, which may include spiritual needs (Axiom proposed theory on Spiritual Nursing Care. 1).
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As people grow older, some tend to contemplate more cultural characteristics of a society (Minayo, 2006). on matters of mortality and spirituality (Axiom 2). The literature affirms that healthcare practices vary Researchers posit that the natural process of aging comes depending on a person’s culture and that culture is the with it the consciousness that life will eventually end. This basis for their explanations for their suffering and illness, creates a context where older adults are more accepting of their search for meaning in these occurrences, treatment deepening their understanding of their mind, body, or spirit choices, and life reevaluation (Mello & Oliveira, 2013). In (Atchley, 1999). 1996, the World Health Organization (WHO), as well as the Spirituality is a complex and abstract subject with many United Nations Educational, Scientific and Cultural perspectives. It is something that touches all people in Organization (UNESCO), recognized the importance and different degrees. By sex, various studies have suggested significance of cultural aspects in international health that females are more spiritual than males. The same study (Mello & Oliveira, 2013). The two international revealed that people with higher educational attainment organizations stated that health care, which includes tend to be less spiritual than those who finished lower nursing care, and culture should be approached in a way levels. Furthermore, this same study demonstrated that that integrates the two from the perspective of benefiting spirituality decreases as income levels increase. As for individuals and countries (Mello & Oliveira, 2013). health status, some studies indicate that religiosity or Based on the above literature, it can be seen how the spirituality appears to positively correlate with physical internal and external environment of a person, both his health (Ellison & Levin, 1998). While patients and their socio-cultural and physical environment, can influence his families have different understandings and degrees of spirituality. spirituality, individual nurses also have different levels of Holistic nursing care includes spiritual care (Axiom 5). spirituality. Nurses are primarily trained in the physical and Taylor (2002), as cited in Monareng (2012), defines nursing care of the patient; however, their levels of ‘spiritual nursing care’ as those activities that facilitate and spirituality can also impinge positively on their care of the provide for a healthy balance between the bio- older person. Other studies have also shown how providing psychosocial and spiritual aspects of the person, and thus spiritual care is influenced by multiple factors, including the contributing to a sense of wholeness and overall well- spirituality of the healthcare provider and their being. To adequately address the concerns of their older understanding of the spiritual practices of the patients patients, nurses must be knowledgeable of their patient’s (Schleder et al., 2013). A study by Kisvetrová et al. (2013) spiritual needs, meet these needs and contribute to found that nurses living in a predominantly secular country maintaining their patient’s positive spirituality. The concept would tend to see themselves as non‐religious and, as a of spirituality has gained researchers’ interest in recent consequence, therefore, believe that providing years. Although spirituality is present in general healthcare spiritual/religious care was not something they were likely literature, the spiritual component of healthcare is still to do. Thus, what the literature would show is that nurses mostly associated with nursing care (Timmins & McSherry, are indeed aware of the concept of spiritual care or spiritual 2012). Even in the oldest forms of nursing, patient care was nursing; however, they may differ in their interpretation and said to be holistic and included spiritual and religious care how they administer such care because of their differing as well. During the Byzantine era, the patients in the understandings of spirituality. Therefore, it helps to hospitals received physical and spiritual care understand that people have different understanding and (Papathanasiou et al., 2013). In addition, theories of levels of spirituality (Axiom 3). nursing recommend a holistic model for healthcare. It has Internal and external environment contributes to a already been substantiated that patient care cannot be and person’s spirituality (Axiom 4). People can find meaning in should not be one-dimensional but should be holistic and life in different ways and through different avenues composed of all aspects such as the biological, (Eckersley, 2005). People would often have many things psychological, social, and spiritual dimensions which are important to them, such as their family, friends, (Papathanasiou et al., 2013). Florence Nightingale, who career, hobbies, interests, and desires. All of these are can be said to be the founder of modern nursing, avenues through which people can find meaning in life. introduced important elements necessary for the healing People can also find spirituality in their connection with process. Some examples included the environment, touch, their nation or ethnic group since spirituality is one of the light, scents, music, silent reflection, and even birds. Each deepest forms of interconnection. There is a link between of those elements helped the patient connect with others, interconnectedness and physical well-being. For example, with nature, and with the divine (Nightingale, 1860). it was found that socially isolated people five times likelier Holistic care may be defined as a comprehensive to die compared to those who have strong ties with their model of caring and is the heart of nursing (Strandberg et family, friends, and or community (Berkman & Glass, al., 2007; Albaqawi et al., 2021). Holistic care is built upon 2000). the principle of holism which puts forward the idea that for In addition, empirical studies would show that health people, the whole is greater than the sum of its parts. In cannot be reduced to just an organic and natural objective addition, mind and spirit both affect the body (Tjale & process, but rather is connected to the experiences of Bruce, 2007). Holistic care then is that care that recognizes individuals and groups, which are in turn related to the that the patient is a whole. Furthermore, it acknowledges
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166 Bangcola, A. A. (2021) that there is interdependence and interconnection between and among the patient’s biological, social, psychological, and spiritual dimensions. Holistic care, being a comprehensive model of caring, includes the following components – education, self-help, medication, complementary treatment, and communication (Morgan & Yoder, 2012). Holistic care is also applied in nursing. In the context of holistic nursing, the patient’s attitude, opinions, emotions, thoughts, and even culture and spiritual beliefs and practices are factored in the care plan and are considered essential to the recovery, happiness, satisfaction, and well- being of the patient (Selimen & Andsoy, 2011). From the axioms generated, the following ideas were put forward as propositions to form the backbone of the theory on Spiritual Nursing Care. The first proposition posited states that the meaning of spirituality differs from person to person (Proposition 1). The second proposition posited is that the patient’s spiritual well-being is influenced by the nurse’s spiritual Figure 1 Spiritual Nursing Care Framework competence as well as the patient’s internal and external variables (Proposition 2). Figure 1 illustrates the Spiritual Nursing Care Framework, which involves the tripartite relationship between the nurse Spiritual Nursing Care Theory as the healthcare provider, the family as providers of The theory being proposed in this paper on Spiritual support, and the patient having spiritual needs. Nursing Care states that every person has holistic needs, The theoretical framework is composed of four which may include spiritual needs that must be satisfied for components: (1) spiritual nursing care, (2) the nurse’s the person to attain spiritual well-being. The theory spiritual competency, (3) the cultural background of the forwards that in order to achieve spiritual well-being and for patient, both as part of the external environment, and (4) the person’s spiritual needs to be satisfied, what is required the patient’s spiritual needs. is the triumvirate interconnection among the nurse, the The Spiritual Nursing Care theory proposes that external environment, and the spiritual nursing care which patients have spiritual needs as part of their holistic needs. may be provided by the nurse as the healthcare provider When these needs are satisfied, they will have a more and the significant others or family as part of the external positive attitude towards healing and thus are more environment. responsive to healthcare interventions which may be The Spiritual Nursing Care theory claims that spiritual manifested in their satisfaction with the spiritual nursing needs are part and parcel of the totality of needs of the care provided by the nurse. The trust between the nurse patient; it is not lesser than any other need. They should and the patient will help in the nursing aspect by creating be considered and dealt with holistically and accorded an atmosphere of rapport between the nurse and the great weight. The theory postulates that satisfaction of patient, thereby making the patient support the decisions spiritual needs contributes to the overall well-being, as it of the nurse when it comes to the spiritual aspects of may contribute to the improvement of the physical and nursing care. As illustrated in the above schematic emotional well-being of the patient (Bangcola, 2019). Thus, diagram, there must be trust between the nurse and the it is assumed that people who find themselves spiritually family members of the patient also because they both act satisfied would have a more positive attitude towards as a healthcare provider and support system for the healing, both emotionally and physically, and are therefore patient. more responsive to healthcare interventions. Furthermore, there must be trust since the nurse is The schematic diagram of the theoretical framework for expected to provide spiritual nursing care, which must be this study was based on the work of the author, the Spiritual sensitive to the patient’s needs and the cultural Nursing Care theory, which proposed that holistic care for background of the patient’s family. This, in turn, will help patients is composed of three interlocking factors that make the patient’s family trust that the spiritual nursing contribute to the satisfaction of the patient’s spiritual needs care provided by the nurse will redound to the benefit of the to attain spiritual well-being: the external environment patient. On the part of the nurse, as a healthcare provider, which includes the nurse as the healthcare provider, and he or she must have spiritual competency in order to which necessitates that he or she must have enough address the spiritual needs of his or her patient adequately. spiritual competency to provide spiritual nursing care; the Competence refers to a set of traits and characteristics culture of the patient’s family or significant others; and at which form the basis for optimal performance. In other the center is the spiritual nursing care itself. words, spiritual competency then is that defined set of
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167 Bangcola, A. A. (2021) attitudes, knowledge, and skills in the domains patient can attain positive health status within his given of spirituality that every nurse should have to effectively physical illness or bodily condition. and ethically practice nursing, regardless of whether or not they consider themselves spiritual or religious. Conclusion There must be congruence between the nurse’s spiritual competency and the spiritual nursing care to be The essence of spiritual nursing care is the understanding provided in order to satisfy the patient’s spiritual needs. As that spirituality can mean different things to different defined in nursing, culturally congruent practice is that people, especially considering the physical and socio- application of evidence-based nursing, which is in line with cultural environment. The Spiritual Nursing Care the preferred cultural values and practices, beliefs, and theoretical framework involves three groups: the patient, worldview of patients (Marion et al., 2016). Therefore, the the nurse, and the family or significant others as part of the spiritually congruent practice would be nursing which is external environment. It is also composed of three sensitive to the preferred spiritual or religious beliefs of the components: the nurse’s spiritual care competence, the patient and his or her significant others. Meanwhile, cultural elements of the external environment, and the spiritual competence is the process wherein nurses spiritual nursing care, the intersection of which directly demonstrate congruent spiritual practice. In other words, influence the satisfaction of the patient’s spiritual needs. the nurse needs to be spiritually competent in providing The higher the spirituality or how much the patient spiritual nursing care that is congruent with the patient’s believes himself to be faithful, the higher the impact the spiritual needs. corresponding faithfulness of his significant others would In whatever healthcare setting, the nurse is likely to impact him. In providing holistic nursing care that includes have patients with culturally diverse beliefs and practices spiritual care, there must be congruence between the concerning their own health, wellness, and illnesses. This nurse’s spiritual competency as well as the spiritual nursing is where the interaction between the nurse and the external care provided to meet patients’ spiritual needs. In other environment (socio-cultural) would also be essential. Not words, the spirituality inclusive nursing care provided only must the nurse provide culturally sensitive spiritual would be the practical application of the nurse’s spiritual nursing care, he or she must also provide spiritually competency, the former’s effectiveness in meeting the congruent nursing care. There may be instances where the patient’s spiritual needs to attain spiritual well-being, being personal belief system of a nurse may not match those of directly influenced by how competent the nurse may be. his or her patient. In this instance, there may be a conundrum since the nurse may have difficulty relating to Declaration of Conflicting Interest his or her patient, which in turn may hinder the nurse from The author declares no conflict of interest in this study. providing adequate spiritual care. Hence, it is necessary for the nurse to interact with the external environment of the Funding patient or his family to be more specific. This is because, This research received no specific grant from any funding agency in the family setting, most persons develop and form their in the public, commercial, or non-profit sectors. values and belief systems as influenced by their socio- Acknowledgment cultural background. I would like to acknowledge Ashyanna Alexine Bangcola for her Meanwhile, the family members may not be expected valuable input and advice, without which I could not have to have the same spiritual competence as the nurse as they completed this manuscript. are already in a unique position of being the primary and fundamental emotional support of the patient. What is Author Biography required is that they be sensitive to the spiritual needs of Dr. Ashley Ali Bangcola is a holder of a Doctor of Science in the patient and assist them as much as they are able. They Nursing degree major in Gerontology Nursing from the Cebu should also assist the nurse in understanding how best to Normal University in the Philippines. She graduated with a Master satisfy the spiritual needs of the patient and handle any of Arts in Nursing major in Nursing Administration from the Mindanao State University in 2011. She is an Assistant Professor confusion the nurse may have as to specific cultural and at the Mindanao State University – College of Health Sciences and religious practices, as the family members are likely to the current Research Coordinator of the same. Her research come from the same socio-cultural environment as the interests include gerontology nursing, nursing education, nursing patient. administration, spiritual health care, and mental health. It is only with the nurse’s spiritual care competence that is congruent with the nursing care provided and is sensitive References to the cultural background of the patient’s family, which Albaqawi, H. M., Butcon, V. E., Albagawi, B. S., Dayrit, R. D., & Pangket, P. (2021). Holistic nursing care among operating would complete the holistic spiritual nursing care provided room nurses: Strengthening the standard of practice in Saudi to the patient. It is through this three-way symbiotic Arabia. Belitung Nursing Journal, 7(1), 8-14. https://doi.org/ relationship that holistic spiritual nursing care may be 10.33546/bnj.1279 perfected. If the nurse is able to provide optimum physical, Atchley, R. C. (1999). Continuity and adaptation in aging: Creating pharmacological and spiritual assistance to the patient and positive experiences. Baltimore, USA: Johns Hopkins the family environment delivers spiritual guidance, then the University Press.
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168 Bangcola, A. A. (2021)
Baker, J., Beddoes, L., Gelderman, W., & Christensen, J. (2015). Koenig, H. G., & Cohen, H. J. (2002). The link between religion Spirituality groups within acute care psychiatry setting. and health: Psychoneuroimmunology and the faith factor. New Retrieved from https://www.covenanthealth.ca/media/63352/ York: Oxford University Press. spirituality-groups-in-psychiatry-jessica-baker-group-cove Lambert, W. (1973). Social psychology: Foundations of modern nant-health-research-day-2015.pdf psychology series. Englewood Cliffs, NJ: Prentice-Hall. Bangcola, A. A. (2019). Spiritual Nursing Care Theory. Levin, J. S., Markides, K. S., & Ray, L. A. (1996). Religious (Unpublished doctoral dissertation), Cebu Normal University, attendance and psychological well-being in Mexican Philippines. Americans: A panel analysis of three-generations data. The Berkman, L. F., & Glass, T. (2000). Social integration, social Gerontologist, 36(4), 454-463. https://doi.org/10.1093/geront/ networks, social support, and health. In L. F. Berkman & I. 36.4.454 Kawachi (Eds.), Social epidemiology (Vol. 1, pp. 137-173). Marion, L., Douglas, M., Lavin, M. A., Barr, N., Gazaway, S., New York: Oxford University Press. Thomas, E., & Bickford, C. (2016). Implementing the new ANA Chaves, L. J., & Gil, C. A. (2015). Older people’s concepts of standard 8: Culturally congruent practice. Online Journal of spirituality, related to aging and quality of life. Ciencia & Saude Issues in Nursing, 22(1). https://doi.org/10.3912/OJIN.Vol22 Coletiva, 20, 3641-3652. https://doi.org/10.1590/1413-81232 No01PPT20 0152012.19062014 McKee, D. D., & Chappel, J. N. (1992). Spirituality and medical Creswell, J. W., & Plano Clark, V. L. (2007). Designing and practice. Journal of Family Practice, 35(2), 201-205. conducting mixed methods research. Thousand Oaks, CA: Mello, M. L., & Oliveira, S. S. (2013). Health, religion and culture: Sage Publications. a dialogue based on Afro-Brazilian customs. Saúde e Ebrahimi, H., Areshtanab, H. N., Jafarabadi, M. A., & Khanmiri, S. Sociedade, 22, 1024-1035. https://doi.org/10.1590/S0104- G. (2017). Health care providers' perception of their 12902013000400006. competence in providing spiritual care for patients. Indian Minayo, M. C. d. S. (2006). The inclusion of violence in the health Journal of Palliative Care, 23(1), 57-61. https://doi.org/10. agenda: Historical trajectory. Ciência & Saúde Coletiva, 11, 4103/0973-1075.197957 375-383. https://doi.org/10.1590/s1413-81232006000200015 Eckersley, R. (2005). Well & good : Morality, meaning and Monareng, L. V. (2012). Spiritual nursing care: A concept analysis. happiness. Melbourne, Vic: Text Publishing. Curationis, 35(1), 1-9. https://doi.org/10.4102/curationis.v35 Ellison, C. G., & Levin, J. S. (1998). The religion-health i1.28 connection: Evidence, theory, and future directions. Health Morgan, S., & Yoder, L. H. (2012). A concept analysis of person- Education & Behavior, 25(6), 700-720. https://doi.org/10.11 centered care. Journal of Holistic Nursing, 30(1), 6-15. 77/109019819802500603 https://doi.org/10.1177/0898010111412189 Erichsen, N.-B., & Büssing, A. (2013). Spiritual needs of elderly Narayanasamy, A., Clissett, P., Parumal, L., Thompson, D., living in residential/nursing homes. Evidence-Based Annasamy, S., & Edge, R. (2004). Responses to the spiritual Complementary and Alternative Medicine, 2013. https://doi. needs of older people. Journal of Advanced Nursing, 48(1), org/10.1155/2013/913247 6-16. https://doi.org/10.1111/j.1365-2648.2004.03163.x Fisher, J. (2011). The four domains model: Connecting spirituality, National Health Service Scotland. (2009). Spiritual care and health and well-being. Religions, 2(1), 17-28. https://doi.org/ chaplaincy: Guidance on Spiritual Care in the NHS in 10.3390/rel2010017 Scotland. Retrieved from https://www.gov.scot/publications/ Forsey, M., Salmon, P., Eden, T., & Young, B. (2013). Comparing spiritual-care-chaplaincy/pages/4/ doctors' and nurses' accounts of how they provide emotional Nightingale, F. (1860). Notes on nursing: What it is, and what it is care for parents of children with acute lymphoblastic not. London: Harrison. leukaemia. Psycho‐Oncology, 22(2), 260-267. https://doi.org/ Papathanasiou, I., Sklavou, M., & Kourkouta, L. (2013). Holistic 10.1002/pon.2084 nursing care: Theories and perspectives. American Journal of Fradelos, E., Fradelou, G., & Kasidi, E. (2014). Pain: Aspects and Nursing Science, 2(1), 1-5. https://doi.org/10.11648/j.ajns.20 treatment in Greek antiquity. Journal of Medical Sciences and 130201.11 Public Health, 2(2), 29-36. Puchalski, C. M. (2001). The role of spirituality in health care. Guerrero-Castaneda, R. F., & Flores, T. C. E. (2017). Spiritual Baylor University Medical Center Proceedings, 14(4), 352- care in old age: Nursing reflection. MOJ Gerontology & 357. https://doi.org/10.1080/08998280.2001.11927788 Geriatrics, 2(4), 71-73. https://doi.org/10.15406/mojgg.2017. Purdy, M., & Dupey, P. (2005). Holistic flow model of spiritual 02.00055 wellness. Counseling and Values, 49(2), 95-106. https://doi. Jacox, A. (1974). Theory construction in nursing: An overview. org/10.1002/j.2161-007X.2005.tb00256.x Nursing Research, 23(1), 4-12. https://doi.org/10.1097/0000 Schleder, L. P., Parejo, L. S., Puggina, A. C., & Silva, M. J. P. d. 6199-197401000-00003 (2013). Spirituality of relatives of patients hospitalized in Kerlinger, F. N. (1973). Foundations of behavioral research. New intensive care unit. Acta Paulista de Enfermagem, 26(1), 71- York: Holt, Rinehart and Winston. 78. https://doi.org/10.1590/S0103-21002013000100012 Kisvetrová, H., Klugar, M., & Kabelka, L. (2013). Spiritual support Selimen, D., & Andsoy, I. I. (2011). The importance of a holistic interventions in nursing care for patients suffering death approach during the perioperative period. AORN Journal, anxiety in the final phase of life. International Journal of 93(4), 482-490. https://doi.org/10.1016/j.aorn.2010.09.029 Palliative Nursing, 19(12), 599-605. https://doi.org/10.12968 Sternberg, R. J. (2009). Cognitive psychology (5th ed.). Belmont, /ijpn.2013.19.12.599 CA: Wadsworth. Koenig, H. G. (2012). Religion, spirituality, and health: The Strandberg, E. L., Ovhed, I., Borgquist, L., & Wilhelmsson, S. research and clinical implications. International Scholarly (2007). The perceived meaning of a (w) holistic view among Research Notices, 2012. https://doi.org/10.5402/2012/2787 general practitioners and district nurses in Swedish primary 30 care: A qualitative study. BMC Family Practice, 8(1), 1-8. https://doi.org/10.1186/1471-2296-8-8
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169 Bangcola, A. A. (2021)
Thompson, K. R. (2005). Axiomatic theories of intentional Walker, L., & Avant, K. C. (1995). Strategies for theory systems: Methodology of theory construction. Scientific construction in nursing (3rd ed.). Norwalk, CT: Appleton & Inquiry Journal, 7(1), 13-24. Lange. Timmins, F., & McSherry, W. (2012). Spirituality: the Holy Grail of Yousefi, H., & Abedi, H. A. (2011). Spiritual care in hospitalized contemporary nursing practice. Journal of Nursing patients. Iranian Journal of Nursing and Midwifery Research, Management, 20, 951-957. https://doi.org/10.1111/jonm.120 16(1), 125–132. 38 Timmins, F., Murphy, M., Neill, F., Begley, T., & Sheaf, G. (2015). An exploration of the extent of inclusion of spirituality and Cite this article as: Bangcola, A. A. (2021). The spiritual care concepts in core nursing textbooks. Nurse development of Spiritual Nursing Care Theory using Education Today, 35(1), 277-282. https://doi.org/10.1016/ deductive axiomatic approach. Belitung Nursing Journal, j.nedt.2014.05.008 7(3), 163-170. https://doi.org/10.33546/ bnj.1456 Tjale, A. A., & Bruce, J. (2007). A concept analysis of holistic nursing care in paediatric nursing. Curationis, 30(4), 45-52. https://doi.org/10.4102/curationis.v30i4.1116
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Belitung Nursing Journal Barriers to exclusive breastfeeding: Volume 7(3), 171-178 © The Author(s) 2021 A cross-sectional study among https://doi.org/10.33546/bnj.1382 mothers in Ho Chi Minh City,
Vietnam
Nhan Thi Nguyen* , Huong Thi Do, and Nhu Thi Van Pham
Abstract Background: Exclusive breastfeeding provides numerous benefits to the health of infants, mothers, economics, and the environment. However, during the exclusive breastfeeding period, the mothers face many barriers. Objective: This study aimed to describe the perceived barrier of breastfeeding and compare its differences among mothers in Vietnam according to demographic and individual characteristics. Methods: A cross-sectional study was conducted among 246 women in Ho Chi Minh City, Vietnam. Data were derived from the original survey using a self-administered questionnaire asking about the barriers of breastfeeding in three aspects: maternal, infant, and socio-environment. Descriptive statistics, Independent t-test, and ANOVA were used to describe the mothers’ characteristics and the breastfeeding barriers. Results: The barrier from the infants was the most noticeable, followed by socio-environment and maternal barriers, respectively. Breastfeeding in public places (M = 2.93, SD = 0.92), baby’s illness (M = 2.74, SD = 0.99), and insufficient milk supply (M = 2.70, SD =0.99) were considered as major barriers to six-month exclusive breastfeeding among mothers in Ho Chi Minh City, Vietnam. Among the age groups, mothers who were more than 35 years old perceived had lower breastfeeding barriers than the younger mothers (F = 3.67, p = 0.03). Conclusion: The investigation of the barriers against exclusive breastfeeding practice can help nurses and midwives develop breastfeeding promotion programs to promote exclusive breastfeeding rate for women in Vietnam.
Keywords barrier; exclusive breastfeeding; perception; mothers; nurses; midwives; Vietnam
Breastfeeding is the most efficacious feeding method for the first six months is also significantly associated with the child, especially the exclusive breastfeeding in the first higher scores in the intelligence quotient test than those six months of infant’s life provides irrefutable benefits for who have no exclusively breastfed (Tasnim, 2014). the infant’s health, mother’s health, economics, and the Regarding the mother’s health, exclusive breastfeeding environment. To illustrate, a baby who receives only breast significantly reduces breast cancer and ovarian cancer, milk in the first six months of life is less mortality and and it postpones returning the menstrual period as a morbidity of gastrointestinal infection diseases, lactational amenorrhea method (Labbok, 2016; Victora et pneumonia, asthma, or diarrhea compared to non- al., 2016). For economics, Walters et al. (2016) estimated breastfed infants (Ballard & Morrow, 2013; Biks et al., the economic benefits of breastfeeding across seven 2015). Additionally, exclusive breastfeeding for infants in countries in Southeast Asia; the results found that the
Faculty of Nursing and Medical Technology, University of Medicine and Article Info: Pharmacy at Ho Chi Minh City, Vietnam Received: 26 February 2021 Revised: 23 March 2021
Accepted: 3 May 2021 Corresponding author: Dr. Nhan Thi Nguyen This is an Open Access article distributed under the terms of the Creative Faculty of Nursing and Medical Technology, University of Medicine and Commons Attribution-NonCommercial 4.0 International License, which allows others to remix, tweak, and build upon the work non-commercially as long as Pharmacy at Ho Chi Minh City. 201 Nguyen Chi Thanh Street, Ward 12, the original work is properly cited. The new creations are not necessarily District 5, Ho Chi Minh City, Vietnam licensed under the identical terms. Mobile: (+84)907307358 Email: [email protected] | [email protected] E-ISSN: 2477-4073 | P-ISSN: 2528-181X
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171 Nguyen, N. T., Do, H. T., & Pham, N. T. V. (2021) health care treatment could be saved 300 million US in the Northern and Middle of Vietnam, where they have dollars annually by reducing the incidence of diarrhea and different cultures from the Southern of Vietnam. Therefore, pneumonia by providing adequate breastfeeding. conducting research in identifying the barriers of exclusive Furthermore, breastfeeding is assumed as climate breastfeeding practices among mothers in the Southern of compatible because of the nature of breast milk, e.g., no Vietnam was important. The findings from this study give need for heating, no need the refrigeration to store, and comprehensive pictures about barriers of exclusive breast milk can be used at any time with the right breastfeeding for six months among mothers in Ho Chi temperature. Minh City, Vietnam. It also provides baseline information Because of the advantages of breast milk, World Health for future researches on the relevant topic. In addition, the Organization (WHO) recommends mothers worldwide findings can help nurses and midwives to manage the exclusively breastfeed their infants during the first six exclusive breastfeeding practice and develop appropriate months after birth (WHO, 2011). However, globally only intervention to minimize the perception of barriers among 40% of infants aged 0-6 months are exclusively breastfed Vietnamese mothers; hence, promoting the rate of (WHO, 2017). In Vietnam, only 24% of infants are exclusive breastfeeding among infants in Vietnam. breastfeeding exclusively for the first six months despite the multiple breastfeeding promotion programs that have Methods been launched by the government (UNICEF, 2016). During six-month exclusive breastfeeding, the mothers Study Design could face many challenges, barriers, or difficulties. The This was a quantitative study with a cross-sectional design common barriers are the perception about insufficient to identify breastfeeding barriers among mothers in Ho Chi breast milk, and breast milk does not provide all the Minh City, Vietnam. It relied on secondary data of the necessary vitamins and supplements (Kim & Chapman, research on “Factors predicting six-month exclusive 2013; Nguyen et al., 2018; Xuan & Nguyen, 2018). Another breastfeeding among mothers in Ho Chi Minh City, barrier of exclusive breastfeeding is the mother’s Vietnam”, conducted by Nguyen et al. (2021). The data perception about foods and other liquids more nutritious were collected from three hospitals named University than breast milk; therefore, formula milk, water, and solid Medical Center, Hung Vuong hospital, and Tu Du hospital food are commonly introduced before six months of age at Ho Chi Minh City, Vietnam. (Lundberg & Thu, 2012). In addition, mothers also face the barrier to exclusive breastfeeding due to the need to return Sample Size and Sampling Method to work outside the home or the feeling of uncomfortable to The population of the study was mothers who were having breastfeed in public places, such as restaurants, babies aged from six to nine months. The study inclusion workplaces, shopping centers, and public transport criteria for mothers included a mother from 18 years old or (Coomson & Aryeetey, 2018). Besides, physical breast older, having a baby from six to nine months, being able to problems, such as mastitis, breast engorgement, sore communicate in the Vietnamese language. For infants, the nipples, and cracked or inverted nipples, become the criterion included a singleton baby with a gestational age challenge for mothers who breastfeed their children of at least 37 weeks. The exclusion criteria for mothers exclusively for six months (Babakazo et al., 2015; Karkee were mothers with chronic disease or other diseases in et al., 2014). which breastfeeding was not allowed by physicians. The Additionally, each culture has its own belief when it exclusion criteria for infants were infants with congenital comes to breastfeeding. Some of these are helpful to disabilities or admission to the hospital during the first six mothers and babies, while others could negatively impact months. a baby’s health. For example, there is a widespread belief The sample size was calculated using Cochran’s among Vietnamese mothers that colostrum is dirty milk and formula (Cochran, 1977). The estimated proportion of should throw away (Dixon, 1992). Discarding colostrum is exclusive breastfeeding in Vietnam was 20% (UNICEF, associated with higher odds of non-exclusive 2016), the error of precision was accepted at 5%, and the breastfeeding during six months (Tamiru et al., 2012). confidence interval of 95% was assumed. Therefore, the According to Health Promotion Model, perceived total sample size in the current study was 246 mothers. barriers to action are anticipated, imagined, or real blocks and costs of understanding a given behavior (Pender et al., Instruments 2011). In the context of exclusive breastfeeding, perceived The samples of this study were drawn from the secondary barriers refer to perceptions about inconvenience, data of the original research, which was mentioned difficulty, or obstacles in performing exclusive previously. The original survey was conducted using a self- breastfeeding to the babies; the higher the perceived administered questionnaire for collecting data. The barriers to breastfeeding, the less implementation of Perceived Barriers to Breastfeeding Scale was developed exclusive breastfeeding among them (Kim & Chapman, by the first author based on the literature review (Babakazo 2013). Few studies documented the barriers of exclusive et al., 2015; Coomson & Aryeetey, 2018; Kim & Chapman, breastfeeding in the Vietnam context (Kim & Chapman, 2013) and the concept of perceived barriers to action from 2013; Nguyen et al., 2018). These studies were conducted the Health Promotion Model (Pender et al., 2011) to
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172 Nguyen, N. T., Do, H. T., & Pham, N. T. V. (2021) measure mothers’ perceptions of factors which were (no.992/HĐĐĐ-ĐHYD) approved this study. Furthermore, considered as breastfeeding barriers. The content validity this study also received the mothers’ agreement to of the scale was tested with three breastfeeding experts, participate in the study. Mothers were also informed that and the item-level content validity (I-CVI) index of this scale they had the right to withdraw from the research and were was 0.91. Originally, this scale was developed in English assured about confidentially of the obtained information. and translated into the Vietnamese language using the back-translation technique. Results The Perceived Barriers to Breastfeeding Scale consisted of 20 items that covered three aspects of Participant’s Characteristics breastfeeding barriers: maternal barriers (item 1-10), infant Among 246 mothers, 61.4% of them aged 26 to 35 years. barriers (item 11-14), and socio-environment barrier (item Slightly half of the mothers achieved the high school or 15-20). The maternal aspect reflects the negative attitude diploma educational levels (52.0%), got the normal delivery or belief of mothers about breastfeeding practice, the lack (53.7%), and were the primiparous mothers (52.0%). of breastfeeding technique or skills, lack of confidence, mother’s physical and psychological changes that would Table 1 Mothers’ characteristics by frequency and percentage bar the exclusive breastfeeding practice. The infant aspect (N =246) reflects the false belief of mothers about the benefits of breast milk for infants and infant’s physical and Individual Characteristics n % psychological conditions. The socio-environment aspect Mother’s age reflects the negative mothers’ perception of inadequate < 25 years old 46 18.7 support from family and health care providers, working 25 – 35 years old 151 61.4 > 35 years old 49 19.9 status, and the adverse effect of formula advertisement Mother’s education against the exclusive breastfeeding practice. The response Less than high school 62 25.2 scale to each item was scored from 1 (strongly disagree) High school or diploma 128 52.0 to 4 (strongly agree). Therefore, the total scores were Bachelor or higher 56 22.8 ranged from 20 to 80, which a higher score means a higher Delivery method level of perceived breastfeeding barrier. The psychometric Normal delivery 132 53.7 properties of the scale were tested with internal Cesarean section 114 46.3 consistency reliability of the scale was 0.92. Parity Primiparous 128 52.0 Multiparous 118 48.0 Data Collection
Data were derived from the secondary data of the original Perceived Barriers to Breastfeeding research; hence, the detailed information of the data The average total score of perceived barriers to collection could be seen in the study of Nguyen et al. breastfeeding was 49.24 (SD = 14.57), which was ranged (2021). from 22 to 76. The score in each item was varied from 1 to
4, which a higher score means a higher level of perceived Data Analysis breastfeeding barrier. The details of each item were Data were coded and analyzed using SPSS (statistical presented in Table 2. package for the social sciences) software program version For the maternal aspect, the results revealed that the 18.0. Descriptive statistics were used to describe the item “My breastfeeding is not successful as expected due participant characteristics, compute the mean and to insufficient breastmilk” had the highest mean score (M = standard deviation of the Perceived Barriers to 2.70, SD = 0.99), followed by the item “Lack of knowledge Breastfeeding Scale. Independent t-test, one-way ANOVA about breastfeeding technique results in my unsuccessful were used to determine the different means between practice” (M = 2.69, SD = 0.99). The item “During mother’s characteristics and perceived barriers to breastfeeding, I often have negative emotion (such as breastfeeding. If a statistically significant difference was feeling anxious, agitated, angry, disgusted, or rageful)” had found when running ANOVA, a post hoc test was done to the lowest mean score (M = 2.04, SD = 0.90). find a specific difference between the groups. Prior to For the infant aspect, the item “My baby’s illness makes performing the ANOVA, the assumptions were tested to breastfeeding very hard” was the highest mean score (M = ensure the accuracy of the findings and confirm no 2.74, SD = 0.99), followed by the item “My baby’s irritating violation of statistical assumptions. mood makes the breastfeeding harder” (M = 2.60, SD =
0.97), and the item “Exclusive breastfeeding does not Ethical Consideration provide my baby with enough nutrition” had the lowest The current study obtained approval for secondary use mean score (M = 2.26, SD = 0.92). from the first author of the original survey with the For the socio-environment aspect, the results showed agreement for using the data. Additionally, the Institutional that item “Breastfeeding in public places is uncomfortable Review Board (IRB) Committee from the University of to me” had the highest mean score (M = 2.93, SD = 0.92), Medicine and Pharmacy at Ho Chi Minh City followed by the item “Lack of support from family members
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173 Nguyen, N. T., Do, H. T., & Pham, N. T. V. (2021) makes my breastfeeding practice more difficult” (M = 2.45, feel unsure of continuing breastfeeding” (M = 2.31, SD = SD = 0.89). The lowest mean score was the item “Formula 0.88). advertisement from TV, parent magazines, etc., makes me
Table 2 Descriptive statistics of perceived barriers to breastfeeding (N = 246)
Do you think that the following items were barriers to your breastfeeding? M SD Maternal 1. Breastfeeding is an exhausting process 2.34 0.84 2. Breastfeeding interferes with my sleeping pattern 2.56 0.97 3. Breastfeeding in front of family members is an embarrassing process for me 2.42 0.99 4. Experiencing physical breast problem (for example, sore or cracked nipple, breast engorgement) 2.52 1.01 discourages me from continuing breastfeeding 5. Lack of knowledge about breastfeeding technique results in my unsuccessful practice 2.69 0.99 6. Breastfeeding makes me feel nervous about my body changes (such as weight gain, saggy breast) 2.27 0.87 7. I haven’t enough skills to practice breastfeeding 2.45 0.92 8. My breastfeeding is not successful as expected due to insufficient breastmilk 2.70 0.99 9. Breastfeeding interferes with my daily life activities 2.31 0.83 10. During breastfeeding, I often have negative emotion (such as feeling anxious, agitated, angry, 2.04 0.90 disgusted, or rageful) Infant 11. Exclusive breastfeeding does not provide my baby with enough nutrition. 2.26 0.92 12. It is difficult for me to keep my baby latch on my breast 2.46 0.94 13. My baby’s irritating mood makes breastfeeding harder 2.60 0.97 14. My baby’s illness makes breastfeeding very hard 2.74 0.99 Socio-environment 15. Breastfeeding in public places is uncomfortable to me 2.93 0.92 16. Breastfeeding limits my social activities with others 2.43 0.83 17. Lack of support from family members makes my breastfeeding practice more difficult. 2.45 0.89 18. Return to work affects my breastfeeding adversely 2.43 0.79 19. Formula advertisement from TV, parent magazines, etc. makes me feel unsure of continuing 2.31 0.88 breastfeeding 20. Lack of support from healthcare personnel makes my breastfeeding practice more difficult. 2.34 0.91
One-way ANOVA test showed a statistically significant enabled us to make direct comparisons between two difference between the mother’s age and breastfeeding means from two individual groups. The post hoc (LSD) test barriers score (F = 3.67, p = 0.03). The post hoc (LSD) test revealed that the mothers who less than 25 years old and calculated the smallest significance between two means as from 25 to 35 years old had higher breastfeeding barrier if a test had been run on those two means (as opposed to scores than those who greater than 35 years old (Table 3). all of the groups together in the case of Tukey’s test). This
Table 3 The difference in breastfeeding barriers scores and mothers’ characteristics (N =246)
Breastfeeding barriers Post hoc Variable n M±SD t/F p Mother’s age 3.67 0.03* < 25 years old 46 53.30±15.31 (1), (2) > (3) 25 – 35 years old 151 49.28±13.92 > 35 years old 49 45.29±15.03 Mother’s education 0.81 0.45 Less than high school 62 51.13±15.17 High school or diploma 128 48.94±14.44 Bachelor or higher 56 47.84±14.57 Delivery method -0.90 0.37 Normal delivery 132 48.46±14.86 Cesarean section 114 50.14±14.23 Parity 0.68 0.50 Primiparous 128 49.84±14.29 Multiparous 118 48.58±14.90 *p <0.05, t = t-test, F = ANOVA, post hoc (LSD)
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Discussion Simultaneously, the baby's mood and appetite are likely to be altered, and the common baby/mother interactions The mothers in the current study were young adults, and towards feeding (Paintal & Aguayo, 2016). The best thing the majority of them were in the appropriate range of as we know that she should continue breastfeeding a sick childbearing ages between 25 to 35 years old. Slightly baby to help the baby shorten the length of the illness and more than half of them were new mothers. The mothers’ quickly recovery because breast milk contains antibodies perception of breastfeeding barriers was at a moderate (Manning et al., 2013). However, it is not easy to level. According to Health Promotion Model, perceived breastfeed an ill, irritated baby. To illustrate, the baby has barriers mean the perception of an individual about the a cold and stuffy nose; when he suckles the breast, it can inconveniences or difficulties of an action (Pender et al., be frustrating the baby, and he is fussier at the breast since 2011). In a breastfeeding context, perceived barriers he cannot breathe during suckling. Sharmin et al. (2016) represent the perception of mothers about the difficulties, reported that 64.8% of mothers in Bangladesh did not give the inconveniences, the challenges that the mothers face exclusive breastfeeding during the baby’s illness time. In during the breastfeeding period; the more perceived the belief of Vietnamese people, breastfeeding is barriers to breastfeeding, the less breastfeeding for the unnecessary for the sick baby since it is difficult to feed the babies (Al-Darweesh et al., 2016). baby during the baby’s illness. Not surprisingly, the infant’s The top barrier by the perception of Vietnamese illness is highly correlated to the inadequate practice of mothers in the current study with the highest score (M = exclusive breastfeeding in Vietnam. 2.93, SD = 0.92) was “breastfeeding in public places was The third-highest score of barriers of exclusive uncomfortable to the mothers”. It seems to be a common breastfeeding from Vietnamese mothers’ perception was barrier from the perceptions of Vietnamese mothers and the insufficient breast milk (M = 2.70, SD = 0.99). mothers from other countries. Coomson and Aryeetey Interestingly, perception about insufficient milk seems to be (2018) conducted mixed methods research to describe the a global barrier for exclusive breastfeeding among mothers breastfeeding experience in public among 300 women in worldwide. In a study by Osman et al. (2009), mothers in Accra, Ghana; these women reported difficulties in Lebanon perceived that they had insufficient breast milk breastfeeding baby in public places due to the feelings of because their babies still felt hunger and cried after shyness, embarrassment, discomfort to expose the feeding. Similarly, a study by Nasser et al. (2018) reported breasts (Coomson & Aryeetey, 2018). According to the that 78% of the mothers in Qatar stopped giving exclusive literature review, there are controversial views of breastfeeding for babies because they thought they did not breastfeeding in public places; some support this practice have enough breast milk. A study in Vietnam reported that while others do not. The rejection or acceptance of 60.9% of the mothers felt that their breast milk was not breastfeeding in public places depends on the requisite enough for the child and the child would be hungry; social norms. For example, a study by Morris et al. (2016) consequently, they considered stopping exclusive in the United Kingdom revealed that breastfeeding in public breastfeeding during the first six months (Nguyen et al., places was inappropriate because breasts were viewed as 2018). There are various reasons for insufficient milk sexual objects. Whereas people in China claimed to supply, such as poor nutrition due to poor appetite of the breastfeed in public was appropriate and did not violate mothers (Lou et al., 2014), poor sucking (Sharmin et al., social morality (Zhao et al., 2017). In Vietnamese culture, 2016), not breastfeeding often enough, over anxiety, it is acceptable for mothers to breastfeed in public places excessive fatigue, and lack of support and guidance from with covered-up breasts to avoid the exposure of their nurse-midwives (Sultana et al., 2013). However, breasts. Vietnamese mothers would find a discreet place insufficient milk is preventable; the finding implied the to feed their baby to prevent discomforting others, guard importance of educating, supporting, and coaching the against judgment, and protect themselves from males’ mothers to overcome this barrier and successfully unwanted gaze. Once a mother feels inconvenient or exclusive breastfeed for the first six months. A previous uncomfortable about breastfeeding in public, she is less study confirmed that mothers having sufficient breast milk likely to breastfeed her baby in public, which, in turn, more for the baby in the first six months were 24.89 times more likely to stop exclusive breastfeeding before six months. likely to give exclusive breastfeeding than mothers with the Similarly, a study by Scott et al. (2015) indicated that perception of insufficient breast milk (Kim & Chapman, mothers in European countries who had a negative attitude 2013). toward breastfeeding in public places were nearly never Next, lack of knowledge about breastfeeding breastfed their babies in public (AOR = 0.05, 95% CI [0.12, techniques resulting in unsuccessful practice was a barrier 0.50]). Those mothers were also more likely to cease by the view of Vietnamese mothers in the current study (M breastfeeding earlier compared to the others. = 2.69, SD = 0.99). A study by Nasser et al. (2018) The second highest score was baby's illness and revealed that approximately 53% of the mothers stopped irritating mood (M = 2.74, SD = 0.99). These Vietnamese exclusive breastfeeding their babies between zero and six mothers identified this barrier as one of the most common. months due to not knowing how to breastfeed the babies One can theorize that when a baby becomes ill, mothers appropriately. Likewise, Sharmin et al. (2016) reported that feel uncertain about caring for him, including feeding. 92.3% of mothers in Bangladesh who were in the non-
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175 Nguyen, N. T., Do, H. T., & Pham, N. T. V. (2021) exclusive breastfeeding group using faulty breastfeeding breastfeeding in public places, such as hospitals, techniques led to poor suckling and attachment. In restaurants, parks, cinemas, etc. Vietnam, the mothers with normal delivery will be The data from this study were drawn from convenience discharged from the hospital after two to three days; with sampling; thus, the representativeness of this study was the short period, the mothers might not learn and absorb limited. It evokes a recommendation for further research. A the breastfeeding techniques provided by the hospital. In cluster random sampling method should be used to obtain fact, breastfeeding is a “learned skill”, more than instincts. a sample with the best representativeness for the entire Thus, it is difficult to be successful in the breastfeeding population in Vietnam. Besides, for comparison with the practice if the mothers have less knowledge and fewer current study, further research should be conducted with skills about breastfeeding techniques. Mothers in the the mothers in rural areas or other regions of the country current study were new mothers who had no breastfeeding to capture a broader picture of perceived barriers to experience before, and that is why lack of techniques in breastfeeding practice in Vietnam. breastfeeding was their concern as a barrier of breastfeeding. Therefore, the teaching about Conclusion breastfeeding techniques for mothers during antennal care visits is suggested for the hospital policy. The failure of exclusive breastfeeding practice in the first Last but not least, the fifth-highest score was the lack six months was derived from the mothers’ perception of of support from family (M = 2.45, SD = .89). The different barriers. These barriers come from the three main Vietnamese mothers exposed this barrier as one of the factors, including maternal, infant, and socio-environment most common. Researches have proved that family factors. The embarrassment, insufficient milk, baby’s support played an essential role in the exclusive illness and irritating mood, lack of knowledge about breastfeeding practice of mothers. For instance, a study by breastfeeding techniques, and lack of support from family Yenti et al. (2018) revealed that mothers in Indonesia who were the most perceived barriers. The investigations in this got family support for breastfeeding were 2.67 times study help nurses, midwives, and healthcare providers (95%CI [1.1, 6.4]) more likely to give exclusive identify the barriers that obstruct the exclusive breastfeeding than those who did not have. Likewise, breastfeeding practice; hence, the breastfeeding another study in Yogyakarta, Indonesia, found that promotion program could be proposed and implemented to mothers who received family support were 2.86 times improve the exclusive breastfeeding practice. (95%CI [1.25, 6.58]) more likely to practice exclusive breastfeeding compared to those who did not (Ratnasari et Declaration of Conflicting Interests al., 2017). Similarly, a study in Ethiopia reported that The authors declare that there is no conflict of interest in this study. mothers who were supported by their husbands were 2.67 times (95%CI [1.04, 6.95]) more likely to breastfeed Funding exclusively (Tewabe et al., 2016). Family plays a crucial Funded by the University of Medicine and Pharmacy at Ho Chi role in breastfeeding practice; thus, receiving support from Minh City, Vietnam. family was important during the breastfeeding period for Acknowledgment the mothers. Not surprisingly, lack of support from family We thanked the University of Medicine and Pharmacy for was perceived as one of the barriers of exclusive providing the fund for conducting this research. We also breastfeeding practice. acknowledged the experts for their valuable time to evaluate the The current study provides the picture of perceived content of the questionnaire. barriers to breastfeeding among mothers in Ho Chi Minh City, Vietnam; it is a piece of the puzzle to complete the Authors’ Contribution NTN made significant contributions to the literature review (review picture of breastfeeding in Vietnam. In addition, it gives of theory which can be applied in the study, recommendation from some implications for nursing and midwifery practice as WHO, policies of Vietnamese government about exclusive mothers perceived they had insufficient milk and breastfeeding, current situation of exclusive breastfeeding in breastfeeding techniques to feed their babies. Therefore, Vietnam), design of the study, data acquisition, nurses and midwives need to be with them in the first hours analysis/interpretation of the study. HTD and NTVP made and days after birth to build their confidence when significant contributions to the literature review (review the benefits breastfeeding the babies. Also, nurses and midwives can of exclusive breastfeeding, the barriers of breastfeeding in other develop the nursing interventions, such as the countries and Vietnam), study design, data acquisition, interpretation of the study findings. All authors drafted the enhancement breastfeeding self-efficacy programs for manuscript, revised it critically for important intellectual content, mothers and students to build and boost self-efficacy so approved the final version of the paper, and agreed to its that the mothers or future mothers can confidently practice submission for publication. reaching the six-month exclusive breastfeeding. The top barrier perceived by mothers in this study was Authors’ Biographies uncomfortable when breastfeeding in public places. It Dr. Nhan Thi Nguyen is a Lecturer at the Midwifery Department, implies that the policy needs to have room for University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam.
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Huong Thi Do, MEd is Dean of Midwifery Department, University Morris, C., Zaraté de la Fuente, G. A., Williams, C. E. T., & Hirst, of Medicine and Pharmacy at Ho Chi Minh City, Vietnam. C. (2016). UK views toward breastfeeding in public: An Nhu Thi Van Pham, MPH is a Former Lecturer at the Midwifery analysis of the public’s response to the Claridge’s incident. Department, University of Medicine and Pharmacy at Ho Chi Minh Journal of Human Lactation, 32(3), 472-480. https://doi.org/ City, Vietnam. 10.1177/0890334416648934 Nasser, A., Omer, F., Al-Lenqawi, F., Al-Awwa, R., Khan, T., El- Data Availability Statement Heneidy, A., . . . Al-Jayyousi, G. (2018). Predictors of The datasets generated during and/or analyzed during the current continued breastfeeding at one year among women attending study are available from the corresponding author on reasonable primary healthcare centers in Qatar: A cross-sectional study. request. Nutrients, 10(8), 983. https://doi.org/10.3390/nu10080983 Nguyen, N. T., Prasopkittikun, T., Payakkaraung, S., & References Vongsirimas, N. (2021). Factors predicting six-month Al-Darweesh, F., Al-Hendyani, R., Al-Shatti, K., Abdullah, A., Taqi, exclusive breastfeeding among mothers in Ho Chi Minh City, M., & Abbas, A. (2016). Knowledge, intention, practice, and Vietnam. Journal of Health Research. https://doi.org/10.1108/ perceived barriers of breastfeeding among married working JHR-03-2020-0080 women in Kuwait. International Journal of Community & Nguyen, P. T. K., Tran, H. T., Thai, T. T. T., Foster, K., Roberts, Family Medicine, 1(108), 1-6. https://doi.org/10.15344/2456- C. L., & Marais, B. J. (2018). Factors associated with 3498/2016/108 breastfeeding intent among mothers of newborn babies in Da Babakazo, P., Donnen, P., Akilimali, P., Ali, N. M. M., & Nang, Viet Nam. International Breastfeeding Journal, 13(1), Okitolonda, E. (2015). Predictors of discontinuing exclusive 1-7. https://doi.org/10.1186/s13006-017-0144-7 breastfeeding before six months among mothers in Kinshasa: Osman, H., El Zein, L., & Wick, L. (2009). Cultural beliefs that may A prospective study. International Breastfeeding Journal, discourage breastfeeding among Lebanese women: A 10(1), 1-9. https://doi.org/10.1186/s13006-015-0044-7 qualitative analysis. International Breastfeeding Journal, 4(1), Ballard, O., & Morrow, A. L. (2013). Human milk composition: 1-6. https://doi.org/10.1186/1746-4358-4-12 Nutrients and bioactive factors. Pediatric Clinics, 60(1), 49-74. Paintal, K., & Aguayo, V. M. (2016). Feeding practices for infants https://doi.org/10.1016/j.pcl.2012.10.002 and young children during and after common illness. Evidence Biks, G. A., Berhane, Y., Worku, A., & Gete, Y. K. (2015). from South Asia. Maternal & Child Nutrition, 12, 39-71. Exclusive breast feeding is the strongest predictor of infant https://doi.org/10.1111/mcn.12222 survival in Northwest Ethiopia: A longitudinal study. Journal of Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2011). Health Health, Population and Nutrition, 34(1), 1-6. https://doi.org/ promotion in nursing practice (6th ed.). Upper Saddle River, 10.1186/s41043-015-0007-z NJ: Pearson Prentice Hall. Cochran, W. G. (1977). Sampling technique (3rd ed.). New York: Ratnasari, D., Paramashanti, B. A., Hadi, H., Yugistyowati, A., John Willey & Sons. Astiti, D., & Nurhayati, E. (2017). Family support and exclusive Coomson, J. B., & Aryeetey, R. (2018). Perception and practice of breastfeeding among Yogyakarta mothers in employment. breastfeeding in public in an urban community in Accra, Asia Pacific Journal of Clinical Nutrition, 26(S1), s31-s35. Ghana. International Breastfeeding Journal, 13(1), 1-10. https://doi.org/10.6133/apjcn.062017.s8 https://doi.org/10.1186/s13006-018-0161-1 Scott, J. A., Kwok, Y. Y., Synnott, K., Bogue, J., Amarri, S., Norin, Dixon, G. (1992). Colostrum avoidance and early infant feeding in E., . . . Team, I. P. (2015). A comparison of maternal attitudes Asian societies. Asia Pacific Journal of Clinical Nutrition, 1(4), to breastfeeding in public and the association with 225-229. breastfeeding duration in four European countries: Results of Karkee, R., Lee, A. H., Khanal, V., & Binns, C. W. (2014). A a cohort study. Birth, 42(1), 78-85. https://doi.org/10.1111/ community-based prospective cohort study of exclusive birt.12138 breastfeeding in central Nepal. BMC Public Health, 14(1), 1- Sharmin, L., Chowdhury, M. A. K. A., Khatun, S., & Ahmed, N. 6. https://doi.org/10.1186/1471-2458-14-927 (2016). Barriers to exclusive breastfeeding among urban Kim, T. D., & Chapman, R. S. (2013). Knowledge, attitude and mothers. Journal of Enam Medical College, 6(2), 88-92. practice about exclusive breastfeeding among women in https://doi.org/10.3329/jemc.v6i2.27763 Chililab in Chi Linh Town, Hai Duong Province, Vietnam. Sultana, A., Rahman, K. U., & Ms, M. S. (2013). Clinical update Journal of Health Research, 27(1), 39-44. and treatment of lactation insufficiency. Medical Journal of Labbok, M. H. (2016). The Lactational Amenorrhea Method (LAM) Islamic World Academy of Sciences, 21(1), 19-28. for postpartum contraception. Retrieved from Tamiru, D., Belachew, T., Loha, E., & Mohammed, S. (2012). Sub- https://www.breastfeeding.asn.au/bfinfo/lactational-amenor optimal breastfeeding of infants during the first six months and rhea-method-lam-postpartum-contraception associated factors in rural communities of Jimma Arjo Lou, Z., Zeng, G., Huang, L., Wang, Y., Zhou, L., & Kavanagh, K. Woreda, Southwest Ethiopia. BMC Public Health, 12(1), 1-9. F. (2014). Maternal reported indicators and causes of https://doi.org/10.1186/1471-2458-12-363 insufficient milk supply. Journal of Human Lactation, 30(4), Tasnim, S. (2014). Effect of breast feeding on child development: 466-473. https://doi.org/10.1177/0890334414542685 At birth and beyond. South East Asia Journal of Public Health, Lundberg, P. C., & Thu, T. T. N. (2012). Breastfeeding attitudes 4(1), 4-8. https://doi.org/10.3329/seajph.v4i1.21831 and practices among Vietnamese mothers in Ho Chi Minh Tewabe, T., Mandesh, A., Gualu, T., Alem, G., Mekuria, G., & City. Midwifery, 28(2), 252-257. https://doi.org/10.1016/ Zeleke, H. (2016). Exclusive breastfeeding practice and j.midw.2011.02.012 associated factors among mothers in Motta town, East Gojjam Manning, M. L., Davis, J., Sparnon, E., & Ballard, R. M. (2013). zone, Amhara Regional State, Ethiopia, 2015: A cross- iPads, droids, and bugs: Infection prevention for mobile sectional study. International Breastfeeding Journal, 12(1), 1- handheld devices at the point of care. American Journal of 7. https://doi.org/10.1186/s13006-017-0103-3 Infection Control, 41(11), 1073-1076. https://doi.org/10.1016/ UNICEF. (2016). Vietnam: Key demographic indicators. j.ajic.2013.03.304 Retrieved from https://data.unicef.org/country/vnm/
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Victora, C. G., Bahl, R., Barros, A. J. D., França, G. V. A., Horton, Yenti, M., Ramadani, M., Nursal, D. G. A., & Maulida, R. (2018). S., Krasevec, J., . . . Rollins, N. C. (2016). Breastfeeding in the Past experience of exclusive breastfeeding, early initiation of 21st century: Epidemiology, mechanisms, and lifelong effect. breastfeeding, and family support are important factors of The Lancet, 387(10017), 475-490. https://doi.org/10.1016/ exclusive breastfeeding practice in Padang Panjang city, S0140-6736(15)01024-7 Indonesia. KnE Life Sciences, 548-555. https://doi.org/10. Walters, D., Horton, S., Siregar, A. Y. M., Pitriyan, P., Hajeebhoy, 18502/kls.v4i4.2317 N., Mathisen, R., . . . Rudert, C. (2016). The cost of not Zhao, Y., Ouyang, Y.-Q., & Redding, S. R. (2017). Attitudes of breastfeeding in Southeast Asia. Health Policy and Planning, Chinese adults to breastfeeding in public: A web-based 31(8), 1107-1116. https://doi.org/10.1093/heapol/czw044 survey. Breastfeeding Medicine, 12(5), 316-321. https://doi. WHO. (2011). Exclusive breastfeeding for six months best for org/10.1089/bfm.2017.0013 babies everywhere. Retrieved from http://www.who.int/media centre/news/statements/2011/breastfeeding20110115/en/ Cite this article as: Nguyen, N. T., Do, H. T., & Pham, N. T. WHO. (2017). Infant and young child Retrieved from V. (2021). Barriers to exclusive breastfeeding: A cross- http://www.who.int/mediacentre/factsheets/fs342/en/ sectional study among mothers in Ho Chi Minh City, Vietnam. Xuan, N. T. T., & Nguyen, N. T. (2018). Breastfeeding experiences Belitung Nursing Journal, 7(3), 171-178. https://doi.org/10.335 of working mothers in Vietnam. Belitung Nursing Journal, 4(3), 46/bnj.1382 279-286. https://doi.org/10.33546/bnj.454
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178 Original Research BNJ
Belitung Nursing Journal Influence of self-esteem, Volume 7(3), 179-185 © The Author(s) 2021 https://doi.org/10.33546/bnj.1424 psychological empowerment, and empowering leader behaviors on assertive behaviors of staff nurses
Ryan Michael F. Oducado*
Abstract Background: Being assertive is essential skill nurses need to learn and develop. While many studies exist on nurses’ assertiveness, there is limited research on the factors associated with Filipino nurses’ assertive behaviors. Objective: This study examined the correlation of self-esteem, psychological empowerment, and leader empowering behaviors on staff nurses’ assertiveness in the workplace. Methods: This cross-sectional study conducted in 2019 involved 223 staff nurses working in two tertiary hospitals in the Philippines. Data were gathered using four validated self-reported scales: self-esteem scale, psychological empowerment scale, leader empowering behavior questionnaire, and workplace assertive behavior questionnaire. Correlational analysis using Pearson’s r was performed to test the relationship between the key variables. Results: The composite scores for the self-esteem, psychological empowerment, empowering leader behaviors, and workplace assertiveness were 32.06 (SD = 3.65), 4.22 (SD = 0.43), 3.86 (SD = 0.51) and 3.61 (SD = 0.55), respectively. Self-esteem (r = 0.216; p = 0.001), psychological empowerment (r = 0.455, p = 0.000), and empowering leader behaviors (r = 0.269; p = 0.000) were significantly correlated with staff nurses’ assertiveness in the workplace. Conclusion: Self-esteem, nurse leadership behaviors, and empowerment play vital roles in staff nurses’ assertiveness. Understanding the factors influencing nurses’ assertiveness is important, and looking into these variables can be beneficial for nursing management when developing strategies to build nurses’ assertiveness. Thus, it is vital to focus on helping nurses nurture healthy self-esteem and initiate empowering conditions at work to aid nurses in setting healthy boundaries and supporting assertive behaviors at work.
Keywords assertiveness; leadership; nurses; self-concept; workplace; Philippines
Assertiveness is the ability to express your ideas, interests, developments in healthcare, nurses are expected to exhibit thoughts, feelings, beliefs, and needs freely, clearly, assertiveness to work with other health care professionals confidently, and honestly, without denying or violating effectively, thereby impacting positively patient safety and others’ rights (Alberti & Emmons, 2008; Oducado, 2021). outcome (Okuyama et al., 2014a). Being the largest Assertiveness is an important skill that nurses must learn workforce in the hospital settings, nurses are uniquely to acquire and need to develop (Oducado, 2021; positioned to speak up for changes in the care plan of their Yoshinaga et al., 2018). With the advancements and patients if they see it deemed necessary (Hall, 2016). In
West Visayas State University, College of Nursing, Iloilo City, Article Info: Philippines Received: 15 March 2021 Revised: 16 April 2021 Accepted: 3 May 2021 Corresponding author: Dr. Ryan Michael F. Oducado This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which allows West Visayas State University, College of Nursing, La Paz, Iloilo others to remix, tweak, and build upon the work non-commercially as long as City, Philippines, 5000 the original work is properly cited. The new creations are not necessarily Email: [email protected] licensed under the identical terms.
E-ISSN: 2477-4073 | P-ISSN: 2528-181X
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179 Oducado, R. M. F. (2021) other words, nurses need to speak up or call the attention assertiveness has not been investigated. Besides, the of the healthcare team member when they see a problem studies earlier cited were conducted in other countries and with regards to patient care, when standard processes are not in the context of Filipino nurses. not followed, or when improper practices are observed. Although there has been growing research on nurses’ However, being assertive and speaking up can be assertiveness abroad, there is a scarcity of published challenging for nurses, and that silence still prevails in research looking into the factors associated with nurses’ many nursing situations (Okuyama et al., 2014b; Rainer, assertiveness in a generally collectivist culture like the 2015; Schwappach & Richard, 2018). Philippines. In general, the Filipino culture and their Asian The importance of assertiveness in nursing cannot be counterparts are predisposed to be conformist, collective, overemphasized. Firstly, assertiveness is necessary for and group-oriented instead of individualistic and assertive establishing a trusting nurse and patient relationship and (Niikura, 1999). Assertiveness is frowned upon as it can be communicating effectively with patients and members of suggestive of pride, and some Filipino traits work against it. the health team (Larijani et al., 2017; Mushtaq, 2018). Alongside this backdrop, this study was conducted to Assertiveness is required for openness to speak up, is determine the influence of self-esteem, psychological instrumental in ensuring patient safety, and is integral to empowerment, and empowering leader behaviors on staff professional accountability (Nacioglu, 2016; Reid & nurses’ workplace assertiveness. Bromiley, 2012). Additionally, nurses are ethically, morally, and legally bound to question an inappropriate or incorrect Methods doctor’s order and speak up to protect patient’s rights and safety (Rainer, 2015; Reuter & Fitzsimons, 2013). Patient Research Design advocacy is an important nursing responsibility (Gerber, A cross-sectional study design was adopted. 2018). Nurses have the critical role as patient advocates, serving as voices of their patients (Palatnik, 2016). The Sample and Setting State Practice Acts in other countries like the United States The participants were registered nurses with staff nurse of America mandate that nurses act as patient advocates positions (N = 403) from two randomly selected tertiary (Gerber, 2018). The Code of Ethics of Filipino Registered hospitals in the Western Visayas part of the Philippines. Nurses explicitly states that nurses should take appropriate Tertiary or teaching and training hospitals were chosen steps to safeguard the rights and privileges of their patients since these hospitals had a greater number of nurses (Board of Nursing of the Philippines, 2004). Being assertive compared to other hospital levels. The Slovin’s formula n = means nurses are defending and safeguarding the rights of N/(1+Ne2) cited in Almeda et al. (2010) was used to their patients. Nurses have to be assertive enough to compute the sample size yielding the desired sample size preserve their rights as well as the rights of their clients of 201. Also, priori power analysis using G*Power 3.1 (Mushtaq, 2018). Lastly, assertiveness is a means which software suggested that a sample size of 84 staff nurses can be used to combat negative and stressful situations like would already be sufficient to achieve a statistical power of mobbing, conflict situations, to communicate better, and to 0.80 in bivariate correlation analysis with 0.05 alpha and enhance empowerment (Asi Karakas & Okanli, 2015; 0.30 medium effect size (Faul et al., 2009). However, to Deltsidou, 2009). enhance the geographical diversity per hospital unit or Given the importance of assertiveness in nursing, department, the researcher included more than the desired identifying variables that influence or promote sample size. A total of 230 questionnaires were randomly assertiveness is therefore necessary. Some prior studies distributed and administered to staff nurses; 223 conducted elsewhere studied the factors affecting responded, obtaining a response rate of 97%. This study assertiveness among nursing students (Ibrahim, 2011; only involved staff nurses. Nurses occupying supervisory Larijani et al., 2017). Other scholars investigated the positions, trainees, volunteers, over 65 years old and effectiveness of assertiveness training on nurses (Asi employed in other hospitals were excluded from the study. Karakas & Okanli, 2015; Kanade, 2018; Nakamura et al., 2017; Shimizu et al., 2004; Yoshinaga et al., 2018) and Instruments nursing students (Omura et al., 2019). Variables such as Data were gathered using four validated self-reported self-esteem (Binuja, 2020; Maheshwari & Gill, 2015; scales used among nurses in studies conducted in other Shrestha, 2019) and psychological empowerment (Azizi et countries. The authors of the scales granted permission to al., 2020; Bostanabad et al., 2018; Ibrahim, 2011) were use the instruments in the current study through email found to be associated with assertiveness. However, for correspondence. most studies, these variables were correlated with general Self-esteem Scale (SES) (Rosenberg, 1965). The 10- assertiveness and not specifically with workplace item SES was used to measure nurses’ global self-worth. assertiveness of nurses. Studies have also shown that Nurses were asked to rate each item using a 4-point scale leadership, managerial, and administrative support (1 = strongly disagree to 4 = strongly disagree). The SES influenced speaking-up and voicing behaviors (Darawad et had a fairly acceptable internal consistency of 0.75 in al., 2020; Lee et al., 2021; Okuyama et al., 2014a; Wong et nursing samples (McMullen & Resnick, 2013) and 0.77 al., 2010), but the role of leader empowering behaviors on
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180 Oducado, R. M. F. (2021) among Filipino youths and adolescents (Reyes et al., interviewed to share their comments about the instruments. 2017). No further changes were made to the instruments as per Psychological Empowerment Scale (PES) the acceptable result of pilot testing. (Spreitzer, 1995). This 12-item scale with four subscales (meaning, competence, self-determination, and impact) Data Collection was used to measure nurses’ psychological empowerment. The survey was conducted between June to July of 2019. All items were answerable in a 5-point Likert scale format Before actual data gathering, administrative clearance to (1 = strongly disagree to 6 = strongly agree). Studies conduct the study was obtained from the Hospital Director conducted among nurses reported fairly high Cronbach’s through the Director of Nursing. In coordination with the alpha values of 0.80 and above (Shapira Lishchinsky & Nursing Service Office, the researcher and trained data Benoliel, 2019; Uner & Turan, 2010). gatherers distributed the survey instruments inside a Leader Empowering Behavior Questionnaire sealed envelope to staff nurses either before they go on (LEBQ) (Konczak et al., 2000). This scale was duty or after shift. Staff nurses were briefly oriented administered to measure staff nurses’ perception of the regarding the purpose of the study, were allowed to ask empowering behaviors of their leader. The LEBQ by questions, and were given the opportunity to refuse to join Konczak et al. (2000) originally consisted of 17 items, but the study. The participants were asked to answer the forms Bester et al. (2015) recently added two items. The 19-item at their most convenient time and place and were asked to version of the scale was utilized in this study, consisting of return them sealed to the researcher or data gathers to six subscales: accountability for outcomes, self-directed ensure confidentiality of responses. The researcher decision-making, information sharing, skills development, allocated sufficient days for data collection to allow the delegation of authority, and coaching for innovative adequate representation of staff nurses despite shifting performance. Nurses responded using a 5-point Likert schedules of staff nurses, and the participants were given scale (1 = strongly disagree to 5 = strongly agree). The ample time to answer the survey. During retrieval, the LEBQ was previously pilot-tested among Filipino nurses completeness of data entry was checked. (Oducado, 2019). Konczak et al. (2000) reported reliability coefficients that range between 0.82 and 0.88. Data Analysis Workplace Assertive Behavior Questionnaire After data checking and cleaning, the responses were (WABQ) (Timmins & McCabe, 2005a, 2005b). This scale encoded and computer-processed via the IBM Statistical was utilized to assess nurses’ assertiveness in the Package for the Social Sciences (SPSS) software version workplace. The participants were asked to indicate how 23. Frequency (n), percentage (%), mean (M), and often they use the eight assertive behaviors towards their standard deviation (SD) were used to quantify and describe nursing colleagues or co-staff nurses, the nursing the data. Kolmogorov-Smirnov (p = 0.20) and Shapiro-Wilk management (head nurses or supervisors), and the (p = 0.31) indicated that data do not significantly deviate medical personnel (doctors or physicians). Nurses were from normal distribution. The Pearson’s r correlation asked to answer using a 5-point Likert scale (1 = never to coefficient was used to determine the relationship between 5 = always). Timmins and McCabe (2005a, 2005b) stated the key variables of the study. The correlation coefficient an acceptable internal consistency (α = 0.88) of items was interpreted following the work of Schober et al. (2018): within the questionnaire. + 0.90-1.00 = very strong positive (negative) correlation, + For all the scales in this study, higher scores indicate a 0.70-0.89 = strong positive (negative) correlation, + 0.40- higher level of self-esteem, psychological empowerment, 0.69 = moderate positive (negative) correlation, + 0.10-0.39 leader empowering behaviors, and assertiveness in the = weak positive (negative) correlation, and + 0.00 to 0.10 = workplace. The personal characteristics of nurses were negligible positive (negative) correlation. A p-value equal to also collected. or less than 0.05 was considered the level of acceptable To make sure that the result of this study will be significance. culturally sensitive and to increase its scientific accuracy, the instruments were subjected to face and content Ethical Consideration validation and pilot testing. Seven local experts with The study was reviewed and approved by the Ethics master’s or doctoral degrees and relevant experience and Committee of the West Visayas State University. A written training in nursing, management, and psychology informed consent form was obtained from all participants. evaluated the items in the instruments to be relevant, clear, No personal identifiers were collected to protect the and culturally appropriate. A survey instrument validation anonymity of the participants and the confidentiality of the rating scale was used in the validation of instruments data. This report is part of a larger study exploring Filipino (Oducado, 2020). Pilot testing was done among 30 nursing nurses’ assertiveness. staff in another hospital. Preliminary reliability testing and actual survey revealed acceptable to high internal Results consistency values of SES (α = 0.87, α = 0.71), PES (α = 0.88, α = 0.88), LEBQ (α = 0.91, α = 0.89) and WABQ (α = Table 1 shows that the mean age was 32.34 years (SD = 0.95, α = 0.92). Five participants during the pilot test were 8.14), and the average number of years of nursing work
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181 Oducado, R. M. F. (2021) experience was 7.36 years (SD = 6.41). The majority were 110, 49.3%) hospitals. There were 126 (56.5%) staff female (n = 153, 68.6%) and Bachelor’s degree holders (n nurses assigned in specialty areas and 97 (43.5%) in = 150, 67.3%). There was an almost equal number of medical and surgical units. participants from public (n = 113, 50.7%) and private (n =
Table 1 Profile of staff nurses
Profile Categories M SD n % Age 32.34 8.14 Years of experience 7.36 6.41 Sex Male 70 31.4 Female 153 68.6 Education Bachelor’s degree 150 67.3 Bachelor’s degree with Master’s units 73 32.7 Type of hospital Public 113 50.7 Private 110 49.3 Hospital unit Specialty Areas 126 56.5 Medical and Surgical 97 43.5
Overall, the composite scores of the key variables in this Table 3 Correlation of independent variables to assertiveness study were above midpoint (Table 2). The composite score of nurses’ self-esteem was 32.06 (SD = 3.65), whereas the Independent variables Pearson’s p-value composite scores of the measures of psychological correlation (r) empowerment and leader empowering behaviors were Self-esteem 0.216 0.001* 4.22 (SD = 0.43) and 3.86 (SD = 0.51), respectively. Psychological Empowerment 0.455 0.000* Assertiveness in the workplace had a composite score of Competence 0.434 0.000* 3.61 (SD = 0.55). Impact 0.412 0.000* Self-determination 0.351 0.000* Table 2 Description of the key variables Meaning 0.272 0.000* Leader Empowering Behaviors 0.269 0.000* Scales/Subscales M SD Accountability for outcomes 0.355 0.000* Self-esteem 32.06 3.65 Delegation of authority 0.262 0.000* Psychological Empowerment 4.22 0.43 Self-directed decision-making 0.200 0.003* Meaning 4.51 0.50 Information sharing 0.192 0.004* Competence 4.26 0.52 Coaching for innovative 0.173 0.010* Self-determination 4.13 0.52 performance Impact 3.97 0.58 Skills development 0.111 0.098 Leader Empowering Behaviors 3.86 0.51 Accountability for outcomes 4.07 0.63 Discussion Self-directed decision-making 3.89 0.69
Information sharing 3.88 0.66 Skills development 3.87 0.73 The present study looked into the influence of self-esteem, Delegation of authority 3.85 0.58 psychological empowerment, and leader empowering Coaching for innovative performance 3.62 0.72 behaviors on nurses’ workplace assertive behaviors. This Assertiveness in the Workplace 3.61 0.55 study demonstrated that self-esteem had a positive, weak, Toward nursing colleagues 3.78 0.55 yet significant correlation with nurses’ workplace Toward medical personnel 3.65 0.65 assertiveness. Healthy self-esteem is important to learning Toward management personnel 3.40 0.68 to be assertive, or being assertive can lead to high levels of self-esteem. Healthy self-esteem represents a critical asset or necessary quality in developing assertiveness (Darjan et The correlation between variables is presented in Table 3. al., 2020). It can be difficult for nurses to assert themselves There was a positive, weak, significant correlation between when nurses have low self-esteem. Those with low self- nurses’ level of self-esteem (r = 0.216; p = 0.001) and esteem are likely to encounter problems defending their assertiveness and staff nurses’ perception of the opinions or making decisions for themselves (Darjan et al., empowering behaviors of their leaders (r = 0.269; p = 2020). Studies among Japanese and Indian nurses found 0.000) and assertiveness. Moreover, statistical analysis that nurses’ self-esteem improved after assertiveness revealed a positive, moderate, significant correlation training (Kanade, 2018; Shimizu et al., 2004). Similarly, a between psychological empowerment (r = 0.455, p = 0.000) significant positive correlation between assertive behavior and assertiveness in the workplace. and self-esteem was reported in a study conducted in India among nurses (Binuja, 2020; Maheshwari & Gill, 2015) and in Nepal among nursing students (Shrestha, 2019). This
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182 Oducado, R. M. F. (2021) study proposes that efforts should be made to improve and process of becoming more assertive, managerial and to achieve healthy and balanced self-esteem among organizational support should also be in place to grant nurses to better communicate and assert themselves in the nurses the necessary power, autonomy, and access to workplace. resources to exercise assertive behaviors (Darawad et al., This study also found that psychological empowerment 2020). was significantly related to assertiveness in the workplace Some shortcomings were encountered in this study that with a moderate positive correlation. Results of the current could be addressed by future scholars. This research was study also indicated a significant correlation between all the limited among nursing staff in two tertiary hospitals. Caution components of psychological empowerment and workplace is recommended when results of the present study are assertiveness. This finding indicates that a higher level of extrapolated with all Filipino nurses and nurses working in psychological empowerment, such as giving nurses the other countries and other healthcare sectors. It might be authority to make decisions and enhancing their useful to replicate the study on a larger scale involving competence, results in higher levels of assertiveness. This nurses from different countries. Another limitation is the finding is relatively consistent with that of the study of Azizi study design (cross-sectional) has temporal limitations and et al. (2020) and Ibrahim (2011). The authors found a cannot establish causality between the variables. The use significant positive relationship between psychological of survey questionnaires is subjected to self-reported bias. empowerment and assertiveness with samples of Validating self-reported data through method triangulation midwifery and nursing students in Iran and nursing students may be conducted in future studies. There may also be in Egypt. A similar finding was reported among Iranian other factors influencing nurses’ assertiveness, such as neonatal nurses (Bostanabad et al., 2018). The result of personality and emotional intelligence not included in this this study suggests the importance of empowering nurses analysis. Nevertheless, this research has contributed to a for them to act more assertively. Accordingly, it is better understanding of the factors influencing nurses’ necessary to pay attention to improving nurses’ assertiveness in the workplace. competence, independence, and autonomy, likewise creating better opportunities for nurses to appreciate the Conclusion impact and value of their work for them to exhibit assertiveness. This research highlighted that higher levels of self-esteem, Finally, it was shown in this study that there was a psychological empowerment, and empowering behaviors positive, weak, but significant relationship between leader of the leader result in higher workplace assertiveness empowering behaviors and workplace assertiveness of among nursing staff. Nurse leadership behaviors and staff nurses. It has been disclosed that managerial and empowerment play vital roles in staff nurses’ assertiveness. organizational support enables nurses to become more The results suggest that empowered nurses are assertive assertive, empowered, and speak up against unsafe nurses. Also, helping nurses nurture healthy self-esteem practices, and the process of becoming assertive or and improve their confidence can potentially lead to better learning to speak up tends to be influenced by the assertive behaviors in the workplace and assist nurses in management’s approach toward nurses (Darawad et al., setting and maintaining healthy boundaries. Nurses’ 2020). Garon (2012) likewise discovered that the strongest evaluation of themselves and empowering conditions theme for nurses to speak up was related to a climate of significantly contribute to nurses’ assertiveness or their openness that is generally created by the leaders chosen method of communicating with others in social (managers and administration). The role of a supportive interactions. Understanding and looking into these factors working culture in facilitating nurses’ ability and willingness can help the nursing management develop strategies to to voice concerns was also noted in another study build and improve nurses’ assertiveness. Interventions and (Mansour et al., 2020). Correspondingly, the study of Wong necessary platforms aimed at enhancing nurses’ self-worth et al. (2010) revealed that authentic leadership influenced should be initiated. At the same time, efforts must be nurses’ trust in their manager, which predicted voicing directed towards fostering greater empowerment at the behavior. Review studies similarly noted that hospital individual and organizational levels to promote administrative support and attitude of leaders or superiors assertiveness in the workplace. were actors influencing health care professionals and nurses’ speaking-up behavior for patient safety (Lee et al., Declaration of Conflicting Interest 2021; Okuyama et al., 2014a). The finding of this current The author has no conflict of interest to declare. study indicates the valuable role of nurse leaders and managers in supporting nurses to exhibit assertive Funding behaviors. Nurses tend or are likely to assert themselves This research received funding from the West Visayas State University – University Research and Development Center. when assertive behavior is supported in the workplace. It is, therefore, vital for the nursing management to set up Acknowledgment empowering conditions at work, such as increasing nurses’ The author would like to thank the Hospital Administration and accountability, autonomy, and self-directed decision- Nursing Directors for allowing the researcher to conduct the study making to support nurses’ assertive behaviors. In the and all the staff nurses who participated in the study. The author
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183 Oducado, R. M. F. (2021) would also like to express his gratitude to Dr. Hilda C. Montaño for correlation and regression analyses. Behavior Research her guidance in the completion of this study. Lastly, the author Methods, 41(4), 1149-1160. https://doi.org/10.3758/BRM.41.4. wishes to acknowledge the Philippine Commission on Higher 1149 Education for the support awarded to the researcher. Garon, M. (2012). Speaking up, being heard: Registered nurses’ perceptions of workplace communication. Journal of Nursing Author Contribution Management, 20(3), 361-371. https://doi.org/10.1111/j.1365- The author made a substantial contribution from the conception, 2834.2011.01296.x finalization, and writing of the final version of this article. Gerber, L. (2018). Understanding the nurse’s role as a patient advocate. Nursing2020, 48(4), 55-58. https://doi.org/10.1097/ Author Biography 01.NURSE.0000531007.02224.65 Ryan Michael F. Oducado, PhD, RN, RM, LPT is an Assistant Hall, N. (2016). Speak up: Easier to say than do. Journal of Professor at West Visayas State University, College of Nursing, Perioperative & Critical Intensive Care Nursing, 2(1), 1000111. Iloilo City, Philippines. https://doi.org/10.4172/jpcic.1000111 Ibrahim, S. A. E. A. (2011). Factors affecting assertiveness among Data Availability Statement student nurses. Nurse Education Today, 31(4), 356-360. The datasets generated during and/or analyzed during the current https://doi.org/10.1016/j.nedt.2010.07.006 study are available from the corresponding author on reasonable Kanade, A. (2018). The effect of assertiveness training program request. on nurses. Indian Journal of Psychiatric Nursing, 15(2), 19-23. https://doi.org/10.4103/2231-1505.255708 References Konczak, L. J., Stelly, D. J., & Trusty, M. L. (2000). Defining and Alberti, R. E., & Emmons, M. L. (2008). Your perfect right: A guide measuring empowering leader behaviors: Development of an to assertive behavior (9th ed.). San Luis Obispo, CA: Impact upward feedback instrument. Educational and Psychological Publishers. Measurement, 60(2), 301-313. https://doi.org/10.1177/001316 Almeda, J. V., Capistrano, T. G., & Sarte, G. (2010). Elementary 40021970420 statistics. Quezon City, Philippines: UP Press. Larijani, T. T., Aghajani, M., Zamani, N., & Ghadirian, F. (2017). Asi Karakaş, S., & Okanli, A. e. (2015). The effect of assertiveness Assertiveness and the factors affecting it among nursing training on the mobbing that nurses experience. Workplace students of Tehran University of Medical Sciences. Health & Safety, 63(10), 446-451. https://doi.org/10.1177/21 International Journal of New Technology and Research, 3(5), 65079915591708 34-38. Azizi, S. M., Heidarzadi, E., Soroush, A., Janatolmakan, M., & Lee, S. E., Choi, J., Lee, H., Sang, S., Lee, H., & Hong, H. C. Khatony, A. (2020). Investigation the correlation between (2021). Factors influencing nurses’ willingness to speak up psychological empowerment and assertiveness in nursing and regarding patient safety in East Asia: A systematic review. Risk midwifery students in Iran. Nurse Education in Practice, 42, Management and Healthcare Policy, 14, 1053. https://doi.org/ 102667. https://doi.org/10.1016/j.nepr.2019.102667 10.2147/RMHP.S297349 Bester, J., Stander, M. W., & Van Zyl, L. E. (2015). Leadership Maheshwari, S. K., & Gill, K. K. (2015). Relationship of empowering behaviour, psychological empowerment, assertiveness and self-esteem among nurses. International organisational citizenship behaviours and turnover intention in Journal of Health Sciences and Research, 5(6), 440-449. a manufacturing division. SA Journal of Industrial Psychology, Mansour, M., Jamama, A., Al-Madani, M., Mattukoyya, R., & Al- 41(1), 1-14. https://doi.org/10.4102/sajip.v41i1.1215 Anati, A. (2020). Reconciling assertive communication skills Binuja, P. (2020). Assertiveness and self-esteem of nurses. Asian with undergraduate nursing education: Qualitative Journal of Nursing Education and Research, 10(2), 160-162. perspectives from British and Saudi newly-graduated nurses. https://doi.org/10.5958/2349-2996.2020.00035.X Health Professions Education, 6(2), 176-186. https://doi.org/ Board of Nursing of the Philippines. (2004). The code of ethics of 10.1016/j.hpe.2020.02.001 registered nurses. Retrieved from https://www.prc.gov.ph/ McMullen, T., & Resnick, B. (2013). Self-esteem among nursing uploaded/documents/Board%20of%20Nursing-CE.pdf assistants: Reliability and validity of the Rosenberg Self- Bostanabad, M. A., Sahebihagh, M. H., Asadollahi, M., & Zakernik, Esteem Scale. Journal of Nursing Measurement, 21(2), 335- M. (2018). Psychological empowerment and its relationship 344. https://doi.org/10.1891/1061-3749.21.2.335 with assertiveness skill among nurses in neonatal wards. Mushtaq, B. (2018). Assertiveness in nursing. COJ Nursing & Cukurova Medical Journal, 43(4), 828-834. https://doi.org/ Health Care, 3(3), 272-273. 10.17826/cumj.389821 Nacioglu, A. (2016). As a critical behavior to improve quality and Darawad, M. W., Mansour, M., & Al-Niarat, T. (2020). patient safety in health care: Speaking up! Safety in Health, Organisational empowerment and assertive communication 2(1), 1-25. https://doi.org/10.1186/s40886-016-0021-x behaviours: A survey of Jordanian newly qualified nurses. Nakamura, Y., Yoshinaga, N., Tanoue, H., Kato, S., Nakamura, S., British Journal of Nursing, 29(7), 419-425. https://doi.org/ Aoishi, K., & Shiraishi, Y. (2017). Development and evaluation 10.12968/bjon.2020.29.7.419 of a modified brief assertiveness training for nurses in the Darjan, I., Negru, M., & Ilie, D. (2020). Self-esteem – the decisive workplace: A single-group feasibility study. BMC Nursing, difference between bullying and assertiveness in 16(1), 1-8. https://doi.org/10.1186/s12912-017-0224-4 adolescence? Journal of Educational Sciences, 41(1), 19-34. Niikura, R. (1999). Assertiveness among Japanese, Malaysian, https://doi.org/10.35923/JES.2020.1.02 Filipino, and US white-collar workers. The Journal of Social Deltsidou, A. (2009). Undergraduate nursing students’ level of Psychology, 139(6), 690-699. https://doi.org/10.1080/00224 assertiveness in Greece: A questionnaire survey. Nurse 549909598249 Education in Practice, 9(5), 322-330. https://doi.org/10.1016/ Oducado, R. M. F. (2019). Leader empowering behaviors and j.nepr.2008.08.002 psychological empowerment as perceived by young hospital Faul, F., Erdfelder, E., Buchner, A., & Lang, A.-G. (2009). staff nurses: A pilot study. Jurnal Ners, 14(1), 47-54. Statistical power analyses using G* Power 3.1: Tests for https://doi.org/10.20473/jn.v14i1.15056
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Oducado, R. M. F. (2020). Survey instrument validation rating Shapira‐Lishchinsky, O., & Benoliel, P. (2019). Nurses’ scale. SSRN. http://dx.doi.org/10.2139/ssrn.3789575 psychological empowerment: An integrative approach. Journal Oducado, R. M. F. (2021). Nurse assertiveness repertoire skills: A of Nursing Management, 27(3), 661-670. https://doi.org/10. training text and workbook (1st ed.). Quezon City, Philippines: 1111/jonm.12726 Central Books. Shimizu, T., Kubota, S., Mishima, N., & Nagata, S. (2004). Okuyama, A., Wagner, C., & Bijnen, B. (2014a). How we can Relationship between self-esteem and assertiveness training enhance nurses’ assertiveness: A literature review. Journal of among Japanese hospital nurses. Journal of Occupational Nursing Care, 3(194), 2167-1168. http://dx.doi.org/10.4172/ Health, 46(4), 296-298. https://doi.org/10.1539/joh.46.296 2167-1168.1000194 Shrestha, S. (2019). Assertiveness and self-esteem among Okuyama, A., Wagner, C., & Bijnen, B. (2014b). Speaking up for nursing students of Manipal College of Medical Science of patient safety by hospital-based health care professionals: A Pokhara, Nepal. Journal of Chitwan Medical College, 9(2), 54- literature review. BMC Health Services Research, 14(1), 1-8. 59. https://doi.org/10.3126/jcmc.v9i2.24535 https://doi.org/10.1186/1472-6963-14-61 Spreitzer, G. M. (1995). Psychological empowerment in the Omura, M., Levett‐Jones, T., & Stone, T. E. (2019). Evaluating the workplace: Dimensions, measurement, and validation. impact of an assertiveness communication training programme Academy of Management Journal, 38(5), 1442-1465. for Japanese nursing students: A quasi‐experimental study. https://doi.org/10.5465/256865 Nursing Open, 6(2), 463-472. https://doi.org/10.1002/nop2. Timmins, F., & McCabe, C. (2005a). How assertive are nurses in 228 the workplace? A preliminary pilot study. Journal of Nursing Palatnik, A. (2016). Speak up for patient safety. Nursing2020 Management, 13(1), 61-67. https://doi.org/10.1111/j.1365- Critical Care, 11(6), 4. https://doi.org/10.1097/01.CCN.00005 2834.2004.00492.x 03425.05594.02 Timmins, F., & McCabe, C. (2005b). Nurses’ and midwives’ Rainer, J. (2015). Speaking up: Factors and issues in nurses assertive behaviour in the workplace. Journal of Advanced advocating for patients when patients are in jeopardy. Journal Nursing, 51(1), 38-45. https://doi.org/10.1111/j.1365-2648. of Nursing Care Quality, 30(1), 53-62. https://doi.org/10.1097/ 2005.03458.x NCQ.0000000000000081 Uner, S., & Turan, S. (2010). The construct validity and reliability Reid, J., & Bromiley, M. (2012). Clinical human factors: The need of the Turkish version of Spreitzer’s psychological to speak up to improve patient safety. Nursing Standard, empowerment scale. BMC Public Health, 10(1), 1-8. 26(35), 35-40. https://doi.org/10.1186/1471-2458-10-117 Reuter, C., & Fitzsimons, V. (2013). Physician orders. AJN The Wong, C. A., Spence Laschinger, H. K., & Cummings, G. G. American Journal of Nursing, 113(8), 11. https://doi.org/10. (2010). Authentic leadership and nurses’ voice behaviour and 1097/01.NAJ.0000432941.27219.95 perceptions of care quality. Journal of Nursing Management, Reyes, M. E. S., Amistoso, M. N. G., Babaran, C. A. C., Bulaong, 18(8), 889-900. https://doi.org/10.1111/j.1365-2834.2010.011 G. B. M., Reyes, V. D. M., & Tubig, N. N. (2017). Death anxiety 13.x and self-esteem of Filipino youths and older adults. North Yoshinaga, N., Nakamura, Y., Tanoue, H., MacLiam, F., Aoishi, K., American Journal of Psychology, 19(2), 435-450. & Shiraishi, Y. (2018). Is modified brief assertiveness training Rosenberg, M. (1965). Society and the adolescent self-image. for nurses effective? A single‐group study with long‐term Princeton, NJ: Princeton University Press. follow‐up. Journal of Nursing Management, 26(1), 59-65. Schober, P., Boer, C., & Schwarte, L. A. (2018). Correlation https://doi.org/10.1111/jonm.12521 coefficients: Appropriate use and interpretation. Anesthesia & Analgesia, 126(5), 1763-1768. https://doi.org/10.1213/ANE.0 CIte this article as: Oducado, R. M. F. (2021). Influence of self- 000000000002864 esteem, psychological empowerment, and empowering leader Schwappach, D., & Richard, A. (2018). Speak up-related climate behaviors on assertive behaviors of staff nurses. Belitung and its association with healthcare workers’ speaking up and Nursing Journal, 7(3),179-185. https://doi.org/10.33546/bnj. 1424 withholding voice behaviours: A cross-sectional survey in Switzerland. BMJ Quality & Safety, 27(10), 827-835. http://dx.doi.org/10.1136/bmjqs-2017-007388
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Belitung Nursing Journal Lived experiences of Overseas Volume 7(3), 186-194 © The Author(s) 2021 Filipino Worker (OFW) nurses https://doi.org/10.33546/bnj.1427 working in COVID-19 intensive care units
Jane Marnel Pogoy and Jezyl C. Cutamora*
Abstract Background: Limited studies focus on the effects of the pandemic on the nurses' overall risks and wellbeing. At present, no single study has been published on Filipino nurses’ experiences outside the country during the COVID- 19 pandemic. Objective: This descriptive phenomenological study explored the Overseas Filipino Worker (OFW) nurses’ experiences working in COVID-19 intensive care units. Methods: The study was conducted in Dubai, United Arab Emirates, where there is a high number of COVID-19 cases. This study utilized a qualitative Husserlian phenomenological approach to describe and explore the lived experiences of the OFW nurses’ caring for COVID-19 critically ill patients. The research key interview informants were eight ICU nurses who cared for COVID-19 patients in Dubai hospitals. Data saturation was reached. Data collection was done in 2020, and Collaizi’s method of data analysis was utilized. Results: A total of 135 significant statements were extracted from the interview transcripts. There were 36 formulated meanings generated, and four themes emerged from this study. The first theme is Challenges During the Pandemic with the following subthemes: Away from Home, Caring for the COVID-19 Patients, and Fear of the Unknown. The second theme is Patient Care during COVID-19 with the following subthemes: COVID-19 ICU Patient Care and The Nursing Profession. Third, Adapting to Change with the subthemes: Living the New Normal and Protecting One’s Self from COVID-19. Lastly, Resilience Amidst the Pandemic with the following subthemes: Being with Others and Seeing Oneself. Conclusion: Despite the existing challenges like cultural differences and homesickness faced by these OFW nurses and the new challenges they are faced with the pandemic today, they were still able to continue living and do what is expected of them. From the hassle of wearing the PPEs, shortage of PPE, and being transferred from one unit in the hospital to another, the OFW nurses were able to adapt to these changes. The nurses already got used to the routine, but the fear of getting infected by the virus is still there.
Keywords lived experiences; OFW nurses; COVID-19; intensive care units; hospitals; United Arab Emirates; patient care
According to the World Health Organization (WHO, 2020a), responsibility (Aliakbari et al., 2014). There are limited COVID-19 is a highly transmissible disease caused by a studies focusing on the effects of the pandemic on the SARS-CoV 2 strain. Literature has shown that nurses need nurses' overall risks and wellbeing. At present, no single to sacrifice their own needs to prioritize the crisis study has been published on Filipino nurses’ experiences management strategies and a need to make selfless and outside the country during the COVID-19 pandemic. Thus, significant contributions out of moral and professional this descriptive phenomenological study will describe and
Cebu Normal University, Philippines Article Info: Received: 16 March 2021 Revised: 18 April 2021 Corresponding author: Accepted: 3 May 2021 Jezyl C. Cutamora, PhD Cebu Normal University This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which allows Block 2 lot 13 888 Acacia Drive Subdivision Capitol Site Cebu City others to remix, tweak, and build upon the work non-commercially as long as 6000 Philippines the original work is properly cited. The new creations are not necessarily Mobile: +63 032 254 4837 / +63 9195044984 licensed under the identical terms.
Email: [email protected] E-ISSN: 2477-4073 | P-ISSN: 2528-181X
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186 Pogoy, J. M., & Cutamora, J. C. (2021) explore Overseas Filipino Workers (OFW) nurses working changes in the medical and nursing management, and the in COVID-19 Intensive Care Units. virus is not readily studied yet. On top of the mentioned COVID-19 infection has quickly spread globally, and challenges, these nurses also are worried about their due to the sudden outbreak, nurses are faced with a lot of families in the Philippines, adjusting to the environment, pressure and new challenges like being transferred to new interacting with people with different cultures, and so much units or wards and adjusting to what is presently called the more. new normal (Sun et al., 2020). Some studies have shown Overseas Filipino Workers (OFW) nurses are already that when nurses are caring for patients with highly faced with challenges every day, especially because they transmissible diseases such as SARS (Chung et al., 2005) are working away from their country. They worry about their and MERS-Cov (Kim, 2018), nurses tend to suffer from safety while working and at the same time worry about their psychological issues such as loneliness, anxiety, fear, families back at home. A lot of changes have been fatigue, sleep disorders, and other physical and mental implemented in the hospital to address staffing problems. health problems. A study found the prevalence rate of Some of the nurses are being pulled out to other units, and psychological effects among nurses involved in the leaves were canceled. In this time of the pandemic, they treatment of infectious disease (such as SARS patients), are forced to find means to adapt to the present situation. namely: depression at 38.5%, insomnia at 37%, and post- As nurses are placed in demanding situations, fulfilling their traumatic stress at 33% (Sun et al., 2020). Furthermore, roles on the frontline while at higher risk just to save others, among the psychological status of Ebola patients’ this study will explore and describe the lived experiences of caregivers, 29% of respondents felt lonely, and 45% the OFW nurses working in COVID-19 Intensive Care received psychological counseling. On the contrary, the Units. This study can help hospital administrators and positive experience and growth brought by the collective government agencies understand the situation of OFW anti-epidemic efforts were also demonstrated (Sun et al., nurses and serve as a basis for them to develop new or 2020). revised policies that are beneficial to the welfare of the Presently, many studies are published on how the nurses and the patients. COVID-19 pandemic has strained the world’s healthcare systems that include nurses. As cited by Mo et al. (2020), Methods among the healthcare workers, nurses are found to be the most anxious and stressed in caring and treating patients Study Design infected with the COVID-19. Nurses who provided direct This study utilized the qualitative Husserlian patient care seemed to be more stressed, overworked, and phenomenological approach to describe and explore the psychologically disturbed and less fulfilled in their job meaning of OFW nurses’ lived experiences caring for compared to nurses in other areas of assignment (Zerbini critically-ill patients with COVID-19. Descriptive et al., 2020). Hospital women nurses who performed phenomenology was used for it has laid the foundation for diagnosis, care, treatment, and management of patients theoretical knowledge and methodological clarity and rigor with COVID-19, have shown psychological disturbances in qualitative nursing research Abalos et al. (2016) and such as anxiety, lack of sleep, and depression (Lai et al., Norlyk and Harder (2010). Husserlian phenomenology 2020). allows the researchers to explore and describe the For many years, Filipino nurses have been migrating structures of consciousness as experienced from the first- abroad to meet the very high demand in other countries. person point of view. The Philippine Overseas Employment Administration estimates more than 13,000 health care professionals Key Informants leave the country every year. Many Filipino families view The key informants are OFW nurses assigned in the the nursing profession as their ticket to a better life earning COVID-19 intensive care units and interviewed at their 15 times more than their salary while working in our local houses and hospitals. The researcher used purposive hospitals (Lorenzo et al., 2007). As other countries have a sampling in choosing the participants or key informants of shortage of nurses, they began hiring Filipino nurses this study. Purposive sampling is a strategy selected that because it is more cost-effective than training their own will give information necessary for the needs of the study nurses (Lorenzo et al., 2007). With Filipinos being fluent in (Polit & Beck, 2017). In this study, the research participants English, innately caring for the elderly and the sick, being were eight ICU nurses who cared for COVID-19 patients in adept in adjusting to new cultures and learning new Dubai hospitals. Exclusion criteria of the study included the languages, and not minding working longer hours, they unwillingness to participate in the study and nurses with a perfectly fit the bill for nursing. COVID-19 diagnosis. The ongoing COVID-19 pandemic poses great pressure, most especially in the critical care areas due to Data Collection the large number of patients requiring critical care (Shang The main instrument of this study is the researchers, as et al., 2020). As observed, Filipino nurses assigned in these cited by Polit and Beck (2017). This highlighted the role of areas face a lot of struggles in managing these critical the researcher during interviews and observations. An patients in terms of implementing new practices, frequent English and vernacular semi-structured interview guide
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187 Pogoy, J. M., & Cutamora, J. C. (2021) made by the researcher was utilized and expert-validated. data to formulate the composite findings for this research The language used was based on informants’ preference. study. This interview guide comprises three parts: warm-up questions, main questions, and follow-up or probing Rigor of the Study questions. Sample grand tour question is “Can you Multiple semi-structured interviews per informant were describe to me your experiences as a Filipino nurse caring done in different time-points to facilitate qualitative research for patients with COIVD-19 in ICU in another country?”. rigor. To enhance the trustworthiness of this study, the Probing was done to encourage the respondents to give following steps were done. First, person triangulation was more information. Probes were neutral to avoid bias. Open- done where auxiliary informants confirmed the statements ended questions were used to provide the respondents with made by the key informants or participants. Other ample opportunity to express their feelings. colleagues not included in the key informants were also Prior to starting the interview, bracketing was done. This interviewed for confirmation of the key informants’ is important to mitigate the preconceptions or biases that statements. The second is time triangulation, where the may taint the research process. During the interview, the same questions were asked at different time points during standard COVID-19 safety protocols were followed. the interview. Lastly, method triangulation wherein aside Important aspects of the research were explained and from multiple individual interviews, observation was done discussed with the key informants, such as the use of a by the researcher to confirm statements and the tape recorder, the interview venue, and the time that can be researcher’s reflection. Observations were done by looking devoted to the interview. Then informed consent was at the congruency of the verbalizations and the facial obtained from the key informants. The researcher remained expressions and non-verbal cues. neutral throughout the interview process. The researcher started the interview with the list of semi-structured Ethical Consideration interview questions the researcher has prepared through The researcher assures that the study adhered to the basic one-on-one, face-to-face interviews. The average interview ethical considerations. The COVID-19 safety protocols duration was one hour and 30 minutes and was duly were implemented throughout the research process. The recorded. The interview was conducted by JMP, spending data gathering was done after the participants were one day per informants. Translation and back-translation informed of the purpose of the study and have provided with the help of a language expert were done to ensure the informed consent. It was made clear to the OFW COVID- accuracy of the translation. 19 ICU nurses that their participation is voluntary and that they can choose not to complete the interview without any Data Analysis consequence. Further, the participants were informed of Colaizzi’s method of data analysis is deemed most fitting their anonymity and that the data provided will be kept and was utilized. This method uses components of confidential. This study was reviewed and approved by Husserlian phenomenology, putting a premium on the Cebu Normal University – Ethics Review Committee with description of the lived experience (Morrow et al., 2015). an approval code of 606/2020-11. Colaizzi’s method of data analysis consists of seven steps. The first is to read and re-read all the participants’ verbatim Results transcripts of the phenomena to acquire a feeling. Second, significant statements or phrases are extracted from Characteristics of Key Informants participants’ transcripts pertaining directly to the research Table 1 shows the profile of the informants of the study, phenomena. Then, formulated meanings are constructed including the code name, age, sex, civil status, and length from the significant statements. Fourth, formulated of time they were working in the COVID-19 ICU. It shows meanings are arranged into cluster themes which evolve that the informants are between 28 and 32 years old, and into emergent themes. Then the results were incorporated most are married. The shortest length of time they spent in into a rich and exhaustive description of the lived the COVID-19 ICU is six months, and the longest is 11 experience. Sixth, the thorough description from the months. They are all registered nurses. Some are master’s participants involved in the research was validated. Lastly, degree holders. new or pertinent data obtained from participants’ validation was incorporated and adapted to attain congruence with Thematic Analysis the lived experience of the participants studied. This study A total of 135 significant statements were extracted from is rooted in the phenomenological framework to explore the the interview transcripts from the eight informants. There OFW ICU nurses’ experiences in caring for the COVID-19 were 36 formulated meanings generated from these patients to develop a composite description of the essence significant statements, and four themes emerged from this of the experience for all the participants. Data was collected study. The first theme is Challenges During the Pandemic and analyzed using the steps from Colaizzi’s descriptive with the following subthemes: (a) Away from Home, (b) phenomenological method. Significant themes and Caring for the COVID-19 Patients, and (c) Fear of the meanings were interpreted through rigorous analysis of Unknown. The second theme is Patient Care during COVID-19 with the following subthemes: (a) COVID-19 ICU
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Patient Care and (b) The Nursing Profession. Third, subthemes, (a) Being with Others and (b) Seeing One self. Adapting to Change with the subthemes: (a) Living the New These themes will be discussed further in the following. Normal, and ( b) Protecting One’s Self from COVID-19. Lastly, Resilience Amidst the Pandemic with the following
Table 1 Profile of the Informants
Code Name Age Sex Civil Status Length of time Working in COVID-19 ICU SN01 29 Female Married Eight months SN02 29 Female Married Six months SN03 29 Male Single Ten months SN04 30 Female Married Six months SN05 32 Female Married Six months SN06 32 Female Married 11 months SN07 31 Male Single Seven months SN08 28 Male Married 11 months
Theme 1. Challenges During the Pandemic Subtheme 2. Caring for the COVID-19 Patients This discusses the problems faced by the key informants This discusses the concerns faced by ICU nurses assigned in COVID-19 ICUs during the pandemic. assigned to care for COVID-19 patients. This includes the According to Sadang (2020), the COVID-19 health crisis hassle of wearing personal protective equipment (PPE), caused an unforeseen paradigm shift in nurses’ life in feeling of anxiety of possibly getting infected, not meeting healthcare systems, resulting in stressful and the standards of care, and thinking about their families back overwhelming challenges in their daily battle against this home worrying about their safety. illness. Subtheme 1. Away from Home According to SN01, SS4 “At first, I was very anxious to handle This is about the challenges faced by the key informants COVID-19 positive patients because I was worried that I might working abroad. It includes the feeling of homesickness, also contract the disease.” SN03 also stated that “Mas kapoy lang sad ang sa COVID-19 kay mag PPE kag taas na time.” being away from the family, the cultural differences that (It’s more tiring in COVID-19 units because you have to wear they have observed, and the cancellation of plans due to PPE for a longer period). the pandemic. SN05 said, SS60 “Naa baya koy newborn sa balay nya SN01 stated that SS2 “Aside from that, being a nurse overseas simbako matakdan ko ig duty.” (I have a newborn at home, and means being away from your family and loved ones, so you I’m scared to get infected). She also added that “Kapoy pud miss out on special occasions and holidays.” She added that kay the usual na daghan na layers na PPE, init kaayo maski “Uhmm, actually church wedding namin dapat ng husband ko aircon pa. Then if naay procedures sa bedside, lisod pud kay but because of this travel ban, di natuloy.” (Because of this di kaayo ka kaklaro tungod sa face shield.” (It’s tiring because travel ban, my church wedding was postponed). of the PPE. It feels really hot wearing them even with the air conditioner. If there are bedside procedures, it is difficult SN04 also mentioned that SS39 “Di naman nawawala yung because you can’t see properly because of the face shield). pagiging homesick” (Homesickness is always there) and added, “Miss ko na anak ko” (I miss my child). Lastly, SN07 verbalized that SS100 “Hadlok ko uy sa akong safety.” (I was scared for my safety). SN07 mentioned that SS95 “Pero di gihapon mawa ang kamingaw uy samot nag close jud kaayo mos imong family.” Front-line nurses experience an enormous amount of (But the feeling of missing your family is always there, work, long-term exhaustion, infection risk, and frustration especially if you have a close relationship with them). with the death of patients they care for. They also face
Lastly, SN08 said SS19 “Kanang homesickness ug cultural anxiety or even disagreement among patients and their differences given naman.” (Homesickness and cultural family members (Shen et al., 2020). differences are given). Subtheme 3. Fear of the Unknown The issue of homesickness has not been addressed by This tackles the fears of the informants regarding the international human resource management for a long time. disease, the unpreparedness for this pandemic, and the Despite the recognition in the literature that expatriates go uncertainty of the future. through the critical issue of adjustment (Haslberger et al., 2014) triggers the feelings of disconnection and missing SN01 stated that SS5 “Also, it is a new illness so little is known home and has been a not-easy-to-achieve situation (Ward about the virus, its transmission and effects on different types et al., 2001). of people.”
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SN02 verbalized that, SS20 “Kuyaw pud kay mas higher imong SN07 said, SS102 “And kailangan sad jud tas mga patients chance ma infect unya handtud karon, wala pay mga certain especially karon.” (And the patients need us especially treatment jud na makaingon kag effective jud plus if ever, nowadays). simbako, matakdan ka, layo pa jus imong family.” (It is risky to get infected because until now there is no certain effective Although nursing care of patients with COVID-19 is treatment, and if ever you get infected, you are very far from largely supportive, it should include a strong emphasis on your family). alleviating the spread of contamination to staff, other
patients, and the community (Deitrick et al., 2020). The first According to SN03, SS34 “In some aspects siguro kay diri sa UAE naa man jud silay disaster plan and kani na pandemic priority of any nurse should be to protect themselves with considered man na disaster but for sure di jud emotionally the appropriate PPE. Nursing care should focus on limiting prepare ang tanan.” (In some aspects, because here in the the exposure and spread of the virus. The whole UAE, they really have a good disaster plan and this pandemic experience of COVID-19 infection, in the form of staying in is considered to be a disaster but one thing is for sure, we are isolation wards, could be very traumatic, even for patients not all emotionally prepared). who are minimally symptomatic or asymptomatic (Sahoo et al., 2020). It is important to provide support to these SN04 said, SS42 “Mahirap kasi wala naman talagang patients, especially during this time. nakapagprepare for this pandemic.” (It’s hard because nobody was really prepared for this pandemic). Subtheme 2. The Nursing Profession The current COVID-19 pandemic presents a Nurses are very valuable in the healthcare systems and considerable occupational vulnerability for the health care are crucial to health promotion, disease prevention, and team, causing fear or anxiety. These can be brought about treatment (Robertson-Malt, 2020). The World Health by knowing or having more information and fear of the Organization (WHO, 2020b) considers nurses and unknown related to the virus (Coelho et al., 2020). Fear of midwives as the cornerstone in helping countries meet their the unknown appears to be a fundamental fear and is a commitments to Universal health coverage. core component of anxiety (Carleton, 2016; Gallagher et al., 2014). SN03 stated that SS38 “It also made me realize how noble the nursing profession is, and I am proud that I have pursued it.”
Theme 2. Patient Care During COVID-19 SN04 mentioned SS58 “Also, dapat din natin alagaan sarili Averting a nosocomial outbreak of COVID-19 through natin para mafulfill natin ang ating duty.” (We need to take care transmission from patients to healthcare workers is of ourselves to fulfill our duties). essential. New and improved policies have been implemented to protect the healthcare worker and the SN05 verbalized, SS61 “Worried kaayo ko all the time pero patient. This section discusses about the changes in the unsaon ta man, part man nis atong trabaho.” (I am worried all care provided to the COVID-19 patients and the roles and the time but this is part of our job). responsibilities of nurses. SN07 said, SS117 “And kita nurses di ta dapat moundang ug Subtheme 1. COVID ICU Patient Care educate sa mga taw and should lead by example.” (And we This tackles about the care provided to the COVID-19 nurses should not stop educating the others and should lead ICU patients in comparison to non-COVID-19 ICU patients. by example). This also includes the support given by the nurses to the patients. Nurses are usually in the front line of care. They make a difference in individual patients’ lives and the community According to SN01, SS6 “Sa COVID-19 positive patients, mas as a whole. Due to their sheer numbers and the locations clustered yung care na binibigay sa kanila.” (In COVID-19 where they often work, nurses are key players in improving patients, we provide clustered care). She also added that SS7 public health outcomes around the world (Robertson-Malt, ”Dapat as much as much as possible, ilessen yung time sa 2020). loob ng patient’s room, to lessen also your exposure.” (As much as possible, we spend less time inside the patient’s room to lessen our exposure). Theme 3. Adapting to Change Change is inevitable, but a drastic one has happened SN02 mentioned, SS24 “Ipafeel nako nila na makarely sila during this pandemic. The way we live nowadays is nako sa scariest time sa ilang life.” (I will let them feel that I am different, and people around the world are starting to adapt there at the scariest part of their life). to these changes. But until a safe and effective coronavirus
vaccine is available, there will always be a risk of infection, SN05 verbalized, SS71 “Ang ako lang is ikeep nako in mind na especially now that people are starting to go back to work. atimanon lang jud sila ug tarong. Mo empathize lang jud ta nila.” (I keep in mind to properly take care of them. We should Businesses are re-opening, and classes at some schools empathize with them). were resumed. This part discusses about the present situation, adjustments made, and self-protection.
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Subtheme 1. Living the New Normal residences or accommodation to pass the time and This talks about the experiences of the key informants verbalized that they have already adjusted to the present with our present situation in this time of the pandemic. situation.
SN03 stated, SS33 “Sauna mogreet with a smile jud kas imong Subtheme 2. Protecting One’s Self from COVID-19 patients, tabi sa mga kauban, party2x, but karon? Di ka The following statements made by the key informants kastorya sa uban without a mask and social distancing.” are indicative of ways on how to protect themselves from (Before, we used to greet the patients with a smile, talk with being infected with COVID-19. our colleagues and attend parties. But now, we can’t even talk
with others without a mask and social distancing). SN01 stated, SS17 “Aside from religiously drinking vitamins SN04 said, SS51 “Wala na din kasi masyadong gala sa labas.” and minerals, during this pandemic, I sanitize everything that I (We don’t go out that much anymore). brought outside including bags, cards, and cell phone.” She also added, SS18 “Every after duty, I make sure to take a bath SN05 verbalized, SS77 “Then mask jud bisag asa kay aside and disinfect properly the uniform I used in the hospital as well sa protection sa imong self, makabayad tag fine.” (We wear as clothes worn outside of the accommodation.” the mask all the time not only to protect ourselves but also to avoid paying the fine). SN04 mentioned, SS54 “As much as possible, healthy diet na din to boost my immunity.” (As much as possible, I make sure to have a healthy diet to boost my immunity). SN06 mentioned about always wearing a mask, SS85 “Wearing a mask is part of my outfit every day since it is now mandatory.” SN07 said, SS116 “Di nato itake for granted ang policies to prevent infection.” (We should not take for granted the policies
to prevent infection). Ever since the WHO declared this pandemic, we were forced to change the way we live. According to the Centers Lastly, SN08 stated about the value for health and having a for Disease Control and Prevention (2021), we have to healthy lifestyle, SS131 “Mas givalue nako akong health ron. practice physical distancing, wearing masks all the time, SS132 Di na ko magsmoke. SS133 Maningkamot ko ug tug and doing hand hygiene all the time to help prevent the jud at least 8 hours a day, and magstart nag kaon ug spread of infection. These practices were followed by the vegetables.” (I value my health more. I don’t smoke anymore. key informants. I try to sleep at least 8 hours a day and started eating vegetables). The present pandemic pushed the key informants to look for ways to connect with their families in the Philippines According to WHO (2020b), good nutrition and even if they are far from them and discover new activities hydration are very important. People who eat a well- while staying at home most of the time. balanced diet be likely to be healthier with stronger immune
systems and reduced risk of chronic illnesses and SN02 said, SS25 “Ngita jud ug paagi na connected gihapon mi despite sa distance.” (We find ways to stay connected despite infectious diseases. As mentioned by the key informants, the distance). they are doing steps to protect themselves from the virus by observing health protocols and boost their immune SN03 stated, SS36 “Physical activities and constant systems. communication lang jud with the family.” (Physical activities and constant communication with the family). Theme 4. Resilience Amidst the Pandemic
Resilience is an extensive concept that encompasses SN04 verbalized about adjusting to the present situation, SS45 individual and social resources to thrive from challenging “Ngayon, nakapag adjust naman na.” (I have adjusted now). She also added that she got more attached to her family, SS48 circumstances (Callueng et al., 2020). Because Filipinos “Mas attached ako sa kanila ngayon. Sila kasi yung source of often experience different calamities and disasters, they inspiration ko at strength.” (I’m more attached to them now remain resilient and seemingly immune to such because they are my source of inspiration ang strength). circumstances (Ang & Diaz, 2018). The current pandemic arises numerous psychological stressors due to health‐ SN05 mentioned about constant communication, SS65 “Video related, social, economic, and individual consequences call video call lang kada adlaw.” (We just call each other and may cause psychological distress (Petzold et al., through video call every day). She also mentioned, “Kailangan 2020). Strategies such as keeping a healthy lifestyle and sad jud mo adapt.” (We need to adapt). social contacts, recognizing anxiety and negative emotions, SN07 stated, SS94 “Pero naanad ra sad kadugayan.” (But I and nurturing self‐efficacy may help with these stressors got used to it eventually). (Petzold et al., 2020). Having a good support system and being more positive and appreciative is helpful for OFWs to Due to the present situation, the key informants looked be more resilient in this time of the pandemic. for alternative ways to connect with their families in the Subtheme 1. Being with Others Philippines using different platforms for this will give them This section discusses the key informants’ support strength while working abroad. They also did more system, including their relationship with their colleagues enjoyable activities with their friends in their respective
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191 Pogoy, J. M., & Cutamora, J. C. (2021) during the pandemic and how this helped maintain their Discussions positive attitude despite being away from home. OFW nurses face a lot of challenges every day, even before SN01 stated about the bond with her colleagues, SS12 “Uhmm this pandemic started. ICU nurses have to take care of mas nagkabonding kami ng workmates ko actually kasi same critically ill patients and are required to be mentally, same kami ng sentiments regarding this pandemic.” (We emotionally, and psychologically prepared every time they bonded more with my colleagues because we share the same sentiments). go to work. When the pandemic started, these OFW ICU nurses were being pulled out from their respective units and SN02 mentioned about teamwork, SS26 “Mas givalue namo transferred to the COVID-19 ICU. New protocols were ang teamwork and mas gaan ang trabaho if magtinabangay.” implemented, adjustments were made, relationships with (We value teamwork more because it makes out work easier). the colleagues were stronger, and slowly, resilience was She also added, SS27 “Mas mofocus ta sa positive kaysa built with each other’s support. For the key informants, negative.” (We focus more on the positive than the negative). these situations are very difficult for them.
Challenges during the pandemic discuss the problems SN04 stated about doing activities together with the colleagues who live with her, SS50 “Sa flat naman, mas nagkaroon kami faced by the OFWs nurses being far from their homes, the ng time magbonding kasi most of the time nasa flat lang talaga issues they encountered when they were transferred to the kami kapag walang duty.” (In our flat, we bonded more COVID-19 ICU, and the fear of the unknown. Even before because we spend more time together during our days off). the pandemic started, these nurses were already faced with SN07 also shared the same sentiments about doing activities the problems of adjusting to a different culture, language with his flatmates, barrier, and homesickness. At present, they are faced with
additional problems like being unable to go home because SS12 “Aw duwa mig video games sa flat.” (We play video their leaves were canceled. One informant also mentioned games in the flat). about her wedding ceremony being postponed because of SN 05 said, SS75 “Kita ra sad juy magsinabtanay ug this. Aside from these personal modifications, there are magtinabangay.” (We understand and help each other). also changes in the workplace settings. The key informants were then transferred to the COVID- The ICU is a stressful work environment. Nurses are 19 ICU because the number of COVID-19 patients needing experiencing exposure to workplace stress, verbal and their care increased. They expressed their feeling of anxiety physical hostility, burn-out, moral distress, circadian rhythm about being in the new unit and anxiety about contracting disruption, and depression (Shaw, 2015). The stressful the disease. They also expressed the hassle of wearing work environment leads to low-quality nursing care. many layers of PPE for long periods. Aside from this, they Teamwork and collaboration prevent errors and promote also mentioned about having a shortage of PPE. The major healthy work environments (Shaw, 2015), which was also issues facing nurses in this situation are the critical scarcity experienced by the key informants. of nurses, beds, and medical supplies, including personal protective equipment, as reviews indicate, psychological Subtheme 2. Seeing Oneself fluctuations and fears of infection among nursing staff This section discusses the realizations of the key (Al Thobaity & Alshammari, 2020). According to the key informants, including being more appreciative and giving informants, the quality of care given to the COVID-19 ICU importance to life. patients was not meeting the standards because they are spending less time inside the patient’s room to limit their SN02 stated that, SS29 “I learned to be more appreciative of exposure. As one informant has mentioned, they are not what I have and what really matters.” turning the patients to sides to release back pressure as often as the patients in the non-COVID-19 ICU. SN04 verbalized, SS57 “Narealize ko na life is short, dapat Furthermore, another challenge the COVID-19 ICU itreasure natin ito.” (I realized that life is short and we should nurses were facing is the fear of the unknown. During the treasure it). time of the interview, there is little information on the SN05 shared the same opinion, SS78 “One, life is short.” management of the disease. They also expressed the feeling of uncertainty about the future. An American Nurses SN08 mentioned about appreciation, SS134 “Ug nalearn sad Survey of more than 30,000 nurses reported that 87% of diay nakog appreciate ang little things.” (I learned to appreciate nurses are very or somewhat afraid to go to work, 58% are the little things). highly concerned about their personal safety, and 55% about caring for a COVID-19 patient or person suspected According to a survey conducted by the National of having the virus (American Nurses Association, 2020). Research Group, roughly 90% of the respondents say that In addition, the difference in the care of patients in the the COVID-19 pandemic “is a good time to reflect on what’s COVID-19 ICU was also stated. Clustering of care is done important to them” (Olin, 2020). The experiences of the to limit exposure. The nurses also verbalized to provide OFW nurses made them realize the value of life that they support to their patients, especially during these times. The have to cherish and appreciate. importance of nursing as a profession was also realized by
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192 Pogoy, J. M., & Cutamora, J. C. (2021) the nurses. They were reminded of their roles and Conclusion responsibilities as a nurse and how noble the nursing profession is. Some expressed that they are just doing what Despite the existing challenges like cultural differences and they have to do because it is part of their job. homesickness faced by these OFW nurses and the new With all of these, being adaptive to change helped these challenges they are faced with the pandemic today, they nurses to cope with the present situation. The new normal were still able to continue living and do what is expected of when going out includes the wearing of a mask every day them. From the hassle of wearing the PPEs, shortage of and observing physical distancing. On their days off, they PPE, and being transferred from one unit in the hospital to mostly stay at home. Adjustments have been made for the another, the OFW nurses were able to adapt to these current situation. They expressed about staying connected changes. with the family, and time spent communicating with them Up until now, the travel ban and cancellation of vacation through video calls has increased. After how many months leaves are still implemented. These nurses found ways to of being assigned in the COVID-19 ICU, they have already be connected with their families through frequent video made necessary changes to adjust to the present situation. calls through the internet. The nurses already got used to With the ongoing pandemic, it is important to protect the routine, but the fear of getting infected by the virus is one’s self. Measures to protect one’s health were done like still there. taking a bath more than usual, having long hours of sleep Support from peers and a positive outlook were also and rest, and having a healthier lifestyle. The nurses also helpful to build resilience. They also learned to value life verbalized that they value health now more than ever. That more and be more appreciative. All of these imply that OFW this also helps building resiliency among them. ICU nurses are resilient as they did their duties Building resilience is possible with the presence of a professionally and that comprehensive support be provided support system. The presence of the nurse’s friends as to safeguard their wellbeing as they continue making their their second family helped them a lot. Closer bonds with significant contributions out of moral and professional their colleagues and workmates were formed through responsibility in taking care of the COVID-19 patients. teamwork and doing activities together at home. Having a more positive outlook also helped them during this Declaration of Conflicting Interest pandemic. Furthermore, the nurses realized the value of life No Conflict of Interest. and how it should not be taken for granted. They also learned to be more appreciative of the little things they Funding have. None.
Lastly, the government and policymakers can possibly Acknowledgment look into the situation of Filipino nurses in their country. We thanked Cebu Normal University, College of Nursing, They are currently anxious because they cannot take their Philippines. leave or spend their vacation in the Philippines, even during their end of the contract periods. This factor adds up to their Authors’ Contribution uncertainty abroad while they are practicing nursing in ICU JMP is the lead author from the conceptualization, formulation, and amidst pandemics. According to Garcia et al. (2018), the finalization of the research paper. JCC contributed significantly to Filipino culture is one of the main factors on why they have the conceptualization, formulation, critiquing, and completion of the research paper. All authors agreed with the final version of the qualms in working away from their home. However, living article. here also means challenges in terms of compensation.
Despite this, true-blooded Filipinos are willing to sacrifice Authors’ Biographies for the family. Jane Marnel Pogoy, RN is a Graduate Study Researcher of Cebu The limitation of the study includes focusing only on ICU Normal University, Philippines. Filipino nurses. Future studies could explore other target Jezyl C. Cutamora, PhD is a Director of Research Institute for populations. Furthermore, the protection of these nurses is Ageing and Health, a Vice Chair of Ethics Review Committee, and highly important to be explored by policymakers, and a Department Chair at the College of Nursing of Cebu Normal University, Philippines. Philippine Nurses Association, and other relevant agencies. Providing them with enough PPE could help Data Availability Statement lessen the stress they feel being assigned in the COVID-19 The datasets generated during and/or analyzed during the current ICU. Although the nurses were able to adapt to the present study are available from the corresponding author on reasonable changes, it is highly suggested to provide an avenue for request. them to voice their concerns and make them feel that support is there from the management. There was no References Abalos, E. E., Rivera, R. Y., Locsin, R. C., & Schoenhofer, S. O. mention from the interviews about any compensation or (2016). Husserlian phenomenology and Colaizzi’s method of support done by the management. data analysis: Exemplar in qualitative nursing inquiry using nursing as caring theory. International Journal of Human Caring(1), 19-23. https://doi.org/10.20467/1091-5710.20.1.19
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Al Thobaity, A., & Alshammari, F. (2020). Nurses on the frontline Morrow, R., Rodriguez, A., & King, N. (2015). Colaizzi’s descriptive against the COVID-19 pandemic: An integrative review. Dubai phenomenological method. The Psychologist, 28(8), 643-644. Medical Journal, 3(3), 87-92. https://doi.org/10.1159/000509 Norlyk, A., & Harder, I. (2010). What makes a phenomenological 361 study phenomenological? An analysis of peer-reviewed Aliakbari, F., Hammad, K., Bahrami, M., & Aein, F. (2014). Ethical empirical nursing studies. Qualitative Health Research, 20(3), and legal challenges associated with disaster nursing. Nursing 420-431. https://doi.org/10.1177/1049732309357435 Ethics, 22(4), 493-503. https://doi.org/10.1177/096973301453 Olin, A. (2020). Amid the pandemic, lessons in what we’ve 4877 overlooked. Retrieved from https://kinder.rice.edu/urbanedge American Nurses Association. (2020). COVID-19 survey /2020/04/29/covid-19-pandemic-lessons-silver-linings-day- responses. Retrieved from: https://www.nursingworld.org/ care ~4987e5/globalassets/covid19/ana_covid19infographic_datas Petzold, M. B., Bendau, A., Plag, J., Pyrkosch, L., Mascarell et1_20200424-final.pdf Maricic, L., Betzler, F., . . . Ströhle, A. (2020). Risk, resilience, Ang, M. C. C., & Diaz, L. B. L. (2018). Perception, resiliency and psychological distress, and anxiety at the beginning of the coping strategies of Filipinos amidst disasters. Unpublished COVID-19 pandemic in Germany. Brain and Behavior, 10(9), Research. Bulacan State University. Bulacan. e01745. https://doi.org/10.1002/brb3.1745 Callueng, C., Aruta, J. J. B. R., Antazo, B. G., & Briones-Diato, A. Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating (2020). Measurement and antecedents of national resilience in and assessing evidence for nursing practice. Philadelphia: Filipino adults during coronavirus crisis. Journal of Community Wolters Kluwer Health. Psychology, 48(8), 2608-2624. https://doi.org/10.1002/jcop.22 Robertson-Malt, S. (2020). COVID-19 drives home the importance 438 of nursing in ensuring community well-being. Retrieved from Carleton, R. N. (2016). Fear of the unknown: One fear to rule them https://www.uowdubai.ac.ae/news/covid-19-drives-home- all? Journal of Anxiety Disorders, 41, 5-21. https://doi.org/10. importance-nursing-ensuring-community-well-being 1016/j.janxdis.2016.03.011 Sadang, J. M. (2020). The lived experience of Filipino nurses’ work Centers for Disease Control and Prevention. (2021). How to in COVID-19 quarantine facilities: A descriptive protect yourself and others. Retrieved from https://www.cdc. phenomenological study. Pacific Rim International Journal of gov/coronavirus/2019-ncov/prevent-getting-sick/prevention. Nursing Research, 25(1), 154-164. html Sahoo, S., Mehra, A., Dua, D., Suri, V., Malhotra, P., Yaddanapudi, Chung, B. P. M., Wong, T. K. S., Suen, E. S. B., & Chung, J. W. Y. L. N., . . . Grover, S. (2020). Psychological experience of (2005). SARS: Caring for patients in Hong Kong. Journal of patients admitted with SARS-CoV-2 infection. Asian Journal of Clinical Nursing, 14(4), 510-517. https://doi.org/10.1111/ Psychiatry, 54, 102355-102355. https://doi.org/10.1016/j.ajp. j.1365-2702.2004.01072.x 2020.102355 Coelho, C. M., Suttiwan, P., Arato, N., & Zsido, A. N. (2020). On Shang, Y., Pan, C., Yang, X., Zhong, M., Shang, X., Wu, Z., . . . the nature of fear and anxiety triggered by COVID-19. Frontiers Chen, D. (2020). Management of critically ill patients with in Psychology, 11, 3109. https://doi.org/10.3389/fpsyg.2020. COVID-19 in ICU: Statement from front-line intensive care 581314 experts in Wuhan, China. Annals of Intensive Care, 10(1), 73. Deitrick, K., Adams, J., & Davis, J. (2020). Emergency nursing care https://doi.org/10.1186/s13613-020-00689-1 of patients with novel coronavirus disease 2019. Journal of Shaw, B. (2015). Evaluation of the impact of TeamSTEPPS Emergency Nursing, 46(6), 748-759. https://doi.org/10.1016/ training on perceptions of teamwork and resilience in the j.jen.2020.07.010 intensive care and perioperative units in a tertiary care Gallagher, M. W., Bentley, K. H., & Barlow, D. H. (2014). Perceived hospital. Regis University, Denver, Colorado. Retrieved from control and vulnerability to anxiety disorders: A meta-analytic https://epublications.regis.edu/theses/682 (682) review. Cognitive Therapy and Research, 38(6), 571-584. Shen, X., Zou, X., Zhong, X., Yan, J., & Li1, L. (2020). https://doi.org/10.1007/s10608-014-9624-x Psychological stress of ICU nurses in the time of COVID-19. Garcia, L., Cutamora, J. C., & Ragay, A. K. (2018). There’s no Critical Care, 24(200). https://doi.org/10.1186/s13054-020- place like home: capturing the experiences of Filipino nurses 02926-2 who opted to stay in the Philippines. The Malaysian Journal of Sun, N., Wei, L., Shi, S., Jiao, D., Song, R., Ma, L., . . . Wang, H. Nursing, 10(2), 3-10. https://doi.org/10.31674/mjn.2018.v10 (2020). A qualitative study on the psychological experience of i02.001 caregivers of COVID-19 patients. American Journal of Haslberger, A., Brewster, C., & Hippler, T. (2014). Managing Infection Control, 48(6), 592-598. https://doi.org/10.1016/j.ajic. performance abroad: A new model for understanding 2020.03.018 expatriate adjustment. Philadelphia: Taylor & Francis. Ward, C., Bochner, S., & Furnham, A. (2001). The psychology of Kim, Y. (2018). Nurses' experiences of care for patients with Middle culture shock. London: Routledge. East respiratory syndrome-coronavirus in South Korea. WHO. (2020a). Coronavirus. Retrieved from https://www.who.int/ American Journal of Infection Control, 46(7), 781-787. health-topics/coronavirus#tab=tab_1 https://doi.org/10.1016/j.ajic.2018.01.012 WHO. (2020b). Nursing and midwifery. Retrieved from https:// Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., . . . Hu, S. (2020). www.who.int/news-room/fact-sheets/detail/nursing-and- Factors associated with mental health outcomes among health midwifery care workers exposed to coronavirus disease 2019. JAMA Zerbini, G., Ebigbo, A., Reicherts, P., Kunz, M., & Messman, H. Network Open, 3(3), e203976-e203976. https://doi.org/10. (2020). Psychosocial burden of healthcare professionals in 1001/jamanetworkopen.2020.3976 times of COVID-19 - a survey conducted at the University Lorenzo, F. M. E., Galvez-Tan, J., Icamina, K., & Javier, L. (2007). Hospital Augsburg. German Medical Science: GMS E-Journal, Nurse migration from a source country perspective: Philippine 18, Doc05-Doc05. https://doi.org/10.3205/000281 country case study. Health Services Research, 42(3p2), 1406- 1418. https://doi.org/10.1111/j.1475-6773.2007.00716.x Cite this article as: Pogoy, J. M., & Cutamora, J. C. (2021). Mo, Y., Deng, L., Zhang, L., Lang, Q., Liao, C., Wang, N., . . . Lived experiences of Overseas Filipino Worker (OFW) nurses Huang, H. (2020). Work stress among Chinese nurses to working in COVID-19 intensive care units. Belitung Nursing support Wuhan in fighting against COVID-19 epidemic. Journal Journal, 7(3), 186-194. https://doi.org/10.33546/bnj.1427 of Nursing Management, 28(5), 1002-1009. https://doi.org/ 10.1111/jonm.13014
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194 Original Research BNJ
Belitung Nursing Journal Symptom experience of adverse Volume 7(3), 195-202 © The Author(s) 2021 drug reaction among male and https://doi.org/10.33546/bnj.1337 female patients with newly diagnosed pulmonary tuberculosis in Thailand
Apichaya Thontham and Rapin Polsook*
Abstract Background: Patients with newly diagnosed pulmonary tuberculosis often suffer from adverse drug reaction symptoms, which leads to the automatic discontinuation of anti- tuberculosis drugs. Thus, understanding symptom experience of adverse drug reactions is necessary. Objective: This study aimed to examine differences in symptoms experienced in four dimensions: presence, frequency, severity, and distress of adverse drug reactions, between male and female patients. Methods: This was a quantitative survey with a cross-sectional design, with data collected between January and April 2020. A total of 394 patients with newly diagnosed pulmonary tuberculosis was selected through a purposive sampling technique. The symptom experiences of adverse drug reactions were measured using a validated instrument. Data were analyzed using mean, standard deviation, and independent t-test. Results: The most commonly reported symptom was itchiness (24.1% in males and 34.9% in females). Vomiting occurred as the most frequent symptom among males (�̅ ± SD = 2.73 ± .88), and fatigue was found to be the most severe and distressing symptom across male patients ( �̅ ± SD = 2.50 ± 1.61 and 2.06 ± 1.30, respectively). In contrast, yellowing of the eyes and skin was most frequent and severe among females ( �̅ ± SD = 3.17 ± .75 and 3.83 ± 1.47, respectively). In addition, flu-like symptoms were evaluated as the most distressing symptom for female patients (�̅ ± SD = 2.80 ± 1.09). The symptom burdens of the females ranged significantly and reached higher than those of the male patients at a p-value of .05 (t = 3.33). Conclusion: Females taking anti-tuberculosis drugs should be carefully monitored to deal with adverse drug reaction symptoms. This finding would help to decrease the severity of disease and improve their quality of life.
Keywords adverse drug reaction; pulmonary tuberculosis; symptom experiences; quality of life; drug-related side effects; nursing; Thailand
Tuberculosis (TB) is a transmissible disease and one of the Organization (WHO) reported 87,789 new TB cases, and ten leading causes of death worldwide (World Health 85.0% of these relapses were pulmonary TB (WHO, 2019). Organization, 2020). TB is caused by bacillus In addition, the WHO indicated that Thailand is one of the Mycobacterium TB, which spreads through the air by, for top 20 countries affected by TB and that only 85.0% of new example, coughing. In 2019, the World Health cases and relapses in 2019 had successful outcomes
Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand Article Info: Received: 6 February 2021 Revised: 7 March 2021 Corresponding author: Accepted: 10 May 2021 Assistant Professor Police Captain Rapin Polsook, PhD, RN Faculty of Nursing, Chulalongkorn University, Boromarajonani This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which allows Srisatapat Building, Rama1 Rd, Floor 11 Patumwan, Bangkok others to remix, tweak, and build upon the work non-commercially as long as 10330, Thailand. the original work is properly cited. The new creations are not necessarily Telephone: 66-22181151 licensed under the identical terms.
Cell phone: 66-8183-2109-5 E-ISSN: 2477-4073 | P-ISSN: 2528-181X Email: [email protected]; [email protected]
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(WHO, 2019). Moreover, the Ministry of Public Health of TB is needed. This study was undertaken to investigate Thailand reported that, among new TB cases, 68.9% were related differences between genders in symptoms males over the age of 15, and 31.1% were female (Health experienced in four dimensions: presence, frequency, Data Center, 2020). severity, and distress of ADRs. TB is treatable and preventable, and about 85.0% of people who develop TB can be successfully treated with Methods regimental 6-month drugs, or first-line anti-TB drugs, which are Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), and Study Design Ethambutol (E) (WHO, 2019). Although most TB patients The study employed a cross-sectional survey designed to are under self-medication, a failure to take medication or compare differences in ADRs according to gender. premature discontinuation of medication caused by an adverse drug reaction (ADRs) from first-line anti-TB drugs Sample and Setting occurs in approximately 60.0-83.5% of cases (Qureshi & Purposive sampling was used to approach participants Kausar, 2013; Abhijeet Singh, Prasad, Balasubramanian, from among Thai pulmonary TB patients. The study was Gupta, & Gupta, 2015). Previous studies have shown that undertaken in TB clinics, with permission from the the most common adverse symptoms of first-line anti-TB institutional review board of seven hospitals in Bangkok, drugs are rashes, peripheral neuropathy, flu-like Thailand. The sample size was calculated by using Taro symptoms, arthralgia, hyperuricemia, nausea, vomiting, Yamane (Yamane, 1973); the level of statistics was set at and optical neuritis (Mathew & Joseph, 2017; Naser et al., a p-value of .05, and 10% was added to protect against a 2016; Saputra, Rakhmawati, Hendrawati, & Adistie, 2020; loss of data that could lower than the minimum simple size Anita Singh, Bhat, & Sharma, 2011). Moreover, drug below the level that is acceptable to obtain the statistical interaction of first-line anti-TB drugs is the cause of drug- power of analysis (Grove & Gray, 2018). Thus, a total of induced liver damage (Ramappa & Aithal, 2013). 394 newly diagnosed pulmonary TB patients were In addition, the literature shows that significant ADRs recruited into the study. The inclusion criteria for the most commonly occur between one and five weeks after participants were: (1) first-line anti-TB drugs received, (2) beginning the medication and that ADRs associated with 25-59 years of age, (3) not receiving anti-HIV drugs, (4) anti-TB drugs persist, on average, for two months after being able to communicate in Thai, (5)having no cognitive patients start taking anti-TB drugs (Mathew & Joseph, impairment, nor complications from the disease; and (6) 2017; Naser et al., 2016; Anita Singh et al., 2011). ADRs being willing to participate. However, participants with any can also cause severe harm to patients, resulting in physical disability (e.g., increased shortness of breath or hospitalization. Many patients suffer from ADRs, leading to increased cough) were excluded from this study. The the automatic discontinuation of anti-TB drugs. However, purpose of this study, its potential benefits, risks, and the patients who adhere to anti-TB drugs through the length of the interview were communicated to all patients. management or control of ADR symptoms increase their All participants signed a consent form, and the information chance of recovery, reduce transmission, and improve their on the topic was encoded for anonymity. quality of life (QOL) (Pal, Duncombe, Falzon, & Olsson, 2013). Instruments Furthermore, the literature review found that gender In this study, symptom experiences have been defined as differences are linked to ADRs in terms of physiological, the perception of an individual symptom or a change in how hormonal, and genetic conditions, which has an impact on a patient feels (Armstrong, 2003). The instrument to the pharmacokinetics and pharmacodynamics of a drug measure symptom experiences was developed based on and may be the cause of the difference in ADRs between symptom management by Dodd et al. (2001), along with a females and males. Some studies have focused on gender related literature review by the authors. The questionnaire differences in the reporting of ADRs and found that females is composed of two parts: a demographic questionnaire report ADRs more often than males. Several other studies and a symptom experience questionnaire. The details of have looked at a particular drug or class of drugs to look each questionnaire are as follows. more closely at gender differences in the reporting of 1) Demographic data questionnaire. The demographic ADRs. They found that the reported prevalence was higher data of participants, including age, gender, marital status, among females compared to males; however, differences education, income, and type of health care coverage, were in the rate of reporting by gender varied by category of assessed. event or sub-class of the drug (Rademaker, 2001; Watson, 2) Symptom experiences questionnaire. The question- Caster, Rochon, & den Ruijter, 2019; Zucker & naire consists of 35 items of symptoms in four dimensions: Prendergast, 2020). Nurses are caring for patients with presence, frequency, severity, and distress. For presence newly diagnosed pulmonary TB and playing a role in dimension, participants were asked to rate as 0 = absent or assessing the ADRs between males and females in order 1 = present; frequency dimension was rated as 1 = rarely, to suggest appropriate strategies for the management of 2 = sometimes, 3 = often, or 4 = always; severity, and ADRs. Thus, a study of gender differences and symptom distress dimensions were rated as 1= very low, 2 = low, 3 experience of ADRs among patients with newly diagnosed = moderate, 4 = high, or 5 = very high. A higher score
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196 Thontham, A., & Polsook, R. (2021) indicates higher levels of symptom perception. The internal consent form. Participants were then asked to complete the consistency reliability of the symptom experiences symptom experiences of the adverse drug reaction questionnaire was in four dimensions: presence, questionnaire. During the process of data collection, frequency, severity, and distress, with Cronbach’s alpha of participants were able to decline or leave without .86, .81, .84, and .86, respectively. consequence. It took approximately half an hour to To calculate the score of symptom experience, we used complete each interview. The data were collected from a method for calculating symptom burden from the Chronic January to April 2020. Kidney Disease Symptom Burden Index (CKD-SBI) questionnaire by Almutary, Bonner, and Douglas (2015). Data Analysis There was no difference between symptom experience and Statistical analysis was carried out with the software symptom burden in this study. The dimensions and scales package SPSS Statistics version 22. The level of statistical are completely the same. The presence dimension ranges significance was set at a p-value of .05. Normality testing between 0 – 35, the frequency dimension ranges between used Q-Q Plots. As data were normally distributed, 0 – 140, and severity and distress dimensions range descriptive statistics and independent t-test were used for between 0 - 175. Higher scores indicate greater symptom data analysis. presence, frequency, severity, and distress. A total symptom burden score of the symptom Ethical Consideration experiences questionnaire is calculated by summing The study was approved by: 1) Human Research subscale score (presence, frequency, severity, and Protection Unit, Faculty of Medicine Siriraj Hospital (REF: distress) then divided by 4 (a minimum score of four Si 864/2019), 2) The Research Ethics Review Committee dimensions that could be achieved from only one symptom for Research Involving Human Research Participants, from a participant report), and then multiplied by a fixed Health Sciences Group, Chulalongkorn University (REF: number of .191 (a constant number - mathematical 287/2562), 3) Nopparat Rajathanee Hospital Ethics maneuver to convert the total of symptom experiences Committee (REF: 4/2563), 4) Lerdsin Hospital Ethics questionnaire to 100). The total score for the symptom Committee (REF: LH621088) and 5) Bangkok Metropolitan experiences questionnaire ranged between 0 and 100 for Administration Human Research Ethics Committee (REF: each participant, which was calculated for all symptoms. In 24). the interpretation of the symptom burden score, a score of 100 indicates that the participant had the highest symptom Results burden. Characteristics of Participants Data Collection The baseline study consisted of 394 pulmonary TB Simple random sampling was used to generate a patients, 62.2% of whom were males and 37.8% were probabilistic sample of newly diagnosed TB. Participants females. Almost half of all males were between 30 and 49 were selected from among the 50 districts in Bangkok, years old. Over half of males were married (58.4%), and Thailand. The researcher divided the 50 districts into three nearly half of males had completed primary education areas by location in Bangkok: inner-city, urban fringe, or (40.4%). Almost half of the males had universal health care suburb. There were 23 hospitals in total: 16 inner-city coverage (45.7%), and almost a third of males had a hospitals, four urban fringe hospitals, and three suburban monthly income of between 1,001 and 15,000 Thai baht per hospitals. The following numbers of the hospital in each month (28.6%), while more than half of females were aged zone were required for statistical analysis: inner-city = 3, 30 to 49 years and married (58.4%). Over a third of urban fringe = 2, and suburb = 2. The number of hospitals participants were attending secondary school (38.3%). needed in each zone is based on the proportion of affiliation Roughly half of the females were covered by universal with hospitals in Bangkok. Then, the proportion of patients health care coverage (49.7%) and just under one-third of available per hospital in each zone was calculated by quota females had no income (30.9%) (Table 1). sampling. Purposive sampling was used to select the study participants who met the inclusion criteria. Symptom Experiences in the Presence Dimension The study was conducted at the TB clinics in seven The three symptoms reported by the male patients that hospitals in Bangkok, Thailand, after approval from each occurred most frequently in the presence dimension were hospital’s Institutional Board (IRB). The researcher itchiness (24.1%), decreased appetite (20.0,%) and described the benefits and risks of protecting human rights numbness of the hands and feet (20.0%). In females, the in non-technical terms prior to obtaining patient approval to three symptoms most frequently reported in the presence participate in the study. If patients met the inclusion criteria dimension were itchiness (34.9%), nausea (34.9%), and and accepted participation, they were asked to sign a decreased appetite (24.2%) (see Table 2).
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Table 1 Demographic and clinical characteristics of the pulmonary tuberculosis patients (N = 394)
Characteristics Male (N = 245) Female (N = 149) n (%) �̅ SD n (%) �̅ SD Age (Years) 42.7 11.4 41.8 11.0 25-29 49 20.0 25 16.8 30-49 105 42.9 74 49.7 50-59 91 37.1 50 33.6 Marital Status Single 89 36.3 45 30.2 Widowed 5 2.0 6 4.0 Divorced 5 2.0 9 6.0 Separate 3 1.2 2 1.3 Married 143 58.4 87 58.4 Education Uneducated 5 2.0 4 2.7 Primary School 99 40.4 53 35.6 Secondary School 85 34.7 57 38.3 Diploma 33 13.5 15 10.1 College or More 23 9.4 20 13.5 Occupation Unemployed 60 24.5 46 30.9 Employee 111 45.3 54 36.2 Merchant 21 8.6 18 12.1 Company Employee 45 18.4 28 18.8 Government Service 8 3.3 3 2.0 Type of Healthcare Coverage Universal Coverage 112 45.7 74 49.7 Civil Servant Medical 14 5.7 5 3.4 Benefit Scheme Social Security 110 44.9 62 41.6 Scheme Pay by Yourself 9 3.7 8 5.4 Monthly Income (Thai Bath) 11,791.4 9,747.7 9,776.5 8,757.4 No income 60 24.5 46 30.9 2,000 – 5,000 1 0.4 2 1.3 5,001 – 10,000 56 22.9 45 30.2 10,001 – 15,000 70 28.6 32 21.5 15,001 – 20,000 33 13.5 13 8.7 ≥ 20,000 25 10.2 11 7.4
Symptom Experiences in the Frequency Dimension Symptom Experiences in the Severity Dimension The three symptoms that occurred most frequently in The three symptom experiences in the severity dimension males were vomiting (�̅ ± SD = 2.73 ± .88), fatigue (�̅ ± that were found to be the most severe among males were SD = 2.65 ± .95), and insomnia (�̅ ± SD = 2.62 ± .8. In fatigue, vomiting, and yellowing of eyes and skin (�̅ ± SD = comparison, the three most common symptoms among 2.50 ± 1.61, 2.30±1.04, and 2.10 ± 1.55, respectively). females were yellowing of the eyes and skin, insomnia, and Yellowing of eyes and skin, flu-like symptoms, and fatigue (�̅ ± SD = 3.17 ± .75, 2.88 ± .85, and 2.78 ± .90, abdominal pain were the three symptom experiences respectively) (see Table 3). found to be most severe in the symptom severity dimension among females (�̅ ± SD = 3.83 ± 1.47, 2.80±1.10, and 2.67 ± 1.21, respectively) (see Table 4).
Table 2 The top 20 highest symptom experiences that participants reported in present dimension(N = 394)
Present Dimension Gender (N = 394) Male (N = 245) Female (N = 149) Symptom n % n % n % 1. Itchiness 111 28.2 59 24.1 52 34.9 2. Nausea 94 23.9 42 17.1 52 34.9 3. Decreased Appetite 85 21.6 49 20.0 36 24.2 4. Numbness of the Hands and Feet 79 20.1 49 20.0 30 20.1 5. Rash 70 17.8 39 15.9 31 20.8
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Table 2 (Cont.) 6. Fatigue 57 14.5 34 13.8 23 15.4 7. Vomiting 53 13.5 22 9.0 31 20.8 8. Joint Pain 53 13.5 27 11.0 26 17.4 9. Insomnia 50 12.7 26 10.6 24 16.1 10. Muscle Pain 48 12.2 37 15.1 11 7.4 11. Dry Mouth 41 10.4 20 8.2 21 14.1 12. Blurred Vision 17 4.3 10 4.1 7 4.7 13. Headache 16 4.1 11 4.5 5 3.4 14. Abdominal Pain 15 3.8 9 3.6 6 4.0 15. Yellowing of Eyes and Skin 14 3.6 8 3.3 6 4.0 16. Dysuria 11 2.8 8 3.3 3 2.0 17. Mood Change 10 2.5 1 0.4 9 6.0 18. Flu-like Symptoms 8 2 3 1.2 5 3.4 19. Tinnitus 6 1.5 3 1.2 3 2.0 20. Swollen Face, Hands, and Feet 6 1.5 3 1.2 3 2.0
Table 3 The top five highest symptom experiences that participants reported in frequency dimension (N = 394)
Male Female Symptom Frequency Dimension Symptom Frequency Dimension 1 2 3 4 �̅ ± SD 1 2 3 4 �̅ ± SD 1) Vomiting 2 6 10 4 2.73±.88 1) Yellowing of eyes and skin 0 1 3 2 3.17±.75 2) Fatigue 4 11 12 7 2.65±.95 2) Insomnia 1 7 10 6 2.88±.85 3) Insomnia 2 10 10 4 2.62±.85 3) Fatigue 1 9 7 6 2.78±.90 4) Rash 6 12 16 5 2.51±.91 4) Rash 3 12 8 5 2.68±.98 5) Yellowing of eyes and skin 3 1 1 3 2.50±1.41 5) Vomiting 3 13 11 4 2.52±.85 Note: Possible range for symptom score was 1 to 4 (1 = rarely 2 = sometimes 3 = often 4 = always )
Table 4 The top five highest symptom experiences that participants reported in severity dimension (N = 394)
Male Female Symptom Symptom Severity Dimension Symptom Symptom Severity Dimension 1 2 3 4 5 �̅ ± SD 1 2 3 4 5 �̅ ± SD 1) Fatigue 1 13 5 8 1 2.50 ± 1.61 1) Yellowing of 0 2 0 1 3 3.83 ± 1.47 Eyes and Skin 2) Vomiting 5 9 4 4 0 2.30 ± 1.04 2) Flu-like 1 0 3 1 0 2.80 ± 1.10 Symptoms 3) Yellowing of Eyes 5 0 0 3 0 2.10 ± 1.55 3) Abdominal 1 2 1 2 0 2.67 ± 1.21 and Skin Pain 4) Flu-like Symptoms 1 1 1 0 0 2.00 ± 1.00 4) Vomiting 8 12 5 3 3 2.39 ± 1.26 5) Abdominal Pain 2 5 2 0 0 2.00 ± .71 5) Fatigue 6 8 4 4 1 2.39 ± 1.20 Note: Possible range for symptom score was 1 to 5 (1 = very low 2 = low 3 = moderate 4 = high 5 = very high)
Table 5 The top five highest symptom experiences that participants reported in distress dimension (N = 394)
Male Female Symptom Symptom Severity Dimension Symptom Symptom Severity Dimension 1 2 3 4 5 �̅ ± SD 1 2 3 4 5 �̅ ± SD 1) Fatigue 17 7 2 7 1 2.06 ± 1.30 1) Flu-like 1 0 3 1 0 2.80 ± 1.10 Symptoms 2) Flu-like Symptoms 1 1 1 0 0 2.00 ± 1.00 2) Insomnia 10 7 5 2 0 1.96 ± 1.00 3) Muscle Pain 20 8 3 6 0 1.86 ± 1.13 3) Joint Pain 15 5 2 1 3 1.92 ± 1.38 4) Insomnia 13 7 3 3 0 1.85 ± 1.05 4) Fatigue 11 6 4 1 1 1.91 ± 1.13 5) Joint Pain 13 8 3 3 0 1.85 ± 1.03 5) Muscle Pain 4 3 3 1 0 0.91 ± 1.04 Note: Possible range for symptom score was 1 to 5 (1 = very low 2 = low 3 = moderate 4 = high 5 = very high)
Symptom Experiences in the Distress Dimension experiences among females in the symptom distress The three symptoms that were found to be the most dimension were flu-like symptoms, insomnia, and joint pain distressing among males were fatigue, flu-like symptoms, (�̅ ± SD = 2.80 ± 1.10, 1.96 ± 1.00, and 1.92 ± 1.38, and muscle pain (�̅ ± SD = 2.06 ± 1.30, 2.00 ± 1.00, and respectively) (see Table 5). 1.86 ± 1.13, respectively). The top three symptom
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Symptom Burden Perceived Among the Participants bloodstream, and it may also leak into the surrounding The range of symptom burden reported by female patients tissues. This is known as hyperbilirubinemia and causes a (Mean= 2.97, SD= 3.48) reached significantly higher than yellow color in the skin and eyes (Anita Singh et al., 2011). that of the males (Mean = 1.88, SD = 2.46; t = 3.33; p = One possible explanation for this difference between .05) (see Table 6). genders is that females usually have lower lean mass, reduced liver clearance, and differences in cytochrome P450 (CYP) enzyme activity than males. Additionally, the Table 6 The burden of symptoms in 4 dimensions (N =394) females may be reporting yellowing of eyes and skin as the
most severe symptom due to the sclera changing from The Symptom Burden in Four Gender Dimensions white to yellow and skin changing from their own skin color Mean SD t p-value to yellow, which is a clinical symptom of hepatitis. In this Male (n = 245) 1.88 2.46 3.33 .001 case, these females need to stop anti-TB drugs, change Female (n = 149) 2.97 3.48 regimens, or begin a new treatment regimen (Raftery et al., 2018). In our study, fatigue was found to be the most severe Discussion and distressing symptom reported by males (�̅ ± SD = 2.50 ± 1.61, and 2.06 ± 1.30, respectively). Fatigue can be This study was undertaken to investigate related caused by any anti-TB drugs (Raftery et al., 2018). This differences between genders in symptom experiences of difference between genders could be explained by the fact ADRs among newly diagnosed pulmonary TB patients. In that males usually have more social and labor-based this study, it was found that more male patients activities than females and that associated issues like experienced ADRs than did female patients. A possible unhealthy diets, work duration, and sleep problems with explanation for this is that males usually participate in more fatigue are often linked to long-term health problems (Lin social and work activities than do females, which promotes et al., 2015). Flu-like symptoms were the most distressing the transmission of the disease. Males are more likely to symptoms among female patients (�̅ ± SD = 2.80 ± 1.10). smoke and also have addictions to alcohol or drugs in These symptoms can be caused by anti-TB drugs, which comparison to females. This increases their risk for TB induce hypersensitivity, modified thermoregulation, the (Imam et al., 2020). pharmacological action of the drug, idiosyncratic sensitivity Additionally, itching was the most common symptom of inherited biochemistry defects, and related among males (24.1%) and females (34.9%). This may be administration. In the narrowest sense, as a sort of caused by Rifampicin as all study participants receive the hypersensitivity, drug fever is a febrile reaction specific to same anti-TB drug regimen, which is widely used for the individual in the treatment process depending on the intrahepatic cholestasis-related itching. Rifampicin is not drug and the idiosyncrasy of the patient. Clinically, it occurs only found in medications that cause liver damage, but it when anti-TB drugs become antigens after the formation of also inhibits the absorption of biliary acid by hepatocytes, the complex. Therefore, most of the females suffered from increasing the concentration of biliary acid in plasma. a high fever. In most cases, the temperature reached a However, it breaks down the entero-hepatic circulation of peak on the initial day, whereas body temperature biliary acids on liver metabolic processes (Pongcharoen & increases caused by Rifampicin increase day by day and Fleischer Jr, 2016). Previous studies have also commonly reach a peak of above 40 degree Celsius within 3 – 6 days reported this side effect (Fei, Zainal, & Ali, 2018; Nazir, (Fang et al., 2016; Yee et al., 2003). Farhat, Adil, & Asrafv, 2019; Sinha, Marak, & Singh, 2013). Based on the symptom burden data, gender was a Vomiting was found to be more severe in males (�̅ ± significant variable in symptom burden at the p-value of SD = 2.73 ± .88). Vomiting may be caused by anti-TB .05 (t = 3.33) because of identifiable differences between drugs such as Isoniazid, Ethambutol, and Pyrazinamide females and males in terms of pharmacokinetic and and is common in the early weeks of treatment (Raftery, hormonal factors when taking anti-TB drugs. Females Tudor, True, & Navarro, 2018). A possible explanation for have a slower gastric emptying time, leaner body mass this is that males may be more likely to consume alcohol, indices, and differences in total body water compared to which can induce liver injury, and which also inhibits males, resulting in females absorbing more anti-TB drugs. absorption irritation that can cause vomiting. So males are As a result, females experienced a higher symptom burden more likely to experience greater severity of vomiting than level than males (Zucker & Prendergast, 2020). females (Iranpour & Nakhaee, 2019; Marçôa, Ribeiro, Zão, This study has several limitations. The results may lack & Duarte, 2018). international generalization due to the setting and cultural Yellowing of the eyes and skin was the most frequent influences in Bangkok, Thailand. Other limitations were and severe symptom among females (�̅ ± SD = 3.17 ± .75, data-based and related to self-reported data, which could and 3.83 ± 1.47, respectively). These symptoms can be have caused an overestimated or underestimation of caused by anti-TB drugs like Isoniazid and Rifampicin, values. The instrument for measuring these variables has which induce liver injury. Thus, if the liver is damaged, it been used only once in a Thai context. Testing of validity may cause leakage of bilirubin from the liver into the and reliability within a Thai context is needed. Future
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200 Thontham, A., & Polsook, R. (2021) studies should be conducted across an entire country's References population to assess the change of symptom experience Almutary, Hayfa, Bonner, Ann, & Douglas, Clint. (2015). Arabic for ADRs among newly diagnosed pulmonary TB patients. translation, adaptation and modification of the dialysis symptom index for chronic kidney disease stages four and Developing intervention programs for females to decrease five. BMC Nephrology, 16(1), 1-8. https://doi.org/10.1186/ ADR symptoms such as itchiness and nausea is needed s12882-015-0036-2 to encourage the continuous taking of anti-TB drugs. Armstrong, Terri S. (2003). Symptoms experience: A concept This study can contribute to knowledge development analysis. Oncology Nursing Forum, 30(4), 601-612. and strengthen nursing science to care for patients with https://doi.org/10.1188/03.ONF.601-606 newly diagnosed pulmonary TB. The findings provide Dodd, Marylin, Janson, Susan, Facione, Noreen, Faucett, Julia, knowledge that offers direction for the development of Froelicher, Erika S., Humphreys, Janice, . . . Rankin, Sally. interventions to decrease ADR symptoms regarding the (2001). Advancing the science of symptom management. differences between male and female patients. Such Journal of Advanced Nursing, 33(5), 668-676. https://doi.org/10.1046/j.1365-2648.2001.01697.x intervention should incorporate the promotion of strategies Fang, Yong, Xiao, Heping, Tang, Shenjie, Liang, Li, Sha, Wei, & to manage ADR symptoms to enhance adherence to anti- Fang, Yuanyuan. (2016). Clinical features and treatment of TB drug regimens in order to reduce transmission and drug fever caused by anti‐tuberculosis drugs. The Clinical improve quality of life. Respiratory Journal, 10(4), 449-454. https://doi.org/10.1111/ crj.12242 Conclusion Fei, Cheah Meng, Zainal, Hadzliana, & Ali, Irfhan Ali Hyder. (2018). Evaluation of adverse reactions Induced by anti-
tuberculosis drugs in Hospital Pulau Pinang. The Malaysian This study found that ADRs were more reported among Journal of Medical Sciences: MJMS, 25(5), 103-114. male patients, but female patients reported a significantly https://doi.org/10.21315/mjms2018.25.5.10 higher symptom burden than males. The results of this Grove, S. K., & Gray, J. . (2018). Understanding nursing research: study suggest that females receiving anti-TB drugs should Building an evidence‐based practice. St. Louis, Missouri: be carefully appropriately monitored for symptoms of Elsevier. ADRs to deal with ADR symptoms. This would help Health Data Center. (2020). Report of age and gender of Thais patients continue taking anti-TB drugs, which should new tuberculosis. Retrieved from https://hdcservice.moph. go.th/hdc/main/index_pk.php decrease the severity of the disease and improve their Imam, Faisal, Sharma, Manju, Khayyam, Khalid Umer, Al-Harbi, quality of life. Naif O., Rashid, Mohd Khan, Ali, Mohammad Daud, . . . Qamar, Wajhul. (2020). Adverse drug reaction prevalence and Declaration of Conflicting Interest mechanisms of action of first-line anti-tubercular drugs. Saudi There are no potential conflicts of interest to declare. Pharmaceutical Journal, 28(3), 316-324. https://doi.org/10. 1016/j.jsps.2020.01.011 Funding Iranpour, Abedin, & Nakhaee, Nouzar. (2019). A review of alcohol- This study received funding from the Ratchadaphiseksomphot related harms: A recent update. Addiction & Health, 11(2), Endowment Fund, Chulalongkorn University, Bangkok, Thailand 129-137. https://doi.org/10.22122/ahj.v11i2.225 (GCUGR1125633058M). Lin, Wei-Quan, Jing, Meng-Juan, Tang, Jie, Wang, Jia-Ji, Zhang, Hui-Shan, Yuan, Le-Xin, & Wang, Pei-Xi. (2015). Factors Acknowledgment associated with fatigue among men aged 45 and older: A The authors thanked all participants for the time and effort devoted cross-sectional study. International Journal of Environmental to this study and the staff of seven hospitals in Bangkok for their Research and Public Health, 12(9), 10897-10909. help during the data collection process. https://doi.org/10.3390/ijerph120910897 Marçôa, R., Ribeiro, A. I., Zão, I., & Duarte, R. (2018). Authors’ Contribution Tuberculosis and gender-Factors influencing the risk of All the authors participated in the final manuscript. A.T. and R.P. tuberculosis among men and women by age group. designed the study, collected data, analyzed the data, wrote, and Pulmonology, 24(3), 199-202. https://doi.org/10.1016/ revised the manuscript. j.pulmoe.2018.03.004 Mathew, Sowmya, & Joseph, Anoop. (2017). Adverse effects of Authors’ Biographies antituberculosis drugs in patients under dots category – 1. Apichaya Thontham is a Registered Nurse at the Siriraj Hospital, Journal of Evidence Based Medicine and Healthcare, 4(8), Bangkok, Thailand. She is also a master's student in the Nursing 415-422. https://doi.org/10.18410/jebmh/2017/80 Science program at the Faculty of Nursing, Chulalongkorn Naser, Syed Mohammad, Nandy, Manab, Banu, Parvin, Banerjee, University, Bangkok, Thailand. Arghya, Paul, Suhrita, Podder, Indrashis, & Mukherjee, Rapin Polsook, PhD, RN is an Assistant Professor at the Faculty Mayukh. (2016). Adverse drug reaction monitoring through of Nursing, Chulalongkorn University. She has published articles active surveillance of antitubercular therapy in an urban related to cardiovascular disease. She is a reviewer and a tertiary care center. Community Acquired Infection, 3(2), 51- member of the editorial teams of the nursing journals. 54. https://doi.org/10.4103/2225-6482.184913 Nazir, Tauseef, Farhat, Sameena, Adil, Mohd, & Asrafv, Zuryat. Data Availability Statement (2019). Adverse drug reactions associated with first line anti- Data sets generated and/or analyzed during the current review are tubercular drugs, their prevalence and causality assessment available from the corresponding author upon reasonable in patients on Directly Observed Treatment Short-course demand. (DOTS) in a tertiary care hospital. International Journal of
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Basic & Clinical Pharmacology, 8(1), 147. https://doi.org/ Singh, Anita, Bhat, Tej K, & Sharma, Om P. (2011). Clinical 10.18203/2319-2003.ijbcp20185174 biochemistry of hepatotoxicity. Journal of Clinical Toxicology, Pal, Shanthi N., Duncombe, Chris, Falzon, Dennis, & Olsson, 4(1), 1-19. https://doi.org/10.4172/2161-0495.S4-001 Sten. (2013). WHO strategy for collecting safety data in public Sinha, Kumarjit, Marak, Izora Trudy R., & Singh, W. Asoka. health programmes: Complementing spontaneous reporting (2013). Adverse drug reactions in tuberculosis patients due to systems. Drug Safety, 36(2), 75-81. https://doi.org/10.1007/ directly observed treatment strategy therapy: Experience at an s40264-012-0014-6 outpatient clinic of a teaching hospital in the city of Imphal, Pongcharoen, Padcha, & Fleischer Jr, Alan B. (2016). Itch Manipur, India. The Journal of Association of Chest management: Systemic agents. Itch-Management in Clinical Physicians, 1(2), 50-53. https://doi.org/10.4103/2320- Practice, 50, 46-53. https://doi.org/10.1159/000446041 8775.123213 Qureshi, D., & Kausar, H. (2013). Adverse effects of first line anti- Watson, Sarah, Caster, Ola, Rochon, Paula A., & den Ruijter, tuberculosis drugs in patients on DOTS CAT1 under revised Hester. (2019). Reported adverse drug reactions in women national tuberculosis control programme (RNTCP). IJBPAS, and men: Aggregated evidence from globally collected 2, 2267-2280. individual case reports during half a century. Rademaker, Marius. (2001). Do women have more adverse drug EClinicalMedicine, 17, 100188. https://doi.org/10.1016/j.ecli reactions? American Journal of Clinical Dermatology, 2(6), nm.2019.10.001 349-351. https://doi.org/10.2165/00128071-200102060-000 WHO. (2019). Global tuberculosis report 2019. Geneva, 01 Switzerland: World Health Organization. Raftery, Ann, Tudor, Carrie, True, Lisa, & Navarro, Catalina. World Health Organization. (2020). Global tuberculosis report (2018). Nursing guide for managing side effects to drug- 2020. Retrieved from https://apps.who.int/iris/bitstream/hand resistant TB treatment. Retrieved from www.icn.ch/what-we- le/10665/336069/9789240013131-eng.pdf do/projects/tbmdr-tb-project Yamane, Taro. (1973). Statistics: An introductory analysis. New Ramappa, Vidyasagar, & Aithal, Guruprasad P. (2013). York: Harper & Row. Hepatotoxicity related to anti-tuberculosis drugs: Mechanisms Yee, Daphne, Valiquette, Chantal, Pelletier, Marthe, Parisien, and management. Journal of Clinical and Experimental Isabelle, Rocher, Isabelle, & Menzies, Dick. (2003). Incidence Hepatology, 3(1), 37-49. https://doi.org/10.1016/j.jceh.2012. of serious side effects from first-line antituberculosis drugs 12.001 among patients treated for active tuberculosis. American Saputra, Muhammad Reza, Rakhmawati, Windy, Hendrawati, Sri, Journal of Respiratory and Critical Care Medicine, 167(11), & Adistie, Fanny. (2020). Knowledge, attitude, and healthcare- 1472-1477. https://doi.org/10.1164/rccm.200206-626OC seeking behavior among families of children with tuberculosis. Zucker, Irving, & Prendergast, Brian J. (2020). Sex differences in Belitung Nursing Journal, 6(4), 127-135. https://doi.org/10. pharmacokinetics predict adverse drug reactions in women. 33546/bnj.1156 Biology of Sex Differences, 11, 1-14. https://doi.org/10.1186/ Singh, Abhijeet, Prasad, Rajendra, Balasubramanian, s13293-020-00308-5 Viswesvaran, Gupta, Nikhil, & Gupta, Pawan. (2015). Prevalence of adverse drug reaction with first-line drugs Cite this article as: Thontham, A., & Polsook, R. (2021). among patients treated for pulmonary tuberculosis. Clinical Symptom experience of adverse drug reaction among male Epidemiology and Global Health, 3, S80-S90. https://doi.org/ and female patients with newly diagnosed pulmonary 10.1016/j.cegh.2015.10.005 tuberculosis in Thailand. Belitung Nursing Journal, 7(3), 195- 202. https://doi.org/10.33546/bnj.1337
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Belitung Nursing Journal Knowledge, attitude, and practice Volume 7(3), 203-209 © The Author(s) 2021 https://doi.org/10.33546/bnj.1405 towards COVID-19 among student nurses in Manila, Philippines: A cross-sectional study
Earl Zedrick S. Quisao1, Raven Rose R. Tayaba1, and Gil P. Soriano1,2*
Abstract Background: Assessing the current understanding of future health care workers about the COVID-19 is very important in order to identify gaps that affect their perceptions and responses, which they can integrate into the people in the community. Objective: This study aimed to investigate the knowledge, attitude, and practice towards COVID-19 of student nurses in Manila, Philippines. Methods: This study utilized a descriptive cross-sectional survey of 314 individuals from October 2020 to December 2020 to evaluate the association of different factors to knowledge, attitude, and practice towards COVID-19. Frequency, percentage, mean, standard deviation, t-test, and one-way ANOVA were used to analyze the data gathered. Results: The survey revealed that the respondents have a mean knowledge score of 18.76 (SD = 1.64), a mean score for attitude of 26.58 (SD = 2.71) and a mean score for practice of 4.26 (SD = 0.93). A significant different were noted in terms of year level with level 3 having a higher mean score (M = 19.01, F = 2.696, p = 0.046) compared to other levels and type of school, with public university students having a higher level of knowledge (M = 18.97, t = 2.070, p = 0.039). In terms of attitude, females have higher mean scores (M = 26.85, t = -2.630, p = 0.009 and students from public university have higher scores (M = 2.81, t = -4.406, p = 0.000) than students from private university. For practice, a significant difference was noted in terms of year level, with level 3 students having a higher mean score (M = 4.42, F = 3.180, p = 0.024) compared to other year levels. Conclusion: Filipino student nurses have a high level of knowledge about COVID-19 and are mainly optimistic about controlling the pandemic. Nevertheless, having constant reminder from the authorities and health care professionals are the solution to aid public knowledge and comprehension relating to COVID-19.
Keywords COVID-19; nursing; students; knowledge; attitude; practice; Philippines
A new strain of flu-causing coronavirus has been spreading symptoms of fever, dry cough, and tiredness to many and affecting the lives of many. Reports showed that the severe symptoms of chest pain, shortness of breath or first case was discovered in Wuhan, China, in December difficulty of breathing (World Health Organization, 2020b). 2019, making Wuhan its place of origin (World Health Experts believe that the virus can easily be transmitted Organization, 2020a). Formerly known to be 2019-nCoV, when susceptible hosts inhaled small droplets that contain this new strain named Severe Acute Respiratory Syndrome the virus, which is expelled from an infected person’s nose Coronavirus 2 (SARS-CoV-2) causes the illness coined as or mouth through coughing, sneezing, or speaking. But as the Coronavirus disease 2019 (COVID-19) having mild the experts continue to study more about this pathogen, it
1 College of Nursing, San Beda University, Manila, Philippines Article Info: 2 Graduate School, Wesleyan University-Philippines, Nueva Ecija, Received: 7 March 2021 Revised: 7 April 2021 Philippines Accepted: 15 May 2021
Corresponding author: This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which allows Gil P. Soriano, MHPEd, RN others to remix, tweak, and build upon the work non-commercially as long as College of Nursing, San Beda University the original work is properly cited. The new creations are not necessarily 638 Mendiola St., San Miguel, Manila, Philippines licensed under the identical terms.
Email: [email protected] E-ISSN: 2477-4073 | P-ISSN: 2528-181X
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
203 Quisao, E. Z. S., Tayaba, R. R. R., & Soriano, G. P. (2021) turns out that there are other ways how this is being 2017). As early as in their 2nd year in the BSN program, transmitted (World Health Organization, 2020b). The virus student nurses are taught how to educate people in the began to spread rapidly, even having cases outside China, community. Assessing their current awareness and making the World Health Organization’s Director-General knowledge about this virus and its prevention can identify declaring the outbreak a Public Health Emergency of gaps that affect their perceptions and responses, which International Concern. It spreads so fast that it became a they can integrate into those people in the community. pandemic just more than a month after the previous COVID-19 is a new strain of infectious virus that has declaration (World Health Organization, 2020a). had a catastrophic effect on every individual within the As the virus continues to spread worldwide, the short time it was first detected. Thus far, only a few Philippines was not able to contain the virus outside its published articles evaluate the knowledge, attitude, and borders. On 30 January 2020, the Philippine Department practice of nursing students towards COVID-19. The of Health (DOH) recorded the first case of COVID-19 in the novelty of this virus, together with its precariousness and country with a Chinese national. On 7 March 2020, the first serious threats, made it hard for health professionals and local transmission was reported (World Health authorities to plan strategic action to stop the spread of the Organization, 2020c). Precisely months have passed since virus. To the best of our knowledge, this is the first study to the primary affirmed COVID-19 case was reported within examine COVID-19 knowledge, attitude, and practice the Philippines. The government executed numerous related sociodemographic characteristics among student actions, including adherence to the guidelines and health nurses in the Philippines. Thus, this study aims to protocols released by the WHO, contact tracing to determine the knowledge, attitude, and practice towards immediately detect and isolate those who have close COVID-19 among student nurses in Manila, Philippines. contacts with carriers, and strict community isolation in Metro Manila extending to Luzon as well as other parts of Methods the country closing almost all establishments, such as shopping centers, hoping to contain the rapidly increasing Study Design cases within the bounds of the Philippines (World Health This study utilized a descriptive cross-sectional survey to Organization, 2020d). determine the level of knowledge, attitude, and practice But despite these numerous actions, the country’s towards COVID-19. situation seems to worsen as time goes by. Ten months after the first recorded case, the country has reported a Participants total of 431,630 confirmed cases with total deaths of 8,392 An online survey using the Likert scale was used to gather (Elflain, 2020; Philippine Department of Health, 2020; the necessary data for this study. Total enumeration of World Health Organization, 2020e). This makes the students from two Colleges of Nursing in Manila was nd Philippines the 2 country in Southeast Asia with the included with a total of 314 student nurses. The inclusion th most number of confirmed cases and ranks 27 globally criteria include: (1) nursing students studying in a college (Elflain, 2020; Petterson et al., 2020; World Health or a university, either public or private, in Metro Manila; (2) Organization, 2020e). According to experts, a significant currently enrolled in the academic year 2020-2021; (3) factor why COVID-19 cases persist to increase is due to have access to internet connection; (4) understands the faulty human behavior (Lee, 2020; Maragakis, 2020) and English language; (5) and of legal age (18 years old and Filipinos are no exceptions. On 25 October 2020, Manila above) who can give informed consent. Bulletin released an article announcing that over 100,000 quarantine violators were arrested by the Philippine Measures National Police (Chavez, 2020). This study utilized the questionnaire developed by Al- This shows that the success of the efforts of the Hanawi et al. (2020) in order to measure the knowledge, government depends on people’s adherence to preventive attitude, and practice towards COVID-19 among nursing measures, which is affected by their knowledge, attitude, students. Respondents were asked about their knowledge and practices. A study revealed that public knowledge is using the 22-item Dichotomous questions where the vital in response to outbreaks (University of Surrey, 2018), questions were answered by yes or no with Cronbach’s which means that public health educators are as crucial as alpha coefficient of 0.71. In terms of attitudes, respondents other front liners, including student nurses. were asked to answer six attitudinal statements and scored In the Philippines, the Bachelor of Science in Nursing as 1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = (BSN) is a four-year program that includes general and agree, and 5 = strongly agree. It has a Cronbach’s alpha professional courses. Professional courses are threaded coefficient of 0.81. In the section of practice, respondents from the first year through the fourth year, emphasizing the five practice statements to be answered by “yes” or “no” concepts with corresponding Related Learning Experience were asked, and a score of one was given for answers that (RLE). The BSN curriculum includes an intensive nursing denote a good practice, and a score of zero was given for practicum designed to improve nursing skills further and answers that denoted bad practice. The total score ranged ensure that the BSN program results expected of an entry- from zero to five, with high scores indicating better level nurse are met (Commission on Higher Education, practices. The instrument was administered using the
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English language translation of Al-Hanawi et al. (2020). No 18.76 (SD = 1.64), the mean attitude score of 26.58 (SD = translation was conducted since English is the medium of 2.71), and the mean practice score of 4.26 (SD = 0.93). Of instruction in the BSN program in the Philippines. the total individuals, 77 (24.5%) were males and 234 (74.5%) were females, aged between 18 and 31. More than Data Collection half of them were enrolled in private schools totaling 177 This study involved the use of primary data collection using (56.4%) individuals, and the majority came from Level 1 a self-administered questionnaire. Prior to data gathering, with 122 (38.9%). These participants were also categorized the researchers got approval from the College Dean according to their family’s monthly income in Philippine through a letter of request to conduct this study. Permission peso (Php), with 112 (35.7%) in the less than Php 20,000 to utilize the COVID-19 knowledge, attitude, and practice bracket, 59 (18.8%) in the Php 20,000-30,000 bracket, 29 instrument was secured from the developer of the tool. (9.2%) in the Php 30,000-40,000 bracket, 26 (8.3%) in the Further, with the Dean’s approval and a clearance from the Php 40,000-50,000 bracket, and 88 (28%) in the more than ethics board, the researchers then collected the data using Php 50,000 bracket. The content of the next tables, Table Google Forms. Given the physical distancing measures 2-4, shows the participants' responses about knowledge, and other restrictions implemented, data were collected attitude, and practice towards COVID-19. online to avoid face-to-face interactions during the course of the collection from October 2020 to December 2020. Table 1 Characteristics of the Participants (N = 314) Data Analysis This study used frequency, percentage, mean, standard Variable Mean (SD) n (%) deviation, independent t-test, and one-way ANOVA to Knowledge 18.76 (1.64) analyzed the data gathered from the respondents. The Attitude 26.58 (2.71) Shapiro Wilk test indicated that the data were normally Practice 4.26 (0.93) Age 19.80 (1.54) distributed. The alpha level of significance was set at 0.05. Gender Male 77 (24.5) Ethical Considerations Female 234 (74.5) This study was conducted in accordance with the Year Level established ethical standards of conducting research with 1st year 122 (38.9) human participants. The researchers obtained ethical 2nd year 86 (27.4) rd clearance from San Beda University – Research Ethics 3 year 75 (23.9) th Board with Protocol Number 2020-040. It was made sure 4 year 31 (9.9) Type of School that respondents were informed regarding the study’s Public 137 (43.6) objectives, associated risks, and benefits of participation Private 177 (56.4) and encouraged to ask any questions regarding the study. Income Written consent was also secured when the respondents Less than Php20,000 112 (35.7) decided to participate. Php20,000 to Php30,000 59 (18.8) Php30,000 to Php40000 29 (9.2) Results Php40,000 to Php50,000 26 (8.3) More than Php50,000 88 (28)
Table 1 shows the socio-demographic characteristics of the participants, which displays the mean knowledge score of
Table 2 Level of knowledge of the participants about COVID-19
Statements n (%) Correct Answer Incorrect Answer SARS-CoV-2 spreads from person to person within close distance of each other (approx. 281 (89.5) 33 (10.5) six feet) SARS-CoV-2 spread through respiratory droplets, which occur when infected people 313 (99.7) 1 (0.3) cough and sneeze SARS-CoV-2 can be contracted by touching a surface or object on which the virus is 312 (99.4) 2 (0.6) attached and then touching one’s mouth, nose, or, perhaps, eyes Close contact or eating wild animals causes COVID-19 145 (46.2) 145 (46.2) People infected with SARS-CoV-2 cannot transmit the virus to others when a fever is not 282 (89.8) 32 (10.2) present The main clinical symptoms of COVID-19 are fever, fatigue, dry cough, myalgia, and 305 (97.1) 9 (2.9) shortness of breath Unlike the common cold, congestion, runny nose, and sneezing are less common in people 139 (44.3) 175 (55.7) infected with SARS-CoV-2
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Table 2 (Cont.) Antibiotics are an effective treatment for COVID-19 247 (78.7) 67 (21.3) Currently, there is no effective cure for COVID-19, but early symptomatic and supportive 302 (96.2) 12 (3.8) treatment can help most patients recover from the diseases Older adults and those with serious chronic illnesses, such as heart or lung disease and 208 (98.1) 6 (1.9) diabetes, are at increased risk of developing more serious complications from COVID-19 Not all people with COVID-19 have severe cases. Only older adults with chronic illnesses 234 (74.5) 80 (25.5) tend to be more severe Pregnant women are more susceptible to infections than non-pregnant women 231 (73.6) 83 (26.4) Children do not appear to be at higher risk for COVID-19 than adults 136 (43.3) 178 (56.70) It is not necessary for children or young people to take precautionary measures to prevent 252 (80.3) 62 (19.7) SARS-CoV-2 transmission After being in a public place, after nose-blowing, coughing, or sneezing, people must wash 287 (91.4) 27 (8.6) their hands with soap and water or use a hand sanitizer containing at least 60% alcohol for at least 20 seconds People should avoid touching their eyes, nose, and mouth with unwashed hands 310 (98.7) 4 (1.3) Ordinary residents can wear general medical masks to prevent the SARS-CoV-2 infection 291 (92.7) 23 (7.3) People should only wear a mask if they are infected with the virus or if they are caring for 271 (86.3) 43 (13.7) someone with suspected SARS-CoV-2 infection Healthy food and drinking water increase the body’s immunity and resistance to COVID- 307 (97.8) 7 (2.2) 19 Isolation and treatment of people infected with the SARS-CoV-2 are effective ways to 313 (99.7) 1 (0.3) reduce the spread of the virus People in contact with someone infected with SARS-CoV-2 should be immediately 313 (99.7) 1 (0.3) quarantined, in an appropriate location, for a general observation period of 14 days To prevent transmission of SARS-CoV-2, people must avoid going to crowded places and 312 (99.4) 2 (0.6) avoid taking public transport
Table 3 Level of the attitude of the participants about COVID-19
Statement n (%) Strongly Disagree Neutral Agree Strongly Agree Disagree It is important to keep my distance from others to avoid 0 0 0 11 (3.5) 303 (96.5) spreading SARS-CoV-2 Washing hands is essential to protect myself from COVID-19 0 0 1 (0.3) 6 (1.9) 307 (97.8) To protect myself from COVID-19 exposure, I should stay 0 1 (0.3) 8 (2.5) 28 (8.9) 277 (88.2) home if I am sick unless I am receiving medical care COVID-19 will eventually be successfully controlled 7 (2.2) 28 (8.9) 88 (28) 76 (24.2) 115 (36.6) Philippines’ strict measures can help win the battle against 28 (8.9) 33 87 (27.7) 65 (20.7) 101 (32.2) COVID-19 (10.5) Compliance with the Department of Health precautions will 3 (1) 11 (3.5) 41 (13.1) 68 (21.7) 191 (60.8) prevent the spread of COVID-19
Table 4 Practices of the participants about COVID-19
Statements n (%) Yes No Have you recently been to a social event involving a large number of people? 58 (18.5) 256 (81.5) Have you recently been to a crowded place? 105 (33.4) 209 (66.6) Have you recently avoided cultural behaviors, such as shaking hands? 265 (84.4) 49 (15.6) Have you been practicing social distancing? 306 (97.5) 8 (2.5) Recently, have you frequently washed your hands with soap and water, for at least 40 302 (96.2) 12 (3.8) seconds, especially after going to a public place or after nose-blowing, coughing, or sneezing?
Table 5 shows the comparison of the characteristics of the other levels and type of school, with public university participants with the level of knowledge, attitude, and students having a higher level of knowledge (M = 18.97, t practice. In terms of knowledge, a significant difference = 2.070, p = 0.039) as compared to private university noted in terms of year level, with 3rd year having a higher students. mean score (M = 19.01, F = 2.696, p = 0.046) compared to
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In terms of attitude, females have higher mean scores a significant difference was noted in terms of year level, (M = 26.85, t = -2.630, p = 0.009 and students from public with 3rd year students having a higher mean score (M = university have higher scores (M = 2.81, t = -4.406, p = 4.42, F = 3.180, p = 0.024) compared to other year levels. 0.000) than students from private university. For practice,
Table 5 Comparison of the characteristics of the participants and average of knowledge, attitude, and practice score
Variable Knowledge score Attitude score Practice score Mean SD F/t p Mean SD F/t p Mean SD F/t p Gender Male 18.62 1.97 -0.732 0.406 25.94 3.21 -2.630 0.009* 4.11 1.03 -1.594 0.112 Female 18.80 1.52 26.85 2.44 4.31 0.89 Year Level 1st year 18.62 1.65 2.696 *0.046 26.55 2.66 1.447 0.229 4.22 0.89 3.180 *0.024 2nd year 18.95 1.51 26.92 2.36 4.32 0.96 3rd year 19.01 1.42 26.57 2.75 4.42 0.79 4th year 18.16 2.22 25.74 3.54 3.83 1.21 Type of School Public 18.97 1.64 2.070 *0.039 25.83 2.81 -4.406 0.000* 4.22 0.94 -0.704 0.482 Private 18.59 1.63 27.15 2.49 4.29 0.93 Income Less than 20,000 18.74 1.52 0.780 0.539 27 2.52 1.396 0.235 4.33 0.96 1.327 0.260 20,000 to 30,000 18.58 1.91 26.63 2.78 4.25 0.88 30,000 to 40000 18.51 2.31 26.45 3.39 3.89 1.05 40,000 to 50,000 19.11 1.42 26 3.12 4.23 0.91 More than 50,000 18.89 1.38 26.21 2.48 4.31 0.89 *p-value is significant at 0.05
Discussion believe that children are at higher risk for COVID-19 compared to adults who may be due to thinking that The objective of the study is to determine the significance children have a weaker immune system, but experts of assessing the level of knowledge, attitude, and practice believe that children are not at higher risk but is equally to be measured can serve as a guide (Azlan et al., 2020). susceptible to the virus as adults do (Beusekom, 2020). These circumstances stipulate the necessity of public Several factors were also incorporated to see if there adherence to preventive and control measures, which is would be any differences in the knowledge of participants. influenced by their knowledge, attitudes, and practices (Al- Among the characteristics of the respondents, the year Hanawi et al., 2020). level and the type of school appear to have a significant The survey on 314 student nurses showed that the difference. The study revealed that third-year students majority of the participants were aware of COVID-19 have a higher mean score than other levels. This is related knowledge, exhibit a positive attitude and dynamic different from other studies that show a higher level of practice throughout the outbreak showing the effect of knowledge in fourth and fifth-year students (Noreen et al., massive public education campaigns, such as social media 2020). This reflects the effectiveness of the new nursing (Peng et al., 2020). Although this study shows that the curriculum where the nursing subject for communicable participants were very much acquainted with the diseases is now embedded in the third year, giving them precautions, symptoms, and transmission of the virus, it more opportunities to have further information about such also manifests that more than half of the participants were diseases at an earlier time. It also came to light that still convinced that having close contact or eating wild students from public schools have a higher mean score animals causes COVID-19. A total of 169 or 53.8% of the than students from private schools, congruent with other participants erroneously answered on this item. This studies (Peng et al., 2020). This may be rooted in private exhibits that these participants still adhere to the claims schools’ inferiority in terms of numbers, including quantity that the virus came from bats that were ingested by people and quality of students and teachers, as well as support in a marketplace in Wuhan despite the fact that several from authorities (The World Bank, 2011). reports are claiming that there may have animals that The result for assessment of the participants’ attitude tested positive for this virus, but there is still no evidence to exhibits notable data. Although almost all of them have a suggest that animals are capable of transmitting the positive attitude in following measures to address the infection to humans (Ohio State University, 2020; Centers spreading of the virus, 39.2% of them think that the current for Disease Control and Prevention, 2021). Another situation will not be controlled anytime sooner. Nearly half significant error was 178 (56.7%) of the respondents of them (47.1%) also think that the country’s austere measures will not be able to control this pandemic. These
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
207 Quisao, E. Z. S., Tayaba, R. R. R., & Soriano, G. P. (2021) outcomes show a remarkable number of individuals who solution to aid public knowledge and comprehension are not assertive in the government’s movement and relating to COVID-19. immediate response, including austere lockdowns, suspension of public transports, school classes, leisure Declaration of Conflicting Interest activities, and implementation of a curfew in disparate The authors have no conflict of interest to disclose. cities. However, some of the participants have been Funding pessimistic regarding this issue owing to the fact that This research did not receive any specific grant from funding people tend to experience negative emotions, such as agencies. panic and anxiety, throughout the time of the pandemic that could influence their attitude. Further, gender and the type Acknowledgment of school were showed to have a significant difference. The The authors would like to express their sincerest gratitude to all results showed that women tend to be more optimistic and the students who participated in the study. have a positive attitude towards this crisis which is also Author Contribution reflected in several studies (Noreen et al., 2020). All the authors have made a substantial contribution from Overall, the majority of the participants abides by the conception to the finalization of this study. EZQ was involved in control and preventive measures that the health workers the conception of the study, data collection, and revising the article along with the authorities enacted. This showed beyond for important intellectual content. RRT was involved in the doubt the eagerness of the participants to adjust and conception of the study, the collection of data, and editing the undergo behavioral changes in the face of the COVID-19 article for important intellectual content. GPS was in charge of the pandemic. The participants espoused good and safe conception and design of the study, analysis and interpretation of practice for the reason that the government’s palpable data, and revising the article for important intellectual content. All authors approved the final version of the article. campaign towards the disease influenced the behavioral change of the individuals. Author Biographies Based on our knowledge, this is the first study Earl Zedrick S. Quisao and Raven Rose R. Tayaba are Bachelor conducted to analyze the knowledge, attitude, and practice of Science Nursing students at San Beda University, College of related to COVID-19 among student nurses in the Nursing, Manila, Metro Manila, Philippines. Philippines. For that reason, it offers valuable information Gil P. Soriano, MHPEd, RN is an Assistant Professor at San Beda about public health education and prevention in Philippine University, College of Nursing, Manila, Metro Manila, Philippines, universities during the COVID-19 pandemic. Our findings and at Wesleyan University Philippines, Graduate School, show that most Filipino undergraduate students have a Cabanatuan City, Nueva Ecija, Philippines. basic understanding of COVID-19, though their Data Availability Statement performance varies by school type and year level. There is The datasets generated during and/or analyzed during the current a difference based on gender and type of school based on study are available from the corresponding author on reasonable the attitude towards COVID-19. These findings indicate request. that gender, year level, and type of school can influence students' responses to the COVID-19 outbreak and References acquisition of public health education, which should be Al-Hanawi, M. K., Angawi, K., Alshareef, N., Qattan, A. M. N., brought to the attention of educators and health officials. Helmy, H. Z., Abudawood, Y., . . . Chirwa, G. C. (2020). These factors should also be considered when developing Knowledge, attitude and practice toward COVID-19 among contingency plans or preparation for students in the event the public in the Kingdom of Saudi Arabia: A cross-sectional study. Frontiers in Public Health, 8, 217. https://doi.org/ of potential public health emergencies. 10.3389/fpubh.2020.00217 Azlan, A. A., Hamzah, M. R., Sern, T. J., Ayub, S. H., & Mohamad, Conclusion E. (2020). Public knowledge, attitudes and practices towards COVID-19: A cross-sectional study in Malaysia. Plos One, The current study was able to lay out an extensive 15(5), e0233668. https://doi.org/10.1371/journal.pone.02336 68 exploration concerning the knowledge, attitude, and Beusekom, M. V. (2020). Study: Kids, adults equally susceptible practice of the student nurses in the Philippines towards to in-home COVID-19 spread. https://www.cidrap.umn.edu/ COVID-19. Knowledge about COVID-19 is pondered to be news-perspective/2020/12/study-kids-adults-equally-suscep the first step in overcoming infectious disease. In addition, tible-home-covid-19-spread# being educated about its basic information, such as its Centers for Disease Control and Prevention. (2021). How to transmission and causes, increased the possibility of protect yourself and others. https://www.cdc.gov/coronavirus/ people being mindful of the spread of communicable 2019-ncov/prevent-getting-sick/prevention.html diseases. The outcome proves that Filipino student nurses Chavez, C. (2020). 124,576 quarantine violators freed; 1,751 remain detained – DILG. https://mb.com.ph/2020/10/25/1245 have a justifiable level of knowledge in the said disease 76-quarantine-violators-freed-1751-remain-detained-dilg/ and are mainly optimistic in their perspective in controlling Commission on Higher Education. (2017). CHED Memorandum the pandemic. Nevertheless, having constant reminder Order No. 15, Series of 2017. https://ched.gov.ph/wp- from the authorities and health care professionals are the content/uploads/2017/10/CMO-15-s-2017.pdf
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Elflain, J. (2020). Number of coronavirus (COVID-19) cases 6/611540WP0P10651e0Govt1s0ESC0Program.pdf?sequenc worldwide as of November 30, 2020, by country. e=1&isAllowed=y&fbclid=IwAR0aawD2UXxEdNey7K9Gi4Kq https://www.statista.com/statistics/1043366/novel-coronavi OepBOPXGGucz6hT4r6POUG2ngptI7JWDYPo rus-2019ncov-cases-worldwide-by-country/ University of Surrey. (2018). Increasing public awareness is vital Lee, B. Y. (2020). Why are Covid-19 cases increasing? Here are in the fight against infectious diseases. https://www.science 7 reasons. https://www.forbes.com/sites/brucelee/2020/11/ daily.com/releases/2018/01/180129104653.htm 23/why-are-covid-19-coronavirus-cases-increasing-here-are- World Health Organization. (2020a). Rolling updates on 7-reasons/?sh=2f35e88d4aa8&fbclid=IwAR2HVe5JbKBSaN coronavirus disease. https://www.who.int/emergencies/dise KLDee7e5vTXXbwPOoUB6NGketxUTziyD1SHf-w4o9xZQ ases/novel-coronavirus-2019/events-as-they-happen Maragakis, L. L. (2020). Coronavirus second wave? Why cases World Health Organization. (2020b). Q&A on coronaviruses increase. https://www.hopkinsmedicine.org/health/conditions (COVID-19). https://www.who.int/emergencies/diseases/nov -and-diseases/coronavirus/first-and-second-waves-of-corona el-coronavirus-2019/question-and-answers-hub/q-a-detail/ virus coronavirus-disease-covid-19#:~:text=symptoms Noreen, K., Rubab, Z.-e., Umar, M., Rehman, R., Baig, M., & Baig, World Health Organization. (2020c). Coronavirus disease F. (2020). Knowledge, attitudes, and practices against the (COVID-19) in the Philippines. https://www.who.int/philip growing threat of COVID-19 among medical students of pines/emergencies/covid-19-in-the-philippines Pakistan. Plos One, 15(12), e0243696. https://doi.org/10. World Health Organization. (2020d). 100 days of COVID-19 in the 1371/journal.pone.0243696 Philippines: How WHO supported the Philippine response. Ohio State University. (2020). What you need to know about https://www.who.int/philippines/news/feature-stories/detail/ COVID-19 and pets and other animals. https://vet.osu.edu/ 100-days-of-covid-19-in-the-philippines-how-who-supported- about-us/news/covid-19-and-animals?fbclid=IwAR3NnIWHo the-philippine-response?fbclid=IwAR1dNvEgqqUH-08b9-1S- RBC60e4LHqsMKwjzcvfLHuf_VPtqgVXEWTOmOowlaN2ad fEP0Lfsc4KGhH4T0DRWttDd-q0bQb1uNV7LkuM#:~:text= RPnMw The%20Philippines%20implemented%20various%20actions,l Peng, Y., Pei, C., Zheng, Y., Wang, J., Zhang, K., Zheng, Z., & icensed%20testing%20labs%20across%20the Zhu, P. (2020). A cross-sectional survey of knowledge, World Health Organization. (2020e). WHO coronavirus disease attitude and practice associated with COVID-19 among (COVID-19) dashboard. https://covid19.who.int/ undergraduate students in China. BMC Public Health, 20(1), 1-8. https://doi.org/10.1186/s12889-020-09392-z Cite this article as: Quisao, E. Z. S., Tayaba, R. R. R., & Petterson, H., Manley, B., & Hernandez, S. (2020). Tracking Soriano, G. P. (2021). Knowledge, attitude, and practice coronavirus’ global spread. https://edition.cnn.com/interactive/ towards COVID-19 among student nurses in Manila, 2020/health/coronavirus-maps-and-ca ses/ Philippines: A cross-sectional study. Belitung Nursing Journal, Philippine Department of Health. (2020). Covid-19 tracker. 7(3), 203-209. https://doi.org/10.33546/bnj.1405 https://www.doh.gov.ph/covid19tracker The World Bank. (2011). Education service contracting. https:// openknowledge.worldbank.org/bitstream/handle/10986/2740
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209 Original Research BNJ
Belitung Nursing Journal The effect of warm compresses on Volume 7(3), 210-218 © The Author(s) 2021 https://doi.org/10.33546/bnj.1452 perineal tear and pain intensity during the second stage of labor: A randomized controlled trial
Soumaya Modoor1,2, Howieda Fouly1,3* , and Hawazen Rawas1
Abstract Background: Warm compress is believed to reduce perineal tear occurrence and decrease pain intensity during the second stage of childbirth. Objective: This study aimed to determine the effect of warm compresses on perineal tear and pain intensity during the second stage of labor. Methods: A randomized controlled trial was conducted between 28 September 2018 to 30 October 2018 in King Khaled Hospital (KKH), affiliated with the Ministry of National Guard Hospital Affairs, King Abdul-Aziz Medical City Western Region, Saudi Arabia. According to eligibility criteria, the sample randomly recruited through lottery included 100 primigravida pregnant women, with 50 in each intervention and control group. Data were presented in the form of frequency and percentages, standard deviation, and mean. Chi-square test was used for data analysis, with p-value significance at ˂ 0.05. Results: Sociodemographic data revealed no statistically significant difference in the age, education, occupation, and residence of both the control and experimental group. The perineum area’s pain intensity after birth showed a statistically significant difference between the intervention and the control groups (p = 0.001). The perineal tear was also significantly different between both groups (p = 0.001). Conclusion: The applied warm compresses on the perineum area positively reduce second and third-degree perineal tear and pain intensity during the second stage of labor and after childbirth. Therefore, midwives and nurses are expected to actively provide effective planned in-service training programs regarding warm compresses' advantages in the second stage of labor and apply this procedure actively.
Keywords pain; pregnant women; perineum; midwifery; hospitals; laceration; nursing; Saudi Arabia
Before the 1930s, women gave birth to children in home delivery, maternal birthing position, perineal massage, settings assisted by traditional midwives. During this time, application of warm compresses, episiotomy, and manual childbirth was a dangerous affair because many pregnant perineal support (MPS) (Gupta et al., 2017). women and newborns lost their lives during or following Labor is the process through which a fetus is delivered childbirth (Corretti & Desai, 2018). However, during after 24 weeks of gestation. Labor begins when uterine intrapartum, different intervention techniques can inhibit the contractions become consistent and cervical effacement risk, like the choice of instrument for operative vaginal and distention increase (Wahyuni et al., 2017). The first
1 College of Nursing, King Saud Bin Abdul-Aziz University for Health Article Info: Sciences, Kingdom of Saudi Arabia Received: 24 March 2021 2 Revised: 25 April 2021 Maternity and Children Hospital, Makkah, Kingdom of Saudi Arabia Accepted: 26 May 2021 3 Faculty of Nursing, Assiut University, Egypt
Corresponding author: This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which allows Assist. Prof. Dr. Howieda Fouly others to remix, tweak, and build upon the work non-commercially as long as College of Nursing, King Saud bin Abdul-Aziz University for Health the original work is properly cited. The new creations are not necessarily Sciences, King Abdul-Aziz Medical City, National Guard Health Affairs licensed under the identical terms. Mail Code 6565 | P.O.Box.9515 Jeddah, 21423 Kingdom of Saudi Arabia Telephone: 966 22246666 Ext. 46243 Phone No: 966538472739 E-ISSN: 2477-4073 | P-ISSN: 2528-181X Email: [email protected] | [email protected]
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210 Modoor, S., Fouly, H., & Rawas, H. (2021) stage of labor occurs in two phases: the latent stage, the forms of third-degree tears are 3a, 3b, and 3c. In 3a tears, time taken for the cervix to open to 3 centimeters, and the less than half of the external anal sphincter is destroyed, active phase, which is the time taken from 3 centimeters to whereas 3b tears involve the destruction of more than half the complete opening of the cervix. During this stage of of the same anatomical area. In 3c tears, the internal anal labor, the main problem is the failure to progress, which sphincter is wrecked. Fourth-degree tears entail the diagnosed if there is less than 2 centimeters dilatation in 4 destruction of the perineum, including the anal sphincter hours or decelerating progress in parous women. Labor complex (internal and external) and the anal or rectal that is slow from the beginning is known as dysfunctional epithelium (Goh et al., 2018). labor, whereas having sudden complications in previously It appears that there is a relationship between the progressive labor is referred to as arrest (Collins et al., extent of perineal trauma and the effect on pain intensity. 2008). Causes of unsatisfactory progress include inefficient The highest reports of complaining due to perineal pain uterine activity, malpresentation, or a large baby. come from women who have third- or fourth-degree tears Our study's primary focus is that the second stage of through the anal sphincter and rectal canal. Women with labor encompasses the period between the full dilatation of intact perineum have a low risk for infection, less blood the cervix and childbirth. The active part begins when the loss, and less pain after childbirth. Most vaginal births are mother starts pushing using the abdominal muscles to associated with tears or trauma in the perineal area "bear down." Different positions may be used during this (Aasheim et al., 2017). Midwives and nurses use various stage, such as standing, squatting, a supine position, or an management techniques of the perineum, which play a all-fours pose (Pillitteri, 2010). On the other hand, the significant role in reducing episiotomy and decreasing or perineum may be complicated by the fetal head, expanding minimizing perineal trauma. One of the most common is the anus as it comes down. Therefore, to support the warm compresses (Moore & Moorhead, 2013). perineum, a pad may be used to hold the perineum and Furthermore, a randomized controlled study by Essa shield the anus while the other hand conserves flexion, and Ismail (2016) reported that pain intensity declined after thereby regulating the head’s rite of passage, reducing warm compresses measured by VAS among the study perineal expansion, and minimizing tears (Geranmayeh et group, and a strong significant effect was noticed on al., 2012). Delivery should occur within three hours of the decreasing the episiotomy rate. In general, it is due to the second stage of labor in nulliparous women and two hours potential treatment effects, including vasodilation, for multiparous women (Simkin et al., 2016). increased blood flow, tissue extensibility, muscle During childbirth in the second stage, women could relaxation, and pain (Akbarzadeh et al., 2016). Studies in have a perineal trauma to the genitalia. The first-degree various parts of the world involving warm compresses tear occurs spontaneously in the perineal skin; the second‐ during second-stage labor in nulliparous and primiparous degree tear consists of the perineal muscles and skin; the women reported that it reduces the intensity of perineal third‐degree tears include the anal sphincter complex, and pain. These findings were reported by Ibrahim et al. (2017) the fourth-degree tears include anal sphincter complex and in Egypt, Baba et al. (2016) in Japan, and Ali et al. (2004) anal epithelium (Fernando et al., 2015). Moreover, trauma in Pakistan, among other countries. may also result from prolonged pressure on the perineal However, many countries have not implemented nerve area during more prolonged childbirth labor significant beneficial practices. Instead, they uphold (Akbarzadeh et al., 2016). The two classifications of ineffective or deleterious practices. For example, routine perineal trauma: spontaneous perineal trauma or tear and procedures such as shaving of the pubic hair, episiotomy, episiotomy (National Institute for Health and Care seizures, electronic fetal monitoring, and intravenous (IV) Excellence; Essa & Ismail, 2016). infusion are commonly observed in some Saudi Arabia The midwives and nurses should only consider areas (Altaweli et al., 2014). The debate still occurs episiotomies in specific situations, such as complicated because some researchers recommended warm vaginal delivery, breech, forceps, shoulder dystocia, and compresses (Essa & Ismail, 2016; Aasheim et al., 2017), ventouse deliveries. A midwife or a nurse may also choose while others found them to have limited or no benefits (Zare to perform an episiotomy when there are symptoms of fetal et al., 2014). The use of warm compresses to prevent or distress or signs that massive perineal trauma may occur. reduce the incidence and degree of perineal tear and pain The indications of extensive perineal trauma include is still controversial (Ibrahim et al., 2017). These numerous perineal tears and perineal buttonholing contradictory results necessitate several studies to fill the (Oladapo et al., 2018). Moreover, perineal tears usually gap in this respect. Therefore, this study aimed to happen in women following vaginal childbirth that exert determine the effect of warm compresses on perineal tear undue pressure on the perineum. It is classified into four and pain intensity during the second stage of labor. groups depending on the extent of tissue damage. First- degree tears affect the skin around the perineum only, Methods whereas second-degree tears damage the perineum and muscles. An episiotomy is an example of a second-degree Study Design tear. Third-degree perineal tears, on the other hand, This study applied a randomized controlled trial, post-test involve damage to the anal sphincter complex. The three only design. The investigator allocates participants to an
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211 Modoor, S., Fouly, H., & Rawas, H. (2021) experimental or control condition on a random basis. So, The number of births in hospitals is estimated at 3000 this study tested if the independent variable, warm births every year. The G*power software program (Faul et compresses, affected the dependent variables: perineal al., 2007) was used to calculate the sample size. The outcome and pain intensity. program allows sample size analyses and high-precision power. Besides, it computes the power values for sample Setting size, effect size, and alpha levels. The aim was to achieve Our study was conducted between 28 September 2018 to the power of 80% with effect size = 0.3, a err prob = 0.05, 30 October 2018 in King Khaled Hospital (KKH), affiliated power (1-B err prob) = 0.80. The estimation was based on with the Ministry of National Guard Hospital Affairs, King two tails a = 0.05. After calculation by G*Power, the sample Abdulaziz Medical City – Western Region, Saudi Arabia. It size was 90 and added 10% for the dropped cases, with a is a 600 bedded Joint Commission International (JCI) total sample size of 100 primigravida pregnant women who accredited Tertiary level Hospital. The setting area for this met the inclusion criteria. experimental study was conducted in the labor and delivery The investigator applied a simple random technique (L&D) unit, which has six beds for delivery, three beds for (lottery) through the participants' allocation into an induction of labor, and one room for operation room (OR). experimental group or control group on a random basis. The patient characteristic and information attained from Each participant assigned the experiment by letter (A) and best care (medical record and patient). control by letter (B). Then paper folded and mixed inside a box, and the investigator asked one of the nurses to pick a Participants number from the box. Then the participant was allocated to All the primiparous pregnant women during the second either the experimental group or control group (Figure 1). stage of labor participated randomly in this study. The To avoid bias, the investigator divided the rooms for the inclusion criteria include age from 18-35 years old, control or experimental groups based on the women’s primigravida, healthy pregnancy, singleton pregnancy, choices of the closed envelope. The experimental group cephalic presentation, full-term, and no contraindication for room was numbered with an odd number, like 1, 3, and the vaginal delivery. The exclusion criteria were multiple control group's room was numbered with an even number pregnant women, complicated labor, the coexistence of like 2, 4,….etc. any medical or obstetrical risk factors, and pregnant women deliver a cesarean section.
Figure 1 Flow chart for the recruitment of the sample
Instruments patients; 2) Numeric Rating Scale (NRS) For Pain (Hawker The instruments in this study consisted of 1) et al., 2011). The investigator got permission to use the NRS Sociodemographic Tool comprising socio-demographic tool for pain assessment. It ranged from zero pain to 10 characteristics including women's age and education level, severest pain in between the two extremity points equal occupation, previous admission to the hospital, reproductive distances measured 1cm as mild pain (1-2) moderate (3-4), history gestational weeks, number of prenatal care visits. severe (5-6), very severe (7-8), and severest pain (9-10). The information is attained from medical records and The NRS can be administered verbally or graphically for
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212 Modoor, S., Fouly, H., & Rawas, H. (2021) self-completion. The investigator asked the women to reveal Intervention a numeric value on the scale that best describes their pain The control group received routine hospital care during the degree scoring. The number that the women indicate to rate second stage of labor, such as half-hourly monitoring and their pain intensity was recorded. The scores extend from documenting the frequency of contractions, assessing the 0–10; 3) Assessment Tool for Perineal Outcomes. It vital signs, and checking the frequency of micturition or includes perineal outcome assessment questions in the catheterization to evacuate the bladder. In addition, a form of an intact perineum, perineal tears degrees “first, vaginal examination was done after abdominal palpation second or third”, and episiotomy guided by the obstetrician without warm compresses. diagnosis and previous studies (Farghaly et al., 2017; Lane The intervention group received routine hospital care et al., 2017). in addition to the application of the warm compresses. All tools were tested for content validity by a jury of four First, the application of warm compresses was made experts in woman health nursing and one from the through applying a sterile perineal pad (gauze) socked in biostatistics field from the College of Nursing, King Saud Bin warm water with a temperature range from 45C-59C Abdul-Aziz University. A previous study also tested the measured by lotion thermometers, and the soaked each reliability of the tool (Ibrahim et al., 2017). In addition, the perineal pad was squeezed before being placed in the second stage and perineal outcome assessment perineum area. Then the warm compresses are given questionnaire were evaluated using Cronbach's Alpha continuously until bulging of the head (Figure 2). coefficient test. The instrument contained relatively similar items, indicated high reliability, with an internal consistency Data Collection of 0.81. The investigators collected data in the labor room between Before the primary data collection phase, the tools for 23 August 2018 to 30 October 2018. The investigators the study were tested at National Guard in King Khaled directly observed, measured, and recorded the pain and Hospital, with ten patients. Those patients were not included perineal outcomes for both groups using the validated in the main study. It took around one week to accomplish. instruments. The participants were also asked to enumerate The data were collected quickly with the interpretation of the severity of pain they have experienced after birth. A participant outcomes. trained health member was assigned to assist the researcher in obtaining consent and interviewing the participants.
Figure 2 Flow chart of the procedure
Data Analysis Ethical Consideration SPSS program version 20 was used for statistical analysis. Ethical approval in this study was obtained from the The variables are presented in the form of frequency and research unit committee at the College of Nursing, Jeddah, percentages, standard deviation, and mean. The Chi- and from King Abdullah International Medical Research square test was used to compete for categorical variables Center (KAIMRC) with approval number of IRBC/ 1711/18 and test a significant difference between the study groups' on 27 September 2018. Prior to the study, each participant outcome criteria. P-value was set at <0.05 for statistically has signed informed consent. The investigators explained significant criteria. the nature of the study objectives and a clear explanation
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213 Modoor, S., Fouly, H., & Rawas, H. (2021) of data collection. Confidentiality was also ensured by square test revealed no statistically significant difference in explaining to the participants that all information was used age between both groups (p = 0.918). In addition, more only for research purposes and their identities were in the than half of them in both groups respectively graduated form of numbers, not names. In addition, the data collected from university (55%), and there was no statistically could only be accessed by the investigators only. All significant difference in educational qualification (p = participants also had the right to withdraw from the study at 0.864). The majority of the participants worked as any time without penalty. housewives (75%) and lived in the urban areas (84%), and most of them had enough income per month (91%). There Results were no significant differences in occupation, current residence, and family income between the control and Table 1 shows that the majority of the participants in this experimental groups (p > 0.05). It is noted that gestational study aged between 23-26 years, 46% of the control group age was similar because of the inclusion criteria of the and 50% of the experimental group, respectively. The Chi- participants (37-42) weeks, so it was not included in the table.
Table 1 Sociodemographic characteristics for control and experimental groups for study participants
Items Control Experiment Total p-value n (%) n (%) N (%) Age (year) 18-22 14 (28.0) 14 (28.0) 28 (28.0) 0.918 23-26 23 (46.0) 25 (50.0) 48 (48.0) 27-30 10 (20.0) 5 (10.0) 15 (15.0) 31-35 3 (6.0) 6 (12.0) 9 (9.0) Educational qualification Primary school 3 (6.0) 3 (6.0) 6( 6.0) 0.864 High school 19 (38.0) 20 (40.0) 39 (39.0) Collegiate education 28 (56.0) 27 (54.9) 55 (55.0) Occupation Working 10 (20.0) 8 (16.0) 18 (18.0) 0.261 Housewives 38 (76.0) 37 (74.0) 75 (75.0) Business 2 (4.0) 4 (8.0) 6 (6.0) Any other specify (online business) 0 1 (2.0) 1 (1.0) Current residence Urban 43(86.0) 41 (82.0) 84 (84.0) 0.622 Rural 7(14.0) 9 (18.0) 16 (16.0) Family income/month More than enough 0 2 (4.0) 2( 2.0) 0.743 Just enough 47 (94.0) 44 (88.0) 91 (91.0) Not enough 3 (6.0) 4 (8.0) 7 (7.0)
Table 2 shows that 28% of the total participants' gestational most participants did not attend any antenatal care classes age was between 38 - 39 weeks. However, 6% of (91%), and more than two-thirds of participants registered gestational age was 37 weeks. Regarding pelvic training, for seven visits during the pregnancy period (70%).
Table 2 Obstetrical history of study participants
Items Control Experiment Total Mean Std. n (%) n (%) N (%) Deviation Week of gestation 37 weeks 2 (2.0) 4 (4.0) 6 (6.0) 39.1 1.136 38 weeks 11 (11.0) 17 (17.0) 28 (28.0) 39 weeks 16( 16.0) 12 (12.0) 28 (28.0) 40 weeks 13 (13.0) 12( 12.0) 25 (25.0) 41 weeks 8 (8.0) 5 (5.0) 13 (13.0) Did you receive pelvic training Yes 6 (6.0) 3 (3.0) 9 (9.0) 1.91 0.287 No 44 (44.0) 47 (47.0) 91 (91.0) Items Median IQR Number of antenatal care visits 7.00 7.00
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214 Modoor, S., Fouly, H., & Rawas, H. (2021)
Table 3 shows that two-fifth of the experimental group statistically significant difference in moderate pain (p = (40%) revealed lesser mild pain than the control group 0.001). Also, a significant difference was found in severe (52%). There was a statistically significant difference in pain (p = 0.001), which was higher in the control group mild pain in both groups (p = 0.001). In addition, more than (14%) than the experimental group (8%). There was no one half of the experimental group (52%) reported moderate having very severe or worst pain. pain than the control group (34%), and there was a
Table 3 Comparing the degree of pain among experimental and control groups immediately after birth (N = 100)
Pain after birth Control Experiment Total df Chi-square p-value n (%) n (%) N (%) Mild pain (1,2) 26 (52.0) 20 (40.0) 46 (46.0) 4 54.6 0.001 Moderate pain (3,4) 17 (34.0) 26 (52.0) 43 (43.0) 4 54.8 0.001 Severe pain (5,6) 7 (14.0) 4 (8.0) 11 (11.0) 1 34.1 0.001 Very severe (7,8) 0 (0.0) 0 (0.0) 0 (0.0) 0 Worst pain (9,10) 0 (0.0) 0 (0.0) 0 (0.0) 0
Table 4 shows that there were significant differences in group had a higher number of episiotomy (24%) than the perineal condition between the experiment and control experiment group (18%), and the majority of the control groups (p = 0.001), which the percentage of intact group (66%) and the experimental group (60%) had a perineum was higher in the experimental group (22%) than perineal tear. in the control group (10%). In addition, those in the control
Table 4 Effect of warm compresses on the perineal outcome for the experimental and control group (N = 100)
Perineal Condition Control Experiment Total Chi-square p-value n (%) n (%) N (%) Intact 5 (10) 11 (22) 16 (16) 50 0.001 Episiotomy 12 (24) 9 (18) 21 (21) 58 0.001 Tear 33 (66) 30 (60) 63 (63) 38 0.001
Table 5 shows a significant difference in the degree of experimental group had lower degrees of perineal tear in perineal tear in both groups (p = 0.043). However, the the first, second, third degree than the control group.
Table 5 Comparison of degree perineal tear between the experimental versus control group (N = 100)
Degree of Perineal Control Experiment Total Chi-square p-value Tear n (%) n (%) N (%) First degree 13 (31.7) 19 (61.3) 32 (44.4) 66.8 0.043 Second degree 24 (58.5) 10 (32.3) 34 (47.2) Third degree 4 (9.8) 2 (6.5) 6 (8.3) Fourth degree 0 (0.0) 0 (0.0) 0 (0.0)
Discussion by a study of Dahlen (2012) that examined pain intensity during the second stage of labor after warm packs. In this Perineal injuries during childbirth may affect our goal to study, among women who received warm packs, their pain maintain perineal preservation, especially among intensity score was less than those who received standard primiparous women. Therefore, interventions for reducing care. As such, women who had warm packs were perineal trauma and perineal pain are desirable. Midwives significantly less likely to report lousy pain or the worst pain and nurses widely advocate warm compresses to reduce experienced at birth compared with women who received perineal trauma and improve comfort during the second routine care without the application of warm packs. Also, stage of labor (Aasheim et al., 2017). our findings reported mild and moderate degrees of pain in Our study aimed to assess the effect of warm the intervention group. compresses on the occurrence of perineal tears and pain Furthermore, Dahlen (2012) examined the concepts of intensity during the second stage of labor. The findings comfort and pain, including warm compresses' positive revealed that the follow-up measurement for pain intensity effects on reducing pain, and fewer women reported that after birth in both the control and experimental groups with the warm compresses helped to numb their perineum area. no statistically significant differences for pain score It seems that the warm compresses helped women to deal measurement at p = 0.175. These findings are supported with the stinging sensation experienced in the perineum during the second stage of labor, also described by
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215 Modoor, S., Fouly, H., & Rawas, H. (2021) midwives as the "ring of fire." Being able to get comfortable nociceptive stimulation and improving comfort for pregnant is a significant predictor of feeling in control during labor women (Ozgoli et al., 2016). and birth. Dissimilar to Essa and Ismail (2016), which was not in Likewise, a study done by Ahmad and Turky (2010) line with the present study’s results, revealing a significant found that pain scores were better for the women who used reduction in episiotomy and vaginal/ perineal tear among warm compresses compared to other women during the the study group (p < 0.000). This finding may reflect the second stage at different points of time. This finding may benefit of applying warm compresses on the perineum reflect the benefit of using warm compresses through the during the second labor stage. In addition, Mohamed et al. second stage of labor. In addition, Akbarzadeh et al. (2016) (2011) found that using a warm compress in the perineum reported that the warm compresses yielded significantly area during the expulsive period reduces the occurrence of decreased pain during the second stage of labor by perineal laceration. increasing blood flow to the damaged or inflamed area, A study of Essa and Ismail (2016) has a dissimilarity which increased the elasticity of the collagen, which helps with our study related to sample size, as theirs was more increase tissue flexibility and provide a good feeling and significant than the current study's. Besides, the perineal psychological convenience, which reduces the pain. In the pad's material was different, as their study used a towel, same vein, warm compresses can relieve pain by but our study used a perineal pad made of gauze layers. enhancing blood circulation in the perineum (Ozgoli et al., Additionally, these findings boost the use of perineal warm 2016). compress by trained birth attendants, in line with the meta- Regarding perineal tears, the results in this study analyses study by Aasheim et al. (2017), which found a revealed that the experimental group was better than the significant effect of using warm compresses on third- and control regarding the intactness of the perineum. However, fourth-degree tears. the experimental group had fewer perineal tears than the In the present study, findings revealed that warm control group. Interestingly, the experimental group had compresses' application showed a reduction in third- and fewer participants who received an episiotomy after fourth-degree tears, reducing second-stage perineal childbirth than the control group. Further, the effect of warm trauma in primiparous women. In the same vein, Aasheim compresses on different degrees of perineal tears reflected et al. (2017) also found that warm compresses and a statistically significant difference between both control massage may reduce severe perineal trauma and third- or and experimental groups at p < 0.043, with better fourth-degree tears. Hands‐off techniques may decrease outcomes for the experimental group than the control the number of episiotomies, but it was not clear that they group in reducing the third degree of laceration and had a valuable effect on other perineal trauma. maintaining perineal integrity Many advantages occur from applying warm Regarding stitches of the perineum, two previous compresses that produce relaxation by reducing muscle randomized studies agreed with the current study indicated spasms and reducing pain intensity during childbirth. This that warm compresses had no effects on the reduction of study reflects the benefit of using warm compresses to stitches in primiparous women, confirming the long-term decrease the perineal trauma, which is evident by reducing effects of warm compresses (Dahlen, 2012). Likewise, the second and third-degree tear rate in the experimental Dahlen et al. (2009) support our findings, as no reduction group compared with the control group. Therefore, all was reported in perineal suturing after application of warm governmental/educational hospitals should provide packs, and the trial was underpowered to assess third- and effective planned in-service training programs for maternity fourth-degree tear. Meanwhile, a study by Akbarzadeh et nurses regarding warm compresses' advantages during al. (2016) was not in line with our current research, the second stage of labor. Further research is required to reporting that a warm compress was effective in reducing assess the effect of warm compresses on multiparous the rate of episiotomy and the mean length of episiotomy women relating to receiving the same benefit of incision, reducing pain intensity after childbirth and comfortable and relief pain degree during the second stage increasing the rate of an intact perineum, which indicates of labor integrating with assessing woman's satisfaction the significant effects of warm compresses on the regarding the use of warm perineal compresses during the reduction of lacerations and perineal trauma. Another second stage of labor. study by Aasheim et al. (2017) also reported that midwives The limitation of the study might include: First, eligible applied different techniques to decrease perineal trauma, participant criteria as primiparous women lead to difficulty genital trauma, episiotomy, pain intensity lubricant collecting data within the determined time of data massage, and antenatal pelvic training. However, no collection. Second, most participants showed satisfaction studies declared the most effective method for reducing regarding warm compresses, but the satisfaction variable the laceration of the perineum during childbirth. Even was not included in this study. though physiology literature has indicated that using a perineal pack during the second stage of labor leads to Conclusion vasodilation, increased blood flow in the perineum area, increased relaxation, and increased muscle stretch, which This study concluded that the application of warm was effective in pain transmission through reduction of compresses during the second stage of labor has better
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216 Modoor, S., Fouly, H., & Rawas, H. (2021) effects on perineal outcomes. In addition, it showed Valsalva maneuver referring to the selected hospitals of evidence of other benefits regarding the positive effect on Shiraz University of Medical Sciences in 2012-2013. reducing the second and third-degree of perineal tear and Advances in Skin & Wound Care, 29(2), 79-84. https://doi.org/ 10.1097/01.ASW.0000476073.96442.91 pain intensity to lower pain degrees within the experimental Ali, S. S., Malik, M., Iqbal, J., & Faruqi, N. J. (2004). Routine group. Therefore, the practice of applying warm perineal episiotomy versus selective episiotomy in primigravidae. compresses in the second stage of labor is highly Annals of King Edward Medical University, 10(4), 482-484. acceptable by mothers and midwives or nurses in helping https://doi.org/10.21649/akemu.v10i4.1272 to reduce perineal pain and increase comfort. Furthermore, Altaweli, R. F., McCourt, C., & Baron, M. (2014). Childbirth care the finding reveals that the experimental group that practices in public sector facilities in Jeddah, Saudi Arabia: A experienced intact perineum reducing tear and pain is descriptive study. Midwifery, 30(7), 899-909. https://doi.org/ better than the control group. Interestingly, the 10.1016/j.midw.2014.03.006 experimental group lesser episiotomies compared to the Baba, K., Kataoka, Y., Nakayama, K., Yaju, Y., Horiuchi, S., & Eto, H. (2016). A cross-sectional survey of policies guiding second control group. stage labor in urban Japanese hospitals, clinics and midwifery birth centers. BMC Pregnancy and Childbirth, 16(1), 1-13. Declaration of Conflicting Interest https://doi.org/10.1186/s12884-016-0814-2 The authors declare no conflict of interest in this study. Collins, S., Arulkumeran, S., Hayes, K., Jackson, S., & Impey, L. (2008). Oxford handbook of obstetrics and gynaecology (2nd Funding ed.). New York: Oxford University Press. None. Corretti, C., & Desai, S. P. (2018). The legacy of Eve's curse: Religion, childbirth pain, and the rise of anesthesia in Europe: Acknowledgment c. 1200-1800s. Journal of Anesthesia History, 4(3), 182-190. We acknowledge the maternity nurses at King Abdulaziz Medical https://doi.org/10.1016/j.janh.2018.03.009 City's labor and delivery department for cooperation during data Dahlen, H. G. (2012). Perineal warm compress reduces risk of collection. third-and fourth-degree tears and should be part of second stage care. Evidence-Based Nursing, 15(4), 103-104. Author Contribution http://dx.doi.org/10.1136/ebnurs-2012-100685 HF drafted the article and language editing. SM reviewed the Dahlen, H. G., Homer, C. S. E., Cooke, M., Upton, A. M., Nunn, literature and data collection. HF, HR, and SM contributed to study R. A., & Brodrick, B. S. (2009). ‘Soothing the ring of fire’: design and concept, critically reviewed and approved the final Australian women's and midwives’ experiences of using version of the manuscript. perineal warm packs in the second stage of labour. Midwifery, 25(2), e39-e48. https://doi.org/10.1016/j.midw.2007.08.002 Author Biographies Essa, R. M., & Ismail, N. I. A. A. (2016). Effect of second stage Soumaya Modoor, RN had a Master of Midwifery Nursing at the perineal warm compresses on perineal pain and outcome College of Nursing King Saud Bin Abdul-Aziz University for Health among primiparae. Journal of Nursing Education and Practice, Sciences, Kingdom of Saudi Arabia. Currently, she is a Senior 6(4), 48-58. https://doi.org/10.5430/jnep.v6n4p48 Midwife Specialist at the Maternity and Children Hospital, Makkah, Farghaly, T. A., Shaaban, O. M., Amen, A. F., Salem, H. T., Saudi Arabia. Elnashar, I., Abdelaleem, A. A., & Badran, E. (2017).
Howieda Fouly, PhD, RN is an Assistant Professor of Maternity Evaluating the role of measuring the perineal length as a Nursing, College of Nursing King, Saud Bin Abdul-Aziz University predictor of progress of labor and obstetrical trauma. Open for Health Sciences, Kingdom of Saudi Arabia, and Associate Journal of Obstetrics and Gynecology, 7(4), 464-472. professor, Faculty of Nursing, Assiut University, Egypt. https://doi.org/10.4236/ojog.2017.74048
Hawazen Rawas, PhD, RN is an Assistant Professor of Medical- Faul, F., Erdfelder, E., Lang, A.-G., & Buchner, A. (2007). G* Surgical Nursing, College of Nursing, King Saud Bin Abdul-Aziz Power 3: A flexible statistical power analysis program for the University for Health Sciences, Kingdom of Saudi Arabia. social, behavioral, and biomedical sciences. Behavior Research Methods, 39(2), 175-191. https://doi.org/10.3758/ Data Availability Statement BF03193146 The datasets generated during and/or analyzed during the current Fernando, R., Sultan, A., Freeman, R., Williams, A., & Adams, E. study are available from the corresponding author on reasonable (2015). The management of third-and fourth-degree perineal request. tears (Green-top Guideline No. 29). Retrieved from https://www.rcog.org.uk/globalassets/documents/guidelines/g References tg-29.pdf Aasheim, V., Nilsen, A. B. V., Reinar, L. M., & Lukasse, M. (2017). Geranmayeh, M., Habibabadi, Z. R., Fallahkish, B., Farahani, M. Perineal techniques during the second stage of labour for A., Khakbazan, Z., & Mehran, A. (2012). Reducing perineal reducing perineal trauma. Cochrane Database of Systematic trauma through perineal massage with vaseline in second Reviews(6), CD006672. https://doi.org/10.1002/14651858. stage of labor. Archives of Gynecology and Obstetrics, CD006672.pub3 285(1), 77-81. https://doi.org/10.1007/s00404-011-1919-5 Ahmad, E., & Turky, H. (2010). Effect of applying warm perineal Goh, R., Goh, D., & Ellepola, H. (2018). Perineal tears-A review. packs during the second stage of labor on perineal pain Australian Journal of General Practice, 47(1/2), 35-38. among primiparous women. Al-Azhar Assiut Medical Journal, https://doi.org/10.31128/AFP-09-17-4333 8(3), 1-26. Gupta, J. K., Sood, A., Hofmeyr, G. J., & Vogel, J. P. (2017). Akbarzadeh, M., Vaziri, F., Farahmand, M., Masoudi, Z., Amooee, Position in the second stage of labour for women without S., & Zare, N. (2016). The effect of warm compress bistage epidural anaesthesia. Cochrane Database of Systematic intervention on the rate of episiotomy, perineal trauma, and postpartum pain intensity in primiparous women with delayed
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217 Modoor, S., Fouly, H., & Rawas, H. (2021)
Reviews(5). https://doi.org/10.1002/14651858.CD002006.pu Oladapo, O. T., Tunçalp, Ö., Bonet, M., Lawrie, T. A., Portela, A., b4 Downe, S., & Gülmezoglu, A. M. (2018). WHO model of Hawker, G. A., Mian, S., Kendzerska, T., & French, M. (2011). intrapartum care for a positive childbirth experience: Measures of adult pain: Visual analog scale for pain (vas Transforming care of women and babies for improved health pain), numeric rating scale for pain (nrs pain), mcgill pain and wellbeing. BJOG: An International Journal of Obstetrics & questionnaire (mpq), short‐form mcgill pain questionnaire (sf‐ Gynaecology, 125(8), 918-922. https://doi.org/10.1111/1471- mpq), chronic pain grade scale (cpgs), short form‐36 bodily 0528.15237 pain scale (sf‐36 bps), and measure of intermittent and Ozgoli, G., Mobarakabadi, S. S., Heshmat, R., Majd, H. A., & constant osteoarthritis pain (icoap). Arthritis Care & Sheikhan, Z. (2016). Effect of LI4 and BL32 acupressure on Research, 63(S11), S240-S252. https://doi.org/10.1002/acr.2 labor pain and delivery outcome in the first stage of labor in 0543 primiparous women: A randomized controlled trial. Ibrahim, H., Elgzar, W. T. I., & Hassan, H. E. (2017). Effect of Complementary Therapies in Medicine, 29, 175-180. warm compresses versus lubricated massage during the https://doi.org/10.1016/j.ctim.2016.10.009 second stage of labor on perineal outcomes among Pillitteri, A. (2010). Maternal & child health nursing: Care of the primiparous women. IOSR Journal of Nursing and Health childbearing & childrearing family. Philadelphia, PA: Lippincott Science, 6(4), 64-76. https://doi.org/10.9790/1959-060405 Williams & Wilkins. 6476 Simkin, P., Whalley, J., Keppler, A., Durham, J., & Bolding, A. Lane, T. L., Chung, C. P., Yandell, P. M., Kuehl, T. J., & Larsen, (2016). Pregnancy, childbirth, and the newborn: The complete W. I. (2017). Perineal body length and perineal lacerations guide (4th ed.). New York: Simon and Schuster. during delivery in primigravid patients. Baylor University Wahyuni, I., Pramono, N., Suherni, T., & Widyawati, M. N. (2017). Medical Center Proceedings, 30(2), 151-153. https://doi.org/ Effect of pregnancy exercise on duration of the first and 10.1080/08998280.2017.11929564 second stage of labor in primigravida mothers during the third Mohamed, M. L., Mohamed, S. L., & Gonied, A. S. (2011). trimester of pregnancy. Belitung Nursing Journal, 3(6), 765- Comparative study between two perineal management 770. https://doi.org/10.33546/bnj.304 techniques used to reduce perineal trauma during 2nd stage Zare, O., Pasha, H., & Faramarzi, M. (2014). Effect of perineal of labor. Journal of American Science, 7(11), 228-232. massage on the incidence of episiotomy and perineal https://doi.org/10.7537/marsjas071111.27 laceration. Health, 2014. https://doi.org/10.4236/health.2014 Moore, E., & Moorhead, C. (2013). Promoting normality in the .61003 management of the perineum during the second stage of labour. British Journal of Midwifery, 21(9), 616-620. Cite this article as: Modoor, S., Fouly, H., & Rawas, H. https://doi.org/10.12968/bjom.2013.21.9.616 (2021). The effect of warm compresses on perineal tear and National Institute for Health and Care Excellence. Intrapartum pain intensity during the second stage of labor: A randomized Care for healthy women and babies: Clinical guideline controlled trial. Belitung Nursing Journal, 7(3), 210-218 [CG190]. Retrieved from https://www.nice.org.uk/guidance/ https://doi.org/10. 33546/bnj.1452 cg190
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218 Original Research BNJ
Belitung Nursing Journal DAHAGA: An Islamic spiritual Volume 7(3), 219-226 © The Author(s) 2021 https://doi.org/10.33546/bnj.1494 mindfulness-based application to reduce depression among nursing students during the COVID-19 pandemic
Meidiana Dwidiyanti1* , Badrul Munif2 , Agus Santoso1, Ashri Maulida Rahmawati3, and Rikhan Luhur Prasetya3
Abstract Background: The COVID-19 pandemic significantly impacts students’ mental health. Most of them may experience depression. Due to restrictions and social distancing during the pandemic, counseling may not be applicable in detecting the problems. Therefore, an Islamic spiritual mindfulness-based application called DAHAGA is created in order to detect and reduce depression. It is believed that this innovative app could reduce mental health problems among students. Objective: This study aimed to determine the effect of DAHAGA on reducing depression among nursing students during the COVID-19 pandemic in Indonesia. Methods: This was a quasi-experimental study with a comparison group pretest/posttest design conducted from May to June 2020. Seventy students were selected using convenience sampling, of which 35 were assigned in an experimental group and a comparison group. The validated Indonesian Version-Beck Depression Inventory-II (BDI- II) was used for data collection. Paired t-test and independent t-test were used for data analysis. Results: There was a significant effect of DAHAGA on depression (p < 0.001). The level of depression after intervention (mean 11.49, SD 4.49) was lower than it before the intervention (mean 17.20, SD 4.94). Additionally, there was a significant difference in depression level between the experimental and comparison groups after the intervention with a p-value of < 0.001. Conclusion: The DAHAGA is proven effective in reducing depression. Therefore, this study offers a new and innovative app that fits with the COVID-19 pandemic to help Muslim students maintain their health status. The findings also support Islamic spiritual mindfulness as a part of nursing interventions among psychiatric nurses to deal with mental health problems, especially depression.
Keywords COVID-19; mindfulness; nursing; students, mental health, depression; Islam; Indonesia
The outbreak of novel coronavirus diseases (COVID-19) (WHO, 2020; Sadang & Palompon, 2021). Due to this was first reported at the end of 2019 in Wuhan, China pandemic, many universities in Indonesia are starting to (Manik et al., 2021). The virus has rapidly spread implement distance teaching and learning activities or throughout the world. On 11 March 2020, the World Health online lectures (Abidah et al., 2020). Organization (WHO) declared the pandemic outbreak
1 Department of Nursing, Diponegoro University, Semarang, Indonesia Article Info: 2 Nursing Program, Institute of Health Sciences Banyuwangi, East Java, Received: 26 April 2021 Revised: 21 May 2021 Indonesia Accepted: 26 June 2021 3 Master Program in Nursing, Diponegoro University, Semarang, Indonesia This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which allows others to remix, tweak, and build upon the work non-commercially as long as Corresponding author: the original work is properly cited. The new creations are not necessarily Dr. Meidiana Dwidiyanti, S.Kp., MSc licensed under the identical terms. Department of Nursing, Diponegoro University (UNDIP) Jl. Profesor Soedarto, SH, Tembalang, Semarang, Indonesia 50275 E-ISSN: 2477-4073 | P-ISSN: 2528-181X Phone/Fax: 08164891140. E-mail: [email protected]
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219 Dwidiyanti, M., Munif, B., Santoso, A., Rahmawati, A. M., & Prasetya, R. L. (2021) Even before the COVID-19 pandemic, research shows This study would benefit mental health nursing services that many nursing students experience depression (Tung that aim to maintain optimal health and well-being and et al., 2018). Similarly, Njim et al. (2020) reported that the prevent psychological disorders. Inability to perform self- prevalence of depression among nursing students in two care or deal with impaired bodily functions related to mental regions in Cameroon reached 69.57%, and 26.40% of and emotional distress is vital in mental health prevention these students experienced severe depression. However, practices, including avoiding depression and suicides Asia was the region with the highest prevalence of (Videbeck, 2008). Nurses should be able to identify depression in nursing students (43.0%) (Tung et al., 2018). problems to prevent depression through innovations that The majority of depression can be increased depending on facilitate the detection of disorders as early as possible, stressors and environmental conditions (Acharya et al., especially during the pandemic. Thus, DAHAGA would be 2018). the best fit to help nurses and nurse educators to develop There is no doubt that the pandemic exacerbates an awareness of the problems faced by nursing students depression among students (Graupensperger et al., 2020). and identify depression levels to increase the ability to Multiple stressors in a pandemic situation contribute to the perform self-care. increased levels of depressive thoughts among students. A previous study found that 72.93% of students in Italian Overview of Islamic Spiritual Mindfulness universities experienced depression during the COVID-19 The Islamic spiritual mindfulness is the combination of pandemic (Villani et al., 2021). In Indonesia, 41.5% of three concepts: mindfulness, spiritual, and Islam. nursing students experienced depression during the Mindfulness is simply a state of mind, a process of keeping pandemic (Hasanah et al., 2020). one’s mind in the present moment, on purpose, non- Prolonged depression can affect students’ academic judgmentally, fully observe and accept what is experienced performance and clinical practice (Chernomas & Shapiro, in life from a place of calm objectivity, and detached from 2013). Also, research showed that 59 and 87% of suicide potentially destructive thoughts and feelings (Creswell, victims suffered from severe depression, and up to 15% of 2017; Dwidiyanti et al., 2019; Munif et al., 2019). Spiritual them eventually die of suicide (Gonda et al., 2007). Hence, means believing and connecting beyond the it is necessary to identify an appropriate approach to help physical/material world to the soul and spirit state of nursing students deal with depression or its symptoms. existence (Dwidiyanti et al., 2019; Munif et al., 2019). Islamic spiritual mindfulness is one of the interventions Meditation and other relaxation techniques connect the two that adopt an Islamic spiritual approach to deal with concepts, in which we pay attention to thoughts, feelings, psychological problems and psychiatric disorders (Asiah et and sensations at that moment without being overwhelmed al., 2019). Mindfulness is practiced with a high level of or overly reactive while connecting to stronger spirits awareness, believing that every problem an individual is (Dwidiyanti et al., 2019; Munif et al., 2019). facing comes from God (Allah), and it is only God (Allah) Mindfulness is found in various forms, in all religious that has the power to overcome (Dwidiyanti et al., 2019; and secular traditions, from East to West, and has roots in Munif et al., 2019). Previous studies have investigated the Buddhism, Hinduism, Judaism, Christianity, and Islam effect of Islamic spiritual mindfulness. It was found that it is (Dwidiyanti et al., 2019; Munif et al., 2019). However, in this effective on anxiety and depression among pregnant study, we focus only on the Islamic perspective. Islamic mothers in Iran (Aslami et al., 2015), drug adherence on spiritual mindfulness refers to a spiritual state of an patients with schizophrenia in Indonesia (Ardinata et al., individual who is conscious of the awareness of God (Allah) 2019; Ardinata et al., 2021), the stress of family of patients over their soul, innermost thoughts/feelings, and actions with schizophrenia (Utama et al., 2020), depression level (Dwidiyanti et al., 2019; Munif et al., 2019). In other words, in older people at nursing homes (Arini et al., 2019), and it is comprehensive self-knowledge and self-awareness depression among patients in a psychiatric hospital in that Allah is always watching us at all times, which Indonesia (Asiah et al., 2019). However, these studies only consequently will change our actions, feelings, thoughts, focused on depression for non-students and were and inner states of being to be better. It can also be conducted before the pandemic. described as a mutual awareness, while we are of Allah, The application of Islamic spiritual mindfulness and the and Allah is aware of us (Mindful Muslim Life, 2021). detection of depression among students may not be Islamic spiritual mindfulness exercise consists of six adequate and limited during the COVID-19 pandemic due steps (Dwidiyanti et al., 2019): (1) intention - generating a to the restriction and social distancing. In fact, most desire in the heart with full awareness according to needs students are studying from home, and the teachers are prayed to Allah accompanied by the belief of unable to monitor. Therefore, the researchers in this study Muroqobahtullah (the belief of feeling supervised by Allah), developed an innovative application called DAHAGA (2) self-evaluation - self-introspection by acknowledging (Deteksi Sehat Bahagia/Happy Healthy Detection), an shortcomings and accepting without judgment of oneself Islamic spiritual mindfulness app, to prevent or reduce and generating a desire to correct mistakes, (3) body scan depression among students. As the application has not yet - realizing every mistake made and believing that Allah is been studied, this study aimed to determine the effect of Most Forgiving by fulfilling the conditions of repentance. DAHAGA on reducing depression among nursing students. The conditions for repentance are to create a sense of
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220 Dwidiyanti, M., Munif, B., Santoso, A., Rahmawati, A. M., & Prasetya, R. L. (2021) regret, stop and be determined not to repeat the sins that that focus on Islamic spiritual mindfulness intervention. have been committed, and fulfill the rights of others who This application offers features that make it easier for have been hurt, such as apologizing, (4) repentance - individuals to self-detect depression they experienced. focusing on feeling the reactions of the heart and body, These features are developed based on the experts’ such as pounding, heat in the chest, heaviness in the neck, agreement through a series of workshop meetings. A etc., and accept these reactions with complete acceptance patent for the DAHAGA app has also been granted by the and relaxation, (5) prayer - praying to God solemnly then Director General of Intellectual Property, Ministry of Law blowing it into the palm and washing it on the organs of the and Human Rights, Indonesia (Grant Number: body that feel hurt or pain, (6) surrender – giving (oneself) EC00202114477). The following are the features of the up to Allah with sincerity to get benefit and prevent harm, “DAHAGA” application (Figure 1 and Table 1): and (7) relaxation - holding the body that hurts or pain, take a deep breath, and then cough (Dwidiyanti et al., 2019).
Methods
Study Design This study used a quasi-experimental design with a comparison group pretest/posttest design. The study was conducted from May to June 2020.
Participants The participants in this study are 148 bachelor nursing students (semesters one to eight) at the Faculty of Medicine, Diponegoro University, Indonesia. The number of participants in this study was calculated using G*Power 3.1 (Faul et al., 2009) with type of a priori power analysis for independent t-test, with Effect Size (ES) value of > 0.80
(Munif et al., 2019), power of 0.95, and error probability ratio of 0.05. The total samples needed were 70, with 35 Figure 1 Homepage of DAHAGA App assigned in an experimental group and a comparison group. Random sampling could not be used in this study because the students would be selected if they fit inclusion criteria, especially the students who experienced mild depression as indicated using Beck Depression Inventory- II (BDI-II), held Islamic religion, and agreed to participate. So, we conveniently examined the students one by one, and those who had depression were asked to join the study until the required samples in each group were fulfilled.
Instrument The Beck Depression Inventory-II (BDI-II) (Beck et al., 1996) was used for data collection. The inventory consists of 21 questions. The Indonesian version of the BDI-II was available (Sorayah, 2018) and considered valid and reliable using a confirmatory factor analysis (CFA). Each answer is scored on a scale value of 0 to 3. Higher total scores indicate more severe depressive symptoms. The standardized cutoffs used differ from the original: 0–13 (minimal depression), 14–19 (mild depression), 20–28 Figure 2 Features of DAHAGA App (moderate depression), 29–63 (severe depression) (Sorayah, 2018). The explanation of each feature is described in the following. Intervention 1. The Problem Feature (or Masalah) is a means to The experimental group in this study was given spiritual make it easier for someone to detect problems that training using DAHAGA. DAHAGA was an android-based they had with their closest people (family members, application that contained mental health service packages such as father, mother, brother, sister, husband,
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221 Dwidiyanti, M., Munif, B., Santoso, A., Rahmawati, A. M., & Prasetya, R. L. (2021) wife, and others), other people (e.g., neighbors, always being grateful and realizing Allah’s grace, friends at home or work, and others), and the and (10) being more open-minded and not quickly environment (Dwidiyanti et al., 2019). The problem getting angry. databases in this feature were validated by the 5. Pretest Feature is to detect depression before the participants of the workshops organized three intervention using the Beck Depression Inventory-II times, related to the environmental problems that (BDI-II) (Beck et al., 1996; Sorayah, 2018). were too broad and had to be more specific. 6. Pretest Feature is to detect depression after 2. The Bad Behavior Feature (or Perilaku Buruk) was intervention using the Beck Depression Inventory-II developed based on a focus group discussion with (BDI-II) (Beck et al., 1996; Sorayah, 2018). 20 participants. They wrote any bad behaviors on 7. Islamic Spiritual Mindfulness (or Latihan their books which were then collected and Mindfulness Spiritual Islam) contains a step-by-step analyzed. This feature contained 13 items of bad tutorial / Standard Operating Procedure (SOP) on behaviors, which were validated by the participants Islamic spiritual mindfulness that had been of the workshops organized three times. These bad previously identified by the researchers. In the SOP, behaviors were used as a reference for the individuals would be invited to consciously independent health targets that should be carried accept the bad behaviors that had been done and out. The validation was related to the behaviors try to correct them through independent health concerning ritual implementation, which need to be targets that would be performed. This feature was simplified and not too detailed. packaged in an audio form that could be listened to This feature is to identify how far the users can by participants. This mindfulness exercise remember and admit (in a mindful state) previous contained six steps: intention, self-evaluation, body bad behaviors they have done. The 13 items include scan, repentance, prayer, surrender, and (1) rarely have five times of prayer, (2) seldom read relaxation. The steps are explained in the Qur’an, (3) rarely Dua (a prayer of invocation), (4) background (overview of Islamic spiritual think negatively, (5) jealous, (6) arrogant, (7) Riya mindfulness). The procedure can be done between (show-off), (8) hurt others, (9) vindictive, (10) lie, 10 to 15 minutes. (11) dirty talk, (12) immoral behavior, and (13) 8. Information Feature (or Informasi Aplikasi) fornication (eye, mind, and physical). contains information related to the app, developers, 3. Self-Detection Feature (or Deteksi Diri) contains and contents. seven items of feelings currently expressed by participants, including angry, broken heart, The comparison group was given a book of Islamic sadness, cough, headache, and hard to breathe. spiritual mindfulness only (Dwidiyanti et al., 2019) (see These items were validated by the participants of Figure 3). There was no spiritual training provided; only workshops organized three times. After the data after the whole process of study was completed, the related to problems, bad behaviors, and self- researchers offered them the same treatments as done in detections were identified, the results were then the experimental group. used to identify factors causing depression. Validation was carried out using real pictures to determine the expression of the problems faced. 4. Independent Health Target Feature (or Target Sehat Mandiri) contains ten items about independent health targets that participants planned to change for improvement. These items were validated by the participants of workshops organized three times. This feature serves as a solution that the participants would achieve after identifying problems, bad behavior, and self- detection. During the validation, several targets were removed as they were confusing and did not relate to the issues that the participants were experiencing. The ten items include (1) forgiving everyone who hurts or disappoints, (2) praying on time and in a congregation, (3) reading Qur’an every day, (4) drawing closer to Allah and always prays or participates in Islamic studies, (5) understanding
yourself and others, (6) being more patient and sincere, (7) learning to smile, at least a day to Figure 3 Islamic spiritual mindfulness book cover twenty people you meet, (8) thinking positively, (9)
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222 Dwidiyanti, M., Munif, B., Santoso, A., Rahmawati, A. M., & Prasetya, R. L. (2021) Data Collection paired t-test and independent t-test were used to determine The data collection was performed using a website linked the effect of the intervention on depression in each group to the “DAHAGA” application for screening. The data were and compare its impact between the experiment and collected in a nursing college with the help of two research comparison groups. The significance level is set at 0.05. assistants. The researchers ensured that the research assistants had been given training for the procedures of the Ethical Consideration data collection. Their jobs were to facilitate the participants This study received ethical clearance from the Health in filling out and using the “DAHAGA” application in the Research Ethics Committee of the Department of Nursing, WhatsApp group. Each participant in the experimental Faculty of Medicine, Diponegoro University, with a group was asked to do a pretest before applying each reference number of 99/EC/KEPK/D.Kep/IV/2020. The feature of Islamic spiritual mindfulness in the app. The researchers also ensured that each student had signed a participants were asked to do the mindfulness exercise six written informed consent prior to data collection. Each has times and then followed by a posttest. All data were a right to withdraw from the study at any time without recorded automatically in the app and could be accessed penalty. Confidentiality of the data was also ensured. by the researchers and admin only. In the comparison group, the pretest and posttest were conducted online using Google Forms. The research Results assistants also helped them via WhatsApp. After practicing mindfulness according to the book, the participants were Seventy participants were able to join and no one asked to do a posttest. withdrawn from the study. The majority of them were aged 18-22 years old and included in the category of early Data Analysis adulthood (Hurlock, 2009). The difference in depression Data were analyzed using descriptive statistics and levels among students can be seen in Table 1. bivariate analysis. As data were normally distributed,
Table 1 Difference in the level of depression among students in the intervention and comparison groups (N = 70)
Group Depression Mean p-value a Pretest Posttest Difference Mean±SD Mean ±SD Experiment (n=35) 17.20±4.94 11.49±4.49 4.28 <0.001a Comparison (n=35) 16.49±4.11 16.34±4.92 1.80 0.861a p-value b 0.513 b <0.001b aPaired t-test | bIndependent t-test
Based on the results of the paired t-test as shown in Table independent t-test analysis, which shows a significant 1, it could be concluded that there was a significant effect difference in depression level after interventions between of DAHAGA on the level of depression in the experimental the experimental and comparison groups. However, the group, seen from a significant difference in the depression findings of this study support previous research (Asiah et level before and after the intervention (p <0.001). In al., 2019) that Islamic spiritual mindfulness intervention is contrast, there was no significant difference in the level of effective not only for patients with depression who are depression in the comparison group before and after the admitted to a psychiatric hospital but also for nursing intervention (p = 0.861). This result is also supported by students, as indicated in our study. the statistical result of the independent t-test, which An innovative intervention created in this study using revealed a significant difference in depression level the DAHAGA application helps the students identify between the experimental group and the comparison problems that they have or the environment quickly group after the intervention with a p-value of <0.001. This through the detection feature. However, identifying the finding indicates that the Islamic spiritual mindfulness problems is essential for the prevention of mental disorders combined with other features in the innovative app (Videbeck, 2008). The app also helps detect the bad effectively reduces depression levels among students. behavior and independent healthy target plans (Dwidiyanti et al., 2019), which consequently awareness among the Discussion students will be increased, and they could cope with their problems independently and prevent mental disorders,
especially depression. Additionally, the app allows the This study aimed to examine the effect of DAHAGA researchers to monitor and help the condition of the application on reducing depression among nursing students, which is considered the benefit of the app. In students. The results revealed a significant effect of the contrast, the use of the Islamic spiritual mindfulness book app on depression level in the experimental group seen alone was not effective in reducing depression levels from the dependent t-test analysis and confirmed by the
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223 Dwidiyanti, M., Munif, B., Santoso, A., Rahmawati, A. M., & Prasetya, R. L. (2021) among students compared to app use, as indicated in this the concepts of Islam, spiritual, and mindfulness merged in study. order to provide holistic nursing care, especially for the Notably, the DAHAGA application is helpful and individuals who hold Islamic religion. practical, especially during the pandemic. Wei et al. (2020) said that the provision of integrated internet-based Limitation of the Study interventions effectively reduced symptoms of stress and We notice two limitations of the study. First, when installing depression related to COVID-19. In this study, the the “DAHAGA” application, some participants experienced DAHAGA application provides eight features: (1) problem, difficulties due to the device restrictions. As a result, there (2) bad behavior, (3) early detection, (4) independent was a time difference in starting the mindfulness exercises health target, (5) pretest, (6) posttest, (7) mindfulness using the application. Further study is recommended to exercises, and (8) information. The problem feature encounter this issue, which the app could be used in any contains questions about the problems faced, while the devices. Second, as the app specifically focuses on bad behavior feature contains questions regarding the individuals who hold Islam; thus, it cannot be used in user’s experiences of the committed behavior. The early others. self-detection element consists of two forms of questions, namely, current feelings and physical conditions. The Conclusion independent health target feature contains target choices/user expectations for independent health. The There was a significant effect of using the DAHAGA- pretest and posttest feature includes questionnaires about Islamic spiritual mindfulness-based app on reducing the depression that should be completed before and after students’ levels of depression. The app can be used to mindfulness exercises. The mindfulness training feature detect and treat depression among college students. Also, contains mindfulness exercise guidelines that aim to help it can be utilized as a part of the intervention in nursing users consciously accept the committed bad behavior and practice. The extended application of the app with non- try to correct it through independent health targets that students and non-Muslims is a necessity to validate the have been planned earlier (Sadipun et al., 2018; Dwidiyanti findings. et al., 2019; Munif et al., 2019). It is noteworthy that Islamic spiritual mindfulness is fully Declaration of Conflicting Interest emphasized in the app. Islamic spiritual mindfulness is an The authors declared that they do not have a conflict of interest, exercise that aims to help individuals aware of their current either individuals or institutions. condition or experience by involving the presence of God (Dwidiyanti et al., 2019). It is also believed that Islamic Funding This study received funding from the Faculty of Medicine, spiritual mindfulness is able to change behaviors and build Universitas Diponegoro, Semarang, Indonesia. positive interpersonal skills through intention and self- evaluation (Dwidiyanti et al., 2019). According to Yapko Acknowledgment (2016), for the healing of depression, a patient should be This work was supported by the Faculty of Medicine, Diponegoro taught about (1) the ability to make effective decisions, (2) University. We also thank the Department of Nursing, Diponegoro effective coping or stress management skills, (3) skills to University, for allowing us to conduct this research. build and maintain positive relationships, (4) problem- solving skills, and (5) building a realistic and motivating Authors’ Contribution All authors contributed equally to the drafting of the manuscript, future. Such abilities are taught at each stage of Islamic revising the manuscript critically for important intellectual content, spiritual mindfulness. The stages of mindfulness include conception, and design of the study, acquisition of data, analysis, the intention and self-evaluation that describe the and/or interpretation of data. All authors approved the final version decisions made effectively concerning the behavior to be of the article. changed. As for coping, stress management in Islamic spiritual mindfulness is taught through seven steps: Data Availability Statement intention, self-evaluation, repentance, body scan, prayer, The research data could not be shared because they were saved surrender, and relaxation (Dwidiyanti et al., 2019). by Diponegoro University’s server. We strictly followed the research ethics to ensure the confidentiality of the data.
Implications of this Study for Nursing Practice Authors’ Biographies Several implications of this study include: First, the findings Dr. Meidiana Dwidiyanti, S.Kp., MSc is a Lecturer of Mental of this study provide evidence to support Islamic spiritual Health Nursing in the Faculty of Medicine, Diponegoro University, mindfulness as a part of nursing intervention among Semarang, Indonesia. She is also the Head of the Postgraduate mental health nurses or psychiatric nurses to reduce Nursing Program at the Nursing Department, Faculty of Medicine, depression in their practice; Second, this study offers a Diponegoro University, Semarang, Indonesia. Ns. Badrul Munif, S.Kep., M.Kep is a Lecturer of Mental Health new and innovative app called DAHAGA, which fit with the Nursing in Nursing Program, Institute of Health Sciences COVID-19 condition today where the utilization of the Banyuwangi, East Java, Indonesia. technology is necessary; Third, the results of the study Agus Santoso, S.Kp., M.Kep is a Lecturer of Nursing provide additional knowledge for nursing science, which Management and Leadership in the Faculty of Medicine,
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Diponegoro University, Semarang, Indonesia. He is also the Head Gonda, X., Fountoulakis, K. N., Kaprinis, G., & Rihmer, Z. (2007). of Degree Nursing Program at the Nursing Department, Faculty of Prediction and prevention of suicide in patients with unipolar Medicine, Diponegoro University, Semarang, Indonesia. depression and anxiety. Annals of General Psychiatry, 6, 23- Ns. Ashri Maulida Rahmawati, S.Kep.,M.Kep is a Student of 23. https://doi.org/10.1186/1744-859X-6-23 Master Program in Nursing, Diponegoro University, Semarang, Graupensperger, S., Benson, A. J., Kilmer, J. R., & Evans, M. B. Indonesia. (2020). Social (un) distancing: Teammate interactions, athletic Ns. Rikhan Luhur Prasetya, S.Kep is a Student of Master identity, and mental health of student-athletes during the Program in Nursing, Diponegoro University, Semarang, COVID-19 pandemic. Journal of Adolescent Health, 67(5), Indonesia. 662-670. https://doi.org/10.1016/j.jadohealth.2020.08.001 Hasanah, U., Fitri, N. L., Supardi, & Livana, P. (2020). Depresi References pada mahasiswa selama masa pandemi COVID-19 Abidah, A., Hidaayatullaah, H. N., Simamora, R. M., Fehabutar, [Depression in students during the COVID-19 pandemic]. D., & Mutakinati, L. (2020). The impact of COVID-19 to Jurnal Keperawatan Jiwa, 8(4), 421-424. Indonesian education and its relation to the philosophy of Hurlock, E. B. (2009). Psikologi perkembangan: Suatu “Merdeka Belajar”. Studies in Philosophy of Science and perkembangan sepanjang rentan kehidupan [Developmental Education, 1(1), 38-49. https://doi.org/10.46627/sipose.v1i1.9 psychology: A development throughout the life]. Jakarta: Acharya, L., Jin, L., & Collins, W. (2018). College life is stressful Erlangga. today–Emerging stressors and depressive symptoms in Manik, M. J., Natalia, S., & Theresia, T. (2021). Social stigma college students. Journal of American College Health, 66(7), towards nurses taking care of patients with COVID-19 in 655-664. https://doi.org/10.1080/07448481.2018.1451869 Indonesia: A mixed-methods study. Belitung Nursing Journal, Ardinata, Aminudin, N., Dwidiyanti, M., Cider, S. P., Rizki, F., 7(2), 98-106. https://doi.org/10.33546/bnj.1322 Andika, T. H., . . . Point, S. (2021). The effect of Islamic Mindful Muslim Life. (2021). Spiritual Mindfulness in the Islamic spiritual mindfulness therapy on the drugs adherence of Context: an Introduction to “Muraqabah”. Retrieved from skizofrenia patients through SI-POS Android application. https://www.mindfulmuslimlife.com/blog/spiritual-mindfulness International Journal of Grid and Distributed Computing, -islamic-context 14(1), 305-312. Munif, B., Poeranto, S., & Utami, Y. W. (2019). Effects of Islamic Ardinata, Dwidiyanti, M., & Sari, S. P. (2019). Kepatuhan minum spiritual mindfulness on stress among nursing students. Nurse obat pasien skizofrenia melalui terapi mindfulness spiritual Media Journal of Nursing, 9(1), 69-77. https://doi.org/ Islam [Medication compliance of patients with schizophrenia 10.14710/nmjn.v9i1.22253 through Islamic spiritual mindfulness therapy]. Jurnal Ilmu Njim, T., Mbanga, C., Mouemba, D., Makebe, H., Toukam, L., Keperawatan Jiwa, 2(2), 79-82. https://doi.org/10.32584/jikj. Kika, B., & Mulango, I. (2020). Determinants of depression v2i2.251 among nursing students in Cameroon: A cross-sectional Arini, Dwidiyanti, M., & Hadi, R. (2019). Effects of Islamic-based analysis. BMC Nursing, 19, 1-6. https://doi.org/10.1186/s129 spiritual mindfulness exercises (Zikr) on depression level 12-020-00424-y among older people at nursing homes in Semarang. (Master Sadang, J. M., & Palompon, D. R. (2021). The development of Thesis), Diponegoro University, Semarang, Indonesia. Need–Threat Internal Resiliency Theory in COVID-19 crisis Asiah, A., Dwidiyanti, M., & Wijayanti, D. Y. (2019). Penurunan utilizing deductive axiomatic approach. Belitung Nursing tingkat depresi pada pasien dengan intervensi minfulness Journal, 7(2), 72-77. https://doi.org/10.33546/bnj.1300 spiritual Islam [A decrease of depression levels in patients Sadipun, D. K., Dwidiyanti, M., & Andriany, M. (2018). Effect of using Islamic spiritual mindfulness intervention]. Jurnal spiritual based mindfulness intervention on emotional control Keperawatan Jiwa, 7(3), 267-274. https://doi.org/10.26714/jkj. in adult patients with pulmonary tuberculosis. Belitung Nursing 7.3.2019.267-274 Journal, 4(2), 226-231. https://doi.org/10.33546/bnj.357 Aslami, E., Alipour, A., Aghayusefi, A., & Najib, F. (2015). Sorayah. (2018). Uji validitas konstruk Beck Depression Assessing the effectiveness of mindfulness-based Islamic– Inventory-II (BDI-II) [Construct validity of Beck Depression spiritual schemas on anxiety of mothers pregnancy and Inventory-II (BDI-II)]. Jurnal Pengukuran Psikologi dan infants physiological health. Quarterly Journal of Health Pendidikan Indonesia, 14(1). https://doi.org/10.15408/jp3i.v4i Psychology, 4(14), 129-140. 1.9259 Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Tung, Y.-J., Lo, K. K. H., Ho, R. C. M., & Tam, W. S. W. (2018). Beck Depression Inventory-II. San Antonio, TX: Psychological Prevalence of depression among nursing students: A Corporation. systematic review and meta-analysis. Nurse Education Chernomas, W. M., & Shapiro, C. (2013). Stress, depression, and Today, 63, 119-129. https://doi.org/10.1016/j.nedt.2018.01. anxiety among undergraduate nursing students. International 009 Journal of Nursing Education Scholarship, 10(1), 255-266. Utama, M., Dwidiyanti, M., & Wijayanti, D. Y. (2020). Penurunan https://doi.org/10.1515/ijnes-2012-0032 tingkat stres keluarga pasien skizofrenia melalui mindfulness Creswell, J. D. (2017). Mindfulness interventions. Annual Review spiritual Islam [Reducing stress level in family members of of Psychology, 68(1), 491-516. https://doi.org/10.1146/ patients with schizophrenia through Islamic spiritual annurev-psych-042716-051139 mindfulness]. Jurnal Keperawatan Jiwa, 8(1), 21-26. Dwidiyanti, M., Fahmi, A. Y., Ningsih, H. E. W., Wiguna, R. I., & https://doi.org/10.26714/jkj.8.1.2020.21-26 Munif, B. (2019). Seni mindfulness spiritual Islam [The arts of Videbeck, S. L. (2008). Psychiatric mental health nursing. Islamic spiritual mindfulness] Semarang: UNDIP Press. Philadelphia: Lippincott Williams & Wilkins. Faul, F., Erdfelder, E., Buchner, A., & Lang, A.-G. (2009). Villani, L., Pastorino, R., Molinari, E., Anelli, F., Ricciardi, W., Statistical power analyses using G* Power 3.1: Tests for Graffigna, G., & Boccia, S. (2021). Impact of the COVID-19 correlation and regression analyses. Behavior Research pandemic on psychological well-being of students in an Italian Methods, 41(4), 1149-1160. https://doi.org/10.3758/BRM.41. university: A web-based cross-sectional survey. Globalization 4.1149
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and Health, 17(1), 1-14. https://doi.org/10.1186/s12992-021- need to know to overcome depression. USA: Yapko 00680-w Publications. Wei, N., Huang, B.-C., Lu, S.-J., Hu, J.-B., Zhou, X.-Y., Hu, C.-C., . . . Wang, Z. (2020). Efficacy of internet-based integrated Cite this article as: Dwidiyanti, M., Munif, B., Santoso, A., intervention on depression and anxiety symptoms in patients Rahmawati, A. M., & Prasetya, R. L. (2021). DAHAGA: An with COVID-19. Journal of Zhejiang University. Science. B, Islamic spiritual mindfulness-based application to reduce 21(5), 400-404. https://doi.org/10.1631/jzus.B2010013 depression among nursing students during the COVID-19 WHO. (2020). Coronavirus disease (COVID-2019) situation pandemic. Belitung Nursing Journal, 7(3), 219-226 reports. Retrieved from https://www.who.int/emergencies/ https://doi.org/10.33546/bnj.1494 diseases/novel-coronavirus-2019/situation-reports/ Yapko, M. D. (2016). Keys to unlocking depression: An internationally known depression expert tells you what you
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Belitung Nursing Journal “Accessibility”: A new narrative of Volume 7(3), 227-234 © The Author(s) 2021 https://doi.org/10.33546/bnj.1409 healthcare services for people living with HIV in the capital city of Indonesia
Mahathir1* , Wiwin Wiarsih2 , and Henny Permatasari2
Abstract Background: The progress of the fight against HIV is highlighted by significant change. HIV of the past is different from HIV of the present. Healthcare services have played an essential role in achieving the optimal goals needed to end the HIV epidemic. However, people living with HIV and those at risk of catching it (PLWH) often misunderstand the rapid growth of HIV healthcare service options. Objective: This study aimed to explore the experiences of PLWH in the healthcare services featured in this study. Methods: A qualitative phenomenological approach was used. Semi-structured interviews were conducted in 2017 with 12 PLWH who engaged with healthcare services in Jakarta, Indonesia, by using a purposive sampling technique. Semi-structured questions were asked which related to their experiences of using the services. Stevick Colaizzi Keen method was used to extract the thematic analysis of the study. Results: The study developed four essential themes of PLWH healthcare use. They were accessibility, availability at all healthcare levels, comprehensiveness of service, and affordability. Conclusion: Providing accessible healthcare services is considered essential by PLWH. It is also pivotal to helping people feel positive about the community-related healthcare services on offer. Nurse-led HIV services must maintain this progress by continuously evaluating the quality-of-service outcomes and promoting the accessibility of the services to the broader population.
Keywords HIV infections; health services; patient acceptance of healthcare; nursing; Indonesia
United Nations Sustainable Development Goals demand Human Services, 2020). Global efforts have been made to sufficient progress in ending the epidemic of AIDS and also reduce this, although the progress is not sufficient. The achieving universal health coverage by providing qualified number of people who have tested positive for HIV may be essential healthcare services (United Nations, 2016). It is reducing globally, but this reduction is not significant vital to establish quality HIV services that offer people- enough, and prevention strategies and programs still need centered, safe, acceptable, appropriate, effective, and encouragement. There is a significant gap between actual efficient care for PLWH (World Health Organization, achievement and the 2020 target. Whereas the target was 2019a). PLWH should be engaged in a qualified diagnostic to bring the number of deaths down to 500,000, it currently and treatment of healthcare services (World Health stands at 770,000. Furthermore, the target for the number Organization, 2016) and must be treated with Antiretroviral of patients acquiring HIV was 500,000, but in 2018 1.7 Therapy (ART) (World Health Organization, 2020). million people became infected (World Health In 2019, a total of 37.9 million people around the world Organization, 2019b). This is why HIV prevention programs was living with HIV and AIDS (US Department of Health & continue to be encouraged.
1 Faculty of Nursing, Universitas Andalas, Indonesia Article Info: 2 Faculty of Nursing, Universitas Indonesia, Indonesia Received: 13 March 2021 Revised: 12 April 2021 Accepted: 22 June 2021 Corresponding author: Ns. Mahathir, M.Kep., Sp.Kep.Kom This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which allows Faculty of Nursing, Universitas Andalas others to remix, tweak, and build upon the work non-commercially as long as Jl. Kampus Unand Limau Manis Fakultas Keperawatan Pauh the original work is properly cited. The new creations are not necessarily Padang Sumatra Barat, Indonesia licensed under the identical terms.
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Patient experience and satisfaction are important to modest. The escalation of stakeholders’ contribution is achieve better health outcomes (Leon et al., 2019). It is urgent and includes the public health service (Mesquita et notably well-known that better healthcare services for al., 2007). The accessibility of healthcare services has to PLWH will improve patients retention with healthcare overcome a number of barriers. Stigmatization among services, maintain patients' adherence to ART, and healthcare is often high (Risal et al., 2018). It is recognized ultimately reduce the HIV viral load (Dang et al., 2013). as a predictor of discriminatory attitudes towards PLWH Discontinuation of healthcare engagement and ART who engage in healthcare facilities (Harapan et al., 2013). adherence will have adverse HIV consequences and Indonesia also experiences the policy and practice increase a major public health problem (Pérez-Salgado et implementation disjunction that will initiate the al., 2015; Anh & Thaweesit, 2019). ART non-adherence will discrimination of treatment and care (Fauk et al., 2019). As contribute to the failure of the immune systems of PLWH. a result, PLWH encounters difficulties in engaging It will also lead to an opportunistic infection that threatens healthcare access; it is also hard for them to adapt to their the quality of life, and in the worst-case, lead to mortality chronic disease (Senyurek et al., 2021). (Johnson et al., 2017). ART is the key to suppressing the Nurses play a major role in the eradication of HIV, viral load in the bloodstream, which is important to providing optimal services starting from preventing prevention strategies. It is well known that viral suppression transmission to promoting the health and well-being of will reduce the risk of passing the infection to others PLWH (Gilks, 2019). Nurses achieve this by implementing (Siedner & Triant, 2019). friendly and approachable services within health services. The dream of an HIV-free world is facing critical gaps Nurses make mutual collaborations with the population and and barriers, including the optimization of healthcare ensure the continuity of care being provided. Nurses services. Healthcare services sometimes have the circulate the information about HIV healthcare services limitations of poor performance and unequal treatments available to the people and seek to improve the quality and (Keller et al., 2014). Program collaboration and service accessibility of these services. Advocating comprehensive integration are now considered vital to health departments delivery must be empowered by nurse-led HIV services to to ensure a comprehensive approach, but this requires bring forth patient-centered care for PLWH (Rouleau et al., inter-sectional understanding (Bernard et al., 2016). 2019). Stigma also adds challenge to improving the accessibility Services for the wider population and PLWH are now of healthcare. Stigma disparaging is the equal access of all broad and advanced. It can be accessed on both a static to receive appropriate services at all levels and basis and a mobile one. The look of healthcare services is circumstances (Moradi et al., 2014). changing hand in hand with the efforts to move forward. Within the ecological and policy factors influencing HIV Implementation faces financial obstacles and the healthcare engagement, the availability of surveillance, progressive needs of the population. This is regarded as testing, prevention, medical and supportive services are the key to widening the outreach of healthcare services crucial. Access within minimal distance, clinic culture, (Falkenberry et al., 2018). HIV service delivery is now medical home, and the availability of appointments also shifting from one size fits for all approach. It will lead to further and better performances and increased accommodate comprehensive delivery across the retention of services (Mugavero et al., 2011). Negative prevention and care continuum through differentiated care experiences between the healthcare providers and at-risk (UNAIDS, 2018). HIV care continuum of HIV has been population sometimes detriments their relationship. The recognized as a progression from serotesting, medical and feeling of awkward interaction, irrelevant questions, healthcare engagement, ART treatment and adherence to blaming, pettiness, poor support, and confidentiality the ultimate goal that is viral suppression (Kay et al., 2016). breaches were often experienced by patients during their The rapid shifting and continual efforts shall be followed by treatments (Stutterheim et al., 2014). progressive evaluation from all perspectives. This study In 2018, Indonesia had a total of 640,000 PLWH; aimed to evaluate the experiences of PLWH who engaged 38,000 among them had died from HIV and AIDS-related with HIV healthcare services in Jakarta, Indonesia. illnesses, 46.000 people were newly infected in that year. Only 51% of the suspected population knew their status, Methods and 17% of them living with HIV were receiving treatment (UNAIDS, 2018). Obviously, the number is very far from the Study Design target and needs intensive attention to improve This research used a qualitative phenomenological achievement. Jakarta and parts of West Java, as one of the method. It describes the phenomena of progressive megalopolis cities in Indonesia, endure significant numbers change within HIV healthcare services. Phenomenology is of PLWH. Jakarta and West Java are both included in the a type of qualitative research that focuses on the top five most popular provinces that contained people who individual’s lived experiences within a specific live with HIV. In 2017, Jakarta itself had around 6,626 phenomenon (Creswell, 2013). This method was used to people who tested HIV positive (Ministry of Health of interpret the experience of the HIV healthcare use from the Indonesia, 2018). service user’s perspective. This study explores the Indonesia’s response to the HIV epidemic is considered experiences of PLWH who used healthcare services in
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Jakarta, Indonesia. Appropriate conditions help lead so far?” Then, based on the participant’s answer, the towards the successful achievement of objectives (Smith, interviewer asked a followed-up question such as “Would 2018). you please describe to me what do you mean by easily accessed?” or “What do you mean by it was different from Participants what you have ever expected? Could you please elaborate Participants in the study were PLWH who used HIV on what more you expected?”. Other follow-up questions healthcare services in Jakarta, Indonesia. Purposive were asked until the data was confirmed and verified. The sampling is very commonly used in qualitative research. interviews lasted between 45-60 minutes. The oral data Purposive sampling allows the qualitative researcher to were recorded through secure tape-recording, and any choose the participants and their characteristics for the non-verbal communication data observed were study. It is essential for phenomenological study to documented in field notes. Data were stored securely accommodate participants who have experienced the topic within a confidential folder on the computer. The recording of the research question. Furthermore, it will ensure the results were then written as a transcript in verbatim form quality of the information provided by the research and combined with the results of the field notes. participants. Therefore, the criteria of participants in this study were PLWH who have engaged with HIV healthcare Data Analysis services and willing to share their experiences. The stages of the data analysis process in this study used The number of participants was determined by the Stevick Colaizzi Keen method (Speziale et al., 2011) by reviewing available information and data saturation. arranging the information of the interviews and transcribing Participants were recruited and selected through a the recordings into verbatim form. The data script was designated HIV non-government organization around the repetitively listened to and read to ensure the accuracy of city. This study evaluates the data collected from twelve significant information. Participant statements were participants. Saturation was achieved when no other bits of marked to point out the important information relating to the new information or issues emerged. Participants in this objectives of the study. Finally, themes were formulated by study were PLWH, who used HIV healthcare services, identifying the important information, classifying it into data such as voluntary counseling, mother-to-child transmission groups, and categorizing themes and sub-themes. programs, and methadone maintenance therapy clinics within hospitals, public health services, and prison clinics. Trustworthiness/Rigor The researchers ensured the trustworthiness of the data Data Collection and results by comparing the results with other research This study was conducted in two non-government and ensuring the participants provided trustworthy organizations (NGOs) in Jakarta, Indonesia, which provide information. Environment familiarity was also confirmed by social support and engagement for PLWH during their life holding pre-interview meetings and advance contact with with the disease. Jakarta has 38 active NGOs and all participants. The researcher also discussed the results foundations in handling HIV/AIDS issues. The two NGOs with fellow researchers and supervisors (WW and HPS) provided the list of participants who matched the study with upper-level degrees of education and expertise. inclusion criteria. The selection of participants for the The transferability of the data was conducted by research was based on the types of HIV healthcare ensuring that other groups of participants fully understood services used by the PLWH, as it was expected to enrich the research results. The findings have been read by the data collected. The researcher made an appointment PLWH, who were not participants in the study but still fit the with the participant before the interviews were conducted inclusion criteria. This study also surveyed a variety of to develop emerging environmental situations and build participants. The reliability of the data is dependent on the trust. They then set the appointment to carry out the saturation of the participant’s information by preparing interviews. The study was conducted between July 2016 to questions that provide accurate answers based on the January 2017. The study collated the data and information topic or issue of the study. This study also used repeat through semi-structured interviews. Two experts questions with an expectation of the same response to independently authenticated the interviews. All interviews clarify and maintain the trustworthiness of the information were conducted by one person (MH). The other provided by the participants. Data and results were also supervisors (WW and HPS) contributed to data analysis presented back to the participants who were involved. The and validated the trustworthiness of the research. The researchers then showed the principles of the results of the interviews were conducted in the Indonesian language and research documentation and findings to participants who then translated by MH to the English language after data engaged in the research. analysis. The interviews were conducted by questioning the Ethical Considerations participants through trigger questions and follow-up All activities within this research are strictly compliant with questions based on the initial responses. The first question the relevant ethical guidelines and considerations. in the questionnaire was, “Could you please tell me how Ensuring that no one was at risk of harm or experiencing has your experience in using HIV healthcare services been negative impacts from the research activities conducted
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229 Mahathir., Wiarsih, W., & Permatasari, H. (2021) was crucial. By providing autonomy, beneficence, non- the HIV healthcare facility. His statement is documented maleficence, confidentiality, and justice, this study was below: committed to protecting the participants involved. This study was reviewed by the Universitas Indonesia Ethical “Actually, there was no obstacle in order to reach out the Council Committee and declared as ethically feasible to be facility, and the hospital was really nearby! The only problem I conducted with ethical clearance number 0272/UN2. have is to provide a specific time to go. We didn't have to be F12.D/HKP.02.04/2015. worried; it is no big deal.” (P5)
The other participant said the same thing; he said that the Results healthcare facilities are near his home. He also said that the facility could be reached while attending another Characteristics of the Participants activity. Along with fitting facial expressions, the participant There were 12 participants in this study who were PLWH stated the following: that used healthcare services in Jakarta, Indonesia. The 12 participants participated voluntarily in semi-structured “No, the public health center where I ran for regularly interviews conducted during the research process. All healthcare services was really close by. I can reach the place participants acknowledged their HIV-positive status, were while I was going somewhere else. But the waiting was still open to being involved in the study, and cooperatively taking some time.” (P3) answered the questions during the interview. In addition, participants did not express objection or unwillingness to Participants said that easy access to healthcare facilities provide answers to any of the questions. The quoted text was linked to the availability of transportation that they in this study was originally in Bahasa Indonesia and could use. There were so many transport choices in order translated to English to fulfill journal requirements. The to reach the services. Following is the relevant participant's characteristic of the participants is displayed in Table 1 statement: below. "... the access was not too difficult for sure, it was easy! Lots Table 1 Participants’ Characteristics of vehicles and public transportation to use." (P1)
Participant Age Education Year of Risk Theme 2: Available at all healthcare levels Code Status Population Six participants felt that the healthcare services are now P1 29 High School 2005 PWID available in all levels of healthcare facilities, from a primary P2 30 Elementary 2006 PWID level to a tertiary one. Participants recognized that the P3 2008 Heterosexual 31 Junior High facilities are part of government efforts to broaden the Male range of available services. Two participants summarized P4 32 Junior High 2008 PWID their experience as the following: P5 34 High School 2008 Prisoner
P6 34 High School 2008 PWID P7 34 High School 2010 Prisoner “It depends on me, where do I want to go, which hospital do I P8 2010 Heterosexual prefer. It’s completely up to me, even though I heard I could 34 Bachelor choose from the services in public health centers around me. Female P9 39 High School 2010 PWID There are so many facilities that I acknowledged, and I chose P10 41 Bachelor 2014 PWID the hospital because I did not want to be recognized.” (P5)
P11 22 High School 2016 MSM P12 31 Diploma 2016 MSM “Surprisingly, at first, I thought it only could be done at the hospital far from my house. But my peer navigator enlightened Note: PWID= People Who Inject Drugs | MSM=Men Who Have Sex with Men me it could also be done in the public health center near my house. It helps me a lot, you know.” (P12) Themes The study developed four significant themes such as Theme 3: Comprehensiveness of service accessibility, availability at all healthcare levels, Participants are fully aware of their risk behaviors. It comprehensiveness of service, and affordability. Each pushed them to start engaging with the healthcare services. Participants get sufficient knowledge and theme is explained in the following. information from the facility, then complete serostatus Theme 1: Accessibility checking and obtain the test results before starting ART Almost all participants stated that they had easy access to and other behavioral therapy all in one place. Most a healthcare facility. According to the participant's participants admitted that all of the services for HIV care they experienced were simply done in one place. One statement, the accessibility of the healthcare facility was determined by the proximity of the HIV healthcare facility participant stated that he felt relieved because the processes were comprehensively all in one place and and the transportation facilities to help them reach it. One of the participants stated that he had no complaints about helped fulfill all needs. Fluently speaking with a heavy tone, the participant expressed the following:
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“I am fully satisfied with all of the services, which began with among the PLWH. A study in Malawi found the ART the registration., I can choose whatever name I want to respect retention increased, and the possibility of loss during my secrecy. They collected me with the others in a room and follow-up decreased. The range of healthcare facilities on told us information related to HIV before asking us to express offer influenced PLWH’s decision to maintain engagement our feelings before getting the test. Some people were crying with healthcare. It also improved annual visits in ART at the time, but I felt so comforted by the manner of the facilitators. I admired that. Then when I tested positive, they enrollment. Distance to travel was recognized as an recommended me to start the ART. They looked after me obstacle for PLWH (Bilinski et al., 2017). Further distance when I disclosed my status. That was a big moment of my life, between the healthcare facility and the patient will increase really.” (P11) the cost for PLWH, who had a lower socioeconomic status (World Health Organization et al., 2013). The other participant felt the same thing with all the The distance to travel for the affected population in rural services provided by the healthcare facility. She areas was also proven to increase transmission probability. experienced all the procedures she needed to in one place Viral suppression is the key to slow HIV transmission. Viral and only needed to think of her feelings at that time. With a load suppression will never be achieved if ART compliance calm tone and soft smile, she spoke as follows: could not be obtained. ART compliance requires routine access to reliable and available facilities. The need to travel “…then they brought me to VCT. I was interviewed by the farther will reduce the likelihood of ART enrollment (Smith nurse, and he told me about HIV. I also ran the test there. et al., 2017). The longer the distance to healthcare When I came back, the doctor announced the result; I am facilities, the lower retention in care and viral suppression positive. They counseled me when I reacted and checked how (Terzian et al., 2018). The longer distance is also regarded I was feeling, and then we planned the ART. They allowed me to ask as many questions and discuss as many things as I as a barrier for healthcare service use (Tafuma et al., wanted to.” (P8) 2018). The availability of healthcare services within all levels Theme 4: Affordability of healthcare facilities is considered an advantage. All-level Five participants stated that most of the HIV healthcare facilities will broaden the range of healthcare services services they accessed were free of charge, but some available to the population. Decentralization of HIV specific services still cost them. For participants who had services and facilities will also expand the range that HIV limited financial income, it sometimes increased their services can reach. A study of decentralization of HIV financial challenges. One participant said that the services healthcare services experienced by the rural communities cost him little but still caused a burden on his financial in Canada concluded that the PLWH prefers the services situation: to expand to all clinics and public health centers. It provides them with a friendly and well-known environment “Most of the services were free; I don't pay that much, only for (Cunningham et al., 2014). It is also cost-effective and the administration. I guess it might be for doctor service only. reduces threats (Kolawole et al., 2017). A study from When I don't have any money, sometimes this fee was Yogyakarta, Indonesia, mentioned that the availability of uncomfortable and hard to take.” (P1) services keeps the process simple and is convenient to the healthcare environments. The transgender women in this The other participant stated that the affordability was study recognized the positive attitudes of the healthcare convenient. The funding system did not burden him professionals and friendly social relationships on both because it was just a small amount to cover. Compared to sides (Fauk et al., 2019). what he was getting, he felt it was quite cheap. With a Expanding ART services delivery helps to achieve the confident tone, he said as follows: desired outcomes of HIV eradication in low and middle- income countries. The expansion of healthcare facilities “It was free, I guess, but there were some specific services for increases the potential of retention and decreases the which I should pay, but that was okay; I think that was normal. mortality rate (Haghighat et al., 2019). The expansion of At first, I thought it would be expensive, but it was mostly free. I feel grateful. (P10) primary healthcare facilities for HIV services is also associated with the reduction of loss in follow-up and fulfills Discussion the gap of incomprehensive healthcare services (Cunningham et al., 2014). Comprehensive care is not
merely one type of essential service at a time. It covers all The themes indicated that there is a significant growth in needs and is patient-centered, i.e., the provision of test HIV services. Easy access to the facilities mirrors the results must be followed by emotional support. A primary success of the healthcare system to provide accessible setting has much more time to deliver good services, and and quality healthcare facilities for PLWH. A study of this increases patient satisfaction. The satisfaction is also factors associated with access to HIV healthcare services linked to the attitude from reception, waiting times, HIV stated that HIV-positive patients preferred the nearest education, and the comfortability of the service from place in order to more easily engage with services (Lubogo healthcare professionals. Satisfaction of PLWH also varies et al., 2015). with the extent of the facilities (Odeny et al., 2013). Distance to care will determine the ART compliance
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Delivering comprehensive healthcare services for the Declaration of Conflicting Interest PLWH will optimize the healthcare continuum. It is well There is no conflict of interest in this study. known that comprehensive health services will evidence Funding the strengths of HIV healthcare services. The Self-funding. comprehensive services also increase patient enrolment and retention (Wroe et al., 2018). Comprehensive care also Acknowledgment boosts the reduction of HIV transmission in the community. Gratitude appreciation to Faculty of Nursing Universitas Andalas Healthcare services focus on prevention and education. and Faculty of Nursing Universitas Indonesia for facilitating and The preventive service scale up the HIV negative and supporting the research. unknown status to check their serostatus (Subramanian et al., 2019). Authors’ Contribution Comprehensive healthcare services for PLWH will MM contributed to developing the research, collecting and analyzing data, presenting results, and drafting the manuscript. optimize the coordination and communication between WW and HP contributed to the study concept and design, data healthcare services. Comprehensive services will unify the analysis, and manuscript development. All authors agreed with the strategies into efficient and effective actions (Watts et al., final version of the article. 2019). Comprehensive healthcare services lead to universal access to ART, improving patient-centered care, Data Availability Statement and scale up the baseline of HIV testing among the All data generated or analyzed during this study are included in population at risk and PLWH (Havlir et al., 2019). this published article.
The affordable cost of engaging healthcare services is Authors’ Biographies helping PLWH to deal with their catastrophic life-changing Ns. Mahathir, M.Kep., Sp.Kep.Kom is a Junior Lecturer at the condition. Low-cost access is believed to be the gateway Faculty of Nursing, Universitas Andalas, Indonesia. He is currently to universal access for all of the population affected by HIV. focusing on community health nursing, HIV and adolescent health Providing universal access will increase the impacts of HIV research. eradication efforts (Hill & Pozniak, 2016). Providing ART to Wiwin Wiarsih, S.Kp., MN is an Assistant Professor at the Faculty all PLWH is mandatory for low and middle-income of Nursing, Universitas Indonesia, Indonesia. She is currently countries to achieve clinical prevention and programmatic active in community health nursing development in Indonesia. Dr. Henny Permata Sari, M.Kep., Sp.Kep.Kom is an Associate benefit for all (Ford et al., 2018). The limitation of the study Professor at the Faculty of Nursing, Universitas Indonesia, found some participants were not able to express the Indonesia. She is currently making her research dedication in qualitative narration of their experience. It required the community health nursing and occupational health. communication competency of semi-structured interviews. It was also found that there is no scoring system in References validating the semi-structured questions. The importance Anh, L. H. T., & Thaweesit, S. (2019). Factors associated with of exploring more about HIV healthcare services literacy hepatitis B and C co-infection among people living with human among PLWH is crucial. immunodeficiency virus. Belitung Nursing Journal, 5(4), 147- 154. https://doi.org/10.33546/bnj.813 The implication of this study can be seen that PLWH Bernard, S., Tailor, A., Jones, P., & Alexander, D. E. (2016). get fairly easy access to HIV healthcare services in urban Addressing the medical and support service needs of people and metropolitan settings. In fact, the healthcare services living with HIV (PLWH) through program collaboration and are now reaching the primary level and easier to access service integration (PCSI). Californian Journal of Health with good links to public transport. Equitable distribution of Promotion, 14(1), 1-14. https://doi.org/10.32398/cjhp.v14i1. health services in urban and big cities shall be implemented 1860 in suburban areas, especially in concentrated epidemics by Bilinski, A., Birru, E., Peckarsky, M., Herce, M., Kalanga, N., the government and policymakers. This study showed that Neumann, C., . . . McBain, R. (2017). Distance to care, enrollment and loss to follow-up of HIV patients during the role of nursing is crucial in circulating the information of decentralization of antiretroviral therapy in Neno District, the availability of services to those PLWH. Malawi: A retrospective cohort study. Plos One, 12(10), e0185699. https://doi.org/10.1371/journal.pone.0185699 Conclusion Creswell, J. W. (2013). Qualitative inquiry and research design: Choosing among five approaches (3rd ed.). Thousand Oaks, CA: SAGE. HIV healthcare services are growing stronger and Cunningham, C. O., Buck, J., Shaw, F. M., Spiegel, L. S., Heo, M., continuing to progress. The old paradigm of HIV being & Agins, B. D. (2014). Factors associated with returning to HIV nothing but a death sentence is fading away. Precise and care after a gap in care in New York State. Journal of Acquired accurate information is increasingly being provided to all Immune Deficiency Syndromes, 66(4), 419-427. https://doi. sectors, communities, and individuals. Healthcare org/10.1097/QAI.0000000000000171 providers and HIV activists are recommended to promote Dang, B. N., Westbrook, R. A., Black, W. C., Rodriguez-Barradas, and campaign about the new perspective of accessibility: M. C., & Giordano, T. P. (2013). Examining the link between patient satisfaction and adherence to HIV care: A structural reduced travel to facilities and less financial hardship from equation model. Plos One, 8(1), e54729. https://doi.org/10. using HIV healthcare services, especially within urban 1371/journal.pone.0054729 cities.
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Falkenberry, H., McCallum, L., Sebayang, M., Burrows, D., & Uganda: The Kumi home based HIV counseling and testing Parsons, D. (2018). Assessment of HIV service packages for program experience. BMC Family Practice, 16(1), 1-9. key populations in Indonesia. Washington, DC: APMG Health. https://doi.org/10.1186/s12875-015-0379-6 Fauk, N. K., Merry, M. S., Putra, S., Sigilipoe, M. A., Crutzen, R., Mesquita, F., Winarso, I., Atmosukarto, I. I., Eka, B., Nevendorff, & Mwanri, L. (2019). Perceptions among transgender women L., Rahmah, A., . . . Angela, R. (2007). Public health the of factors associated with the access to HIV/AIDS-related leading force of the Indonesian response to the HIV/AIDS health services in Yogyakarta, Indonesia. Plos One, 14(8), crisis among people who inject drugs. Harm Reduction e0221013. https://doi.org/10.1371/journal.pone.0221013 Journal, 4(1), 1-6. https://doi.org/10.1186/1477-7517-4-9 Ford, N., Vitoria, M., & Doherty, M. (2018). Providing antiretroviral Ministry of Health of Indonesia. (2018). InfoDatin-HIV-AIDS-2018. therapy to all who are HIV positive: The clinical, public health Retrieved from https://pusdatin.kemkes.go.id/article/view/20 and programmatic benefits of treat all. Journal of the 111200002/infodatin-hiv.html. International AIDS Society, 21(2). https://doi.org/10.1002/ Moradi, G., Mohraz, M., Gouya, M. M., Dejman, M., Seyedalinaghi, jia2.25078 S., Khoshravesh, S., & Ardakani, H. M. (2014). Health needs Gilks, C. (2019). Role of communities in AIDS response. The of people living with HIV/AIDS: From the perspective of policy Indian Journal of Medical Research, 150(6), 515-517. makers, physicians and consultants, and people living with https://doi.org/10.4103/ijmr.IJMR_2526_19 HIV/AIDS. Iranian Journal of Public Health, 43(10), 1424- Haghighat, R., Steinert, J., & Cluver, L. (2019). The effects of 1435. decentralising antiretroviral therapy care delivery on health Mugavero, M. J., Norton, W. E., & Saag, M. S. (2011). Health care outcomes for adolescents and young adults in low-and middle- system and policy factors influencing engagement in HIV income countries: A systematic review. Global Health Action, medical care: Piecing together the fragments of a fractured 12(1), 1668596. https://doi.org/10.1080/16549716.2019.166 health care delivery system. Clinical Infectious Diseases, 8596 52(suppl_2), S238-S246. https://doi.org/10.1093/cid/ciq048 Harapan, H., Feramuhawan, S., Kurniawan, H., Anwar, S., Odeny, T. A., Penner, J., Lewis-Kulzer, J., Leslie, H. H., Shade, S. Andalas, M., & Hossain, M. B. (2013). HIV-related stigma and B., Adero, W., . . . Bukusi, E. A. (2013). Integration of HIV care discrimination: A study of health care workers in Banda Aceh, with primary health care services: Effect on patient satisfaction Indonesia. Medical Journal of Indonesia, 22(1), 22-29. and stigma in rural Kenya. AIDS Research and Treatment, https://doi.org/10.13181/mji.v22i1.518 2013, 485715. https://doi.org/10.1155/2013/485715 Havlir, D. V., Balzer, L. B., Charlebois, E. D., Clark, T. D., Pérez-Salgado, D., Compean-Dardón, M. S., Staines-Orozco, M. Kwarisiima, D., Ayieko, J., . . . Chamie, G. (2019). HIV testing G., & Ortiz-Hernández, L. (2015). Satisfaction with healthcare and treatment with the use of a community health approach in services and adherence to antiretroviral therapy among rural Africa. New England Journal of Medicine, 381(3), 219- patients with HIV attending two public institutions. Revista de 229. https://doi.org/10.1056/NEJMoa1809866 Investigación Clinica, 67(2), 80-88. Hill, A. M., & Pozniak, A. L. (2016). How can we achieve universal Risal, A., Irwan, A. M., & Sjattar, E. L. (2018). Stigma towards access to low-cost treatment for HIV? Journal of Virus people living with HIV/AIDS among counseling officers in Eradication, 2(4), 193-197. https://doi.org/10.1016/S2055- South Sulawesi, Indonesia. Belitung Nursing Journal, 4(6), 6640(20)30871-2 552-558. https://doi.org/10.33546/bnj.543 Johnson, L. F., May, M. T., Dorrington, R. E., Cornell, M., Boulle, Rouleau, G., Richard, L., Côté, J., Gagnon, M.-P., & Pelletier, J. A., Egger, M., & Davies, M.-A. (2017). Estimating the impact (2019). Nursing practice to support people living with HIV with of antiretroviral treatment on adult mortality trends in South antiretroviral therapy adherence: A qualitative study. The Africa: A mathematical modelling study. PLoS Medicine, Journal of the Association of Nurses in AIDS Care, 30(4), e20- 14(12), e1002468. https://doi.org/10.1371/journal.pmed.1002 e37. https://doi.org/10.1097/JNC.0000000000000103 468 Senyurek, G., Kavas, M. V., & Ulman, Y. I. (2021). Lived Kay, E. S., Batey, D. S., & Mugavero, M. J. (2016). The HIV experiences of people living with HIV: A descriptive qualitative treatment cascade and care continuum: Updates, goals, and analysis of their perceptions of themselves, their social recommendations for the future. AIDS Research and spheres, healthcare professionals and the challenges they Therapy, 13(1), 1-7. https://doi.org/10.1186/s12981-016-012 face daily. BMC Public Health, 21(1), 1-15. https://doi.org/ 0-0 10.1186/s12889-021-10881-y Keller, S. C., Yehia, B. R., Momplaisir, F. O., Eberhart, M. G., Siedner, M. J., & Triant, V. (2019). Undetectable= Untransmittable Share, A., & Brady, K. A. (2014). Assessing the overall quality and your health: The personal benefits of early and continuous of health care in persons living with HIV in an urban therapy for HIV infection. The Journal of Infectious Diseases,, environment. AIDS Patient Care and STDs, 28(4), 198-205. 219(2), 173-176. https://doi.org/10.1093/infdis/jiy445 https://doi.org/10.1089/apc.2014.0001 Smith, D. W. (2018). "Phenomenology", the Stanford encyclopedia Kolawole, G. O., Gilbert, H. N., Dadem, N. Y., Genberg, B. L., of philosophy. California: Metaphysic Research Lab Stanford Agaba, P. A., Okonkwo, P., . . . Ware, N. C. (2017). Patient University. experiences of decentralized HIV treatment and care in Smith, M. K., Miller, W. C., Liu, H., Ning, C., He, W., Cohen, M. S., Plateau State, North Central Nigeria: A qualitative study. AIDS & Wang, N. (2017). Effects of patient load and travel distance Research and Treatment, 2017. https://doi.org/10.1155/2017/ on HIV transmission in rural China: Implications for treatment 2838059 as prevention. Plos One, 12(5), e0177976. https://doi.org/10. Leon, C., Koosed, T., Philibert, B., Raposo, C., & Benzaken, A. S. 1371/journal.pone.0177976 (2019). HIV/AIDS health services in Manaus, Brazil: Patient Speziale, H. S., Streubert, H. J., & Carpenter, D. R. (2011). perception of quality and its influence on adherence to Qualitative research in nursing advancing the humanistic antiretroviral treatment. BMC Health Services Research, imperative (5th ed.). Philadelphia: Lippincott Williams & 19(1), 1-11. https://doi.org/10.1186/s12913-019-4062-9 Wilkins. Lubogo, D., Ddamulira, J. B., Tweheyo, R., & Wamani, H. (2015). Stutterheim, S. E., Sicking, L., Brands, R., Baas, I., Roberts, H., Factors associated with access to HIV care services in eastern Van Brakel, W. H., . . . Bos, A. E. R. (2014). Patient and
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provider perspectives on HIV and HIV-related stigma in Dutch International Association of Providers of AIDS Care (JIAPAC), health care settings. AIDS Patient Care and STDs, 28(12), 18, 2325958219880532. https://doi.org/10.1177/2325958219 652-665. https://doi.org/10.1089/apc.2014.0226 880532 Subramanian, S., Edwards, P., Roberts, S. T., Musheke, M., & World Health Organization. (2016). Global health sector strategy Mbizvo, M. (2019). Integrated care delivery for HIV prevention on HIV 2016-2021. Geneva, Switzerland: World Health and treatment in adolescent girls and young women in Zambia: Organization. Protocol for a cluster-randomized controlled trial. JMIR World Health Organization. (2019a). Maintaining and improving Research Protocols, 8(10), e15314. https://doi.org/10.2196/ quality of care within HIV clinical services. Retrieved from 15314 https://apps.who.int/iris/handle/10665/325857 Tafuma, T. A., Mahachi, N., Dziwa, C., Moga, T., Baloyi, P., World Health Organization. (2019b). Progress report on HIV, viral Muyambo, G., . . . Murungu, J. (2018). Barriers to HIV service hepatitis and sexually transmitted infections 2019: utilisation by people living with HIV in two provinces of Accountability for the global health sector strategies, 2016– Zimbabwe: Results from 2016 baseline assessment. Southern 2021. Retrieved from https://apps.who.int/iris/handle/10665/ African Journal of HIV Medicine, 19(1). https://doi.org/10. 324797 4102/hivmed.v19i1.721 World Health Organization. (2020). HIV/AIDS treatment and care. Terzian, A. S., Younes, N., Greenberg, A. E., Opoku, J., Hubbard, Retrieved from https://www.who.int/health-topics/hiv-aids/#tab J., Happ, L. P., . . . Castel, A. D. (2018). Identifying spatial =tab_3 variation along the HIV care continuum: The role of distance World Health Organization, UNICEF, & UNAIDS. (2013). Global to care on retention and viral suppression. AIDS and Behavior, update on HIV Treatment 2013: Results, impact and 22(9), 3009-3023. https://doi.org/10.1007/s10461-018-2103-8 opportunities. Retrieved from https://www.unaids.org/sites/ UNAIDS. (2018). Differentiated service for HIV: A decision default/files/media_asset/20130630_treatment_report_en_0. framework for differentiated antiretroviral therapy delivery for pdf key population - The last mile to universal access. Retrieved Wroe, E. B., Dunbar, E. L., Kalanga, N., Dullie, L., Kachimanga, from https://differentiatedservicedelivery.org/Portals/0/adam/ C., Mganga, A., . . . Nazimera, L. (2018). Delivering Content/2a0WxWUHfUKtul1mKWdmGQ/File/Decision%20Fr comprehensive HIV services across the HIV care continuum: amework%20Key%20Population%20Web3.pdf A comparative analysis of survival and progress towards 90- United Nations. (2016). Transforming our world: The 2030 agenda 90-90 in rural Malawi. BMJ Global Health, 3(1). http://dx.doi. for sustainable development. Retrieved from https://stg- org/10.1136/bmjgh-2017-000552 wedocs.unep.org/bitstream/handle/20.500.11822/11125/une pswiosm1inf7sdg.pdf?sequence=1 US Department of Health & Human Services. (2020). The global Cite this article as: Mahathir., Wiarsih, W., & Permatasari, H. HIV/AIDS epidemic. Retrieved from https://www.hiv.gov/hiv- (2021). “Accessibility”: A new narrative of healthcare services basics/overview/data-and-trends/global-statistics for people living with HIV in the capital city of Indonesia. Watts, G. F., Kelley, D., Wilson, M. M., Arts, S., & Mims, J. (2019). Belitung Nursing Journal, 7(3), 227-234. https://doi.org/10. Jurisdictional coordination of integrated HIV prevention and 33546/bnj.1409 patient care planning and implementation. Journal of the
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234 Original Research BNJ
Belitung Nursing Journal Psychometric properties of Quality- Volume 7(3), 235-245 © The Author(s) 2021 of-Life Index for Vietnamese women https://doi.org/10.33546/bnj.1332 with breast cancer three weeks postmastectomy
Ha Thi Nhu Xuan1* and Sureeporn Thanasilp2
Abstract Background: The patient’s quality of life immediately after mastectomy usually receives less attention than the quality of life after three months, six months, or a year. It is because the focus is mainly on surgical complications. Many instruments measure the quality of life from three months onwards. Still, the quality-of-life instruments right after postmastectomy are not yet verified. Objective: This paper aimed to test the reliability and validity of the Quality-of-Life Index Vietnamese version (QOLI- V) in Vietnamese women with breast cancer three weeks postmastectomy. Methods: The descriptive cross-sectional study was designed to analyze the psychometric properties of a Vietnamese version of the modified Quality of Life Index. The modified process was conducted after granting permission from the original authors. The content validity of the modified index was examined by five experts. Brislin’s model was used for the translation process. The 26-item QOLI-V was tested in 265 patients with breast cancer stage II three weeks postmastectomy who expected to have a poorer quality of life score. The reliability of the index was measured using Cronbach's alpha. The construct validity was examined using confirmatory factor analysis (CFA). Result: The content validity index results showed that the lowest I-CVI was .80 and the highest was 1.00. S-CVI/Ave was 0.95, and S-CVI/UA was 0.76. The Cronbach's alpha of QOLI-V was .84, which was considered acceptable. Most of the 26 items featured the correct item-total correlation of .30 to .60. There were only two items correlated with the total scale at .18, and the item with the lowest correlation (.06) was deleted from the item set. The CFA of model 1 with 26 items was not an ideal fit with the data, with Chi-Square/df = 2.15, CFI = .815, GFI = .853, TLI = .792, RMSEA = .066. After deleted an item #general quality of life, and the CFA of model 2 was conducted on the 25-item index. The final result indicated the improvement of the model fit, with Chi-Square/df =2.26, CFI = .852, GFI = .814, TLI = .790, RMSEA = .069. Conclusion: The 25-item QOLI-V version is considered valid and reliable to measure the quality of life of Vietnamese women with breast cancer three weeks postmastectomy. Nurses and midwives could use this instrument to measure the quality of life of the patients, and the patients could use it for self-assessment.
Keywords quality of life; mastectomy; factor analysis; psychometrics; nursing; Vietnam
Patients with breast cancer feel considerable uncertainty these are events they could not foresee and are therefore when diagnosed with a life-threatening (or terminal) illness. wholly unprepared. From systematic reviews, the stage Later on, patients facing the treatment process realize from mastectomy one month to initial chemotherapy
1 Faculty of Nursing and Medical Technology, University of Medicine and Article Info: Pharmacy at Ho Chi Minh City, Vietnam Received: 1 February 2021 2 Revised: 2 March 2021 Faculty of Nursing Chulalongkorn University, Bangkok, Thailand Accepted: 10 May 2021
Corresponding author: This is an Open Access article distributed under the terms of the Creative Dr. Ha Thi Nhu Xuan, PhD, APN, RN Commons Attribution-NonCommercial 4.0 International License, which allows others to remix, tweak, and build upon the work non-commercially as long as Faculty of Nursing and Medical Technology, University of Medicine and the original work is properly cited. The new creations are not necessarily Pharmacy at Ho Chi Minh City licensed under the identical terms. 217 Hong Bang street, District 5, Ho Chi Minh City, Vietnam Mobile: +84 356435986 E-ISSN: 2477-4073 | P-ISSN: 2528-181X
Email [email protected]
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
235 Xuan, H . T . N., & Thanasilp, S. (2021) represented a transition time of poor adjustment and by Padilla and Grant (1985) as physical well-being, social decreased quality of life (Paraskevi, 2012). However, most concerns, body image concerns, psychological well-being, of the studies focus on describing and providing support for and diagnosis/treatment response remains the most quality of life as much as three months, six months, or over suitable application for QOL postmastectomy. one year postmastectomy, but ignoring the immediate poor Following Padilla and Grant (1985), physical well-being quality of life for the patients in the hours, days, and weeks can be considered a strength, fatigue, ability to work, after their mastectomy during the transition from hospital to current health, and perceived usefulness. Psychological home (Razdan et al., 2016). According to previous studies, well-being implies happiness, satisfaction, fun, general it has been shown that decreased quality of life after QOL, pleasure in eating and sleep. The body image surgery may predict early treatment discontinuation in concerns mean the ability to look at the changes in one’s patients with breast cancer (King et al., 2000; Richardson body, the tendency to worry, and the ability to adjust and et al., 2007). The later poor quality of life will lead to live with body changes. The social concerns focus on reoccurrence, metastatic, or even death among this group social rejection, social contact, or the need for privacy. (Coates et al., 2000; Mols et al., 2005). Thus, poor quality Diagnosis/treatment response relates to surgical treatment of life in patients with breast cancer postmastectomy exists symptoms, which are defined as the ability to have as an urgent problem and requires effective interventions sufficient sexual activity, nutrition, weight, pain, and to reduce it. In addition to introducing a measure for the severity of pain, nausea, and vomiting (Padilla & Grant, concept of quality-of-life postmastectomy, a reliable and 1985). In postmastectomy patients, the attributes of valid scale must necessarily be established. physical, psychological, and social concerns of QOL might be the same as other cancers; however, the defining Definition of Quality of Life of Patients attributes of body image and treatment response might Postmastectomy differ. The body image in breast cancer patient Quality of life (QOL) is the primary goal that most people postmastectomy relates to the ability to look at the changes attain during their daily life. Since this concept has been of the body, worry over scarring, perceived femininity, and recognized, QOL is not separate from health because it is how easy it is to live with anybody changes (Barolia, 2008; considered as the person’s sense of well-being that stems Denford et al., 2011; Fobair et al., 2006; Lindwall & from the satisfaction and dissatisfaction with aspects of life Bergbom, 2009; Toriy et al., 2013). The treatment (Ferrans, 1990) or functional capacity, symptoms (physical response of mastectomy patients focuses on symptoms and psychological) and perceptions of health (Mccorkle et around the hand and shoulder such as the ability to raise al., 1989). The quality of life in the nursing context is related the hand, any swelling of the arm, the sensitivity of the to a specific illness, and it can be considered similar breast incision, sufficient nutrition, weight, as well as the meaning with health-related quality of life. A concept severity and frequency of pain (Champion et al., 2014; analysis of nursing, based on the guiding theory of Janz et al., 2007; Taghian et al., 2014). Operationally, the Peplau’s, Rogers’, Leininger’s, King’s, and Parse, is concept of quality of life on postmastectomy patients is defined as a contextual, intangible, subjective perception defined as the perception of life experienced based on five of one’s lived experience (Plummer & Molzahn, 2009). domains: physical well-being, psychological well-being, Cella (1994) identified four dimensions of quality of life in body image concerns, social concerns, and treatment the context of cancer that encompasses physical well- responses. Defining attributes of QOL consist of physical being, functional well-being, emotional well-being, and well-being (strength, fatigue, ability to work, current health social well-being. The concept of Cella (1994) and its four and perceived usefulness), psychological well-being significant domains of quality of life help investigate the (happiness, satisfaction, fun/hobbies, eating pleasure and concept multi-dimensionally. Besides, (Padilla & Grant, sleep), body image concern (look at the body, scare of 1985) describe the quality of life as five dimensions: scarring, perceived femininity, ability to live with losing a physical well-being, social concerns, body image breast, the worry of future living without a breast), social concerns, psychological well-being, and concerns (family, friends or healthcare giver staff contact, diagnosis/treatment response. In breast cancer, the social rejection, and privacy needs and treatment concept of QOL describes the impact of breast cancer on responses (ability raising the hand, swelling of the arm, the domains of physical, social, psychological well-being, sensitive of destroying breast, nutrition sufficient, weight, and spiritual well-being (Ferrell et al., 1998). severity, and frequency of pain) Receiving a mastectomy also raises concerns about body image, uncertainty in the situation of illness, surgical Existing Instruments symptoms, lacking nursing care or social support, and poor Most of the effective existing instruments measuring the patient-physician communication impacting the patient’s quality of life for patients with breast cancer are all well- quality of life (Denieffe et al., 2014; Mandelblatt et al., 2003; known instruments that have been used to examine QOL Wronska et al., 2007). Thus, in patients with breast cancer in many stages of breast cancer (Perry et al., 2007). postmastectomy, the concept of quality of life should be Among those, FACT-B and EORTC-BR23 are specific for more specific, clearly describing the situation, which occurs patients during chemotherapy treatment. QOL-BR23 among this group. That is why the definition of QOL defined focuses on physical function, whereas FACT-B
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236 Xuan, H . T . N., & Thanasilp, S. (2021) emphasizes emotional well-being (Nguyen et al., 2015). definition of quality-of-life postmastectomy with five EORTC-QLQ30 and SLDS-BC or QOLI are suitable for domains of physical well-being, psychological well-being, QOL in general. Interestingly, the QOLI of Padilla and social concerns, body image concerns, and Grant (1985) is based on the concept of QOL across a treatment/diagnosis response. The length of 23 items with range of cancers in women, though sharing similar self-administer base on the visual line for the most concern circumstances to breast cancer patients, such as cervical in the past four weeks. Summarily, with the same aspects cancer, colorectal cancer, and hysteric cancer post- of colostomy and mastectomy on colorectal and breast surgery. The original QOLI of Padilla and Grant (1985) cancer patients, the QOLI of Padilla and Grant (1985) identifies 14 factors and has been validated in many covers most aspects of the operational definition of quality studies measuring QOL; hence it has proven validity and of life postmastectomy. Thus, this instrument will be reliability (Rukholm et al., 1998). Over time, the QOLI has selected to test the psychometric properties in the breast been modified for colostomy patients by adding nine items cancer population postmastectomy. The summary of the focusing on some aspects of symptoms post-surgery. The comparison of the tools measuring QOL is presented in dimensions of QOLI would seem to be closest to the Table 1.
Table 1 Summary of existing instruments measuring QOL for patients with breast cancer
Name & Authors Purpose Domains Scale Duration Items Type Reliability Validity European QOL in the 5 (Therapy side effects; Four-point Past 23 Self-report Reliabilities Discriminant Organization for breast cancer arm symptoms; breast Likert scale week (10 minutes) ranged from validity of Research and population at symptoms; body ranging from .70 to .91 mutually Treatment of various image; sexual 1 (Not at all) exclusive Cancer QOL Breast stages and functioning) to 4 (Very groups based Cancer-Specific with patients much) on their initial Version with differing performance (EORTC QLQ- modalities status scores BR23) produced (Sprangers et al., medium to 1996) large effect sizes ranging from .43 to 1.1
European QOL in the 9 (Physical; role, Four-point Past 30 Self- Reliabilities The correlation Organization for general cognitive; emotional; Likert scale week administere ranged from coefficient Research and cancer social; fatigue; pain; ranging from d .69 to .90. between the Treatment of population nausea and vomiting; 1 (Not at all) (Under 10 (Carlsson & QLQ-C30 and Cancer QOL global health status to 4 (Very minutes) Hamrin, the Profile of Cancer-Specific and quality of life) much); 1 1996) Mood States Version (Very poor) (POMS) was (EORTC QLQ-C30) to 4 Test-retest .56 (Aaronson et al., (Excellent) reliabilities (Mclachlan et 1993) ranged from al., 1998). .63 to .87 (Hjermstad et al., 1995)
Functional Specific to 6 (Physical well-being; Five points Past 37 Self-report Internal Spearman Assessment of breast cancer social/family well-being; Likert scale week or consistency correlations Cancer Therapy – patients emotional well-being; ranging from interviewer- was .90 between FBSI Breast Symptom functional well-being; 0 (Not at all) administere and FACT Index (FACT-B) relationship with to 4 (Very d (estimated ranged from (Brady et al., 1997) doctors; additional much) 25 minutes) .34 to .84 concerns) Functional Living Assess the 5(Physical functioning; Answer Past two 22 Self- Reliability Correlation Index – Cancer effect that mental functioning; questions by weeks; administere ranged from coefficients (FLIC) cancer social functioning; placing a Past d .64 to .87 between FLIC (Morrow et al., treatment general health/well- vertical line month; (Under 10 (Morrow et and SF-36 1992) and being; gastrointestinal at the point in Today minutes) al., 1992) ranged from symptoms on symptoms) the best .50 to .62 functional present point (Wilson et al., ability in all 2005). areas of life
Life Satisfaction Measure 6 (Quality of family Seven points Past 32 Self-report Reliabilities Correlation Questionnaire one’s general relation; physical Likert scale week (estimated ranged from coefficients (LSQ) sense of symptoms; ranging from 20 minutes) .62 to .92 between LSQ (Carlsson & Hamrin, satisfaction socioeconomic 1 (very and EORTC 1996) with life as it situation; quality of much) to 7 QLQ-C30 were relates to daily activities; (Not at all) -.68 to .54 school, sickness impact; and relationships, quality of close friend leisure time, relation) religious practices, and overall health for women with breast cancer
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Table 1 (Cont.) Medical Outcome Developed to 8 (Physical functioning; Scaled using Unspecifi 36 Self- Reliability Correlation Short Form Health assess role limitations due to various ed administere ranged from coefficients Survey health- physical health; role scales d .74 to .98 between the (SF-36) related QOL limitations due to (5 minutes) (Hays et al., SF-36 and the (Ware et al., 1993) emotional problems; 1995) General Health energy/fatigue; Questionnaire emotional well-being; (GHQ-29) were social functioning; -.35 to =.61 bodily pain; health) (correlations are negative because the two scales run in opposite directions) (Failde & Ramos, 2000) Quality of Life Index Assess 5 (Activity; daily living; Three points Past two 5 Interviewer Internal Correlation (QL-Index) health health; support; Likert Scale weeks administere consistency coefficients (Spitzer et al., 1981) outcomes of outlook) d or self- of .78 ranged from those with administere .40 to .63 (32) cancer and d other chronic (Under 10 diseases minutes) Satisfaction with Developed 5 (Social functioning; Seven points Unspecifi Self-report Reliabilities Correlation Life Domains Scale for appearance; physical Likert-type ed 32 (estimated ranged from coefficient for Breast Cancer satisfaction functioning; scale ranging 20 minutes) .90 to .93 between SLDS- (SLDS-BC) with life communication with from 1 (A BC and FACT- (Spagnola et al., among medical providers; “delighted” B was .59 2003) breast cancer spirituality) face) to 7 (A patients “very unhappy” face World Health Designed to 4 (Physical health; Five points Past two 26 Self- Reliability Correlation Organization Quality examine psychological; social Likert scale weeks administere ranged from coefficients of Life – Brief domain level relationships with varying d .66 to .84. between the Version profiles environment) anchors (estimated Similar WHOQOL- (WHOQOL-BREF) assessing 15-20 alphas have BREF and SF- (Whoqol Group, the quality of minutes) been shown 36 ranged from 1998) life for test-retest .36 to .78 reliability (Da Silva Lima ranging from et al., 2005) .66 to .87 Quality of Life Index Examine the 4 (Physical concerns, 10 points Past one 23 Self- Reliability (Padilla & Grant, quality of life psychological concern, analog scale. month administere Ranged from 1985) of colostomy social concern, body Patients d .65 to .85 patients image concerns, placing a 10 minutes treatments, and vertical line responses at the point in the best present point
Methods model for CFA in physical health care. A systematic review also proposed that the number of subjects should be equal Study Design to the number of items multiplied by 10 in the nursing field The descriptive cross-sectional study was designed to (Watson & Thompson, 2006). It is estimated that 265 analyze the psychometric properties of a Vietnamese patients were included to test the psychometric properties version of the modified Quality of Life Index (QOLI-V) on of QOLI_V, with 26 items modified from QOLI (Padilla & patients three weeks postmastectomy. The modified Grant, 1985) combined with the five domains. process was conducted by researchers after granting permission, acceptance, and consultation of the original Instrument Validation authors. The demographic form and the modified quality of life index Vietnamese version (QOLI-V) were used to collect data in Sample and Setting this study. The demographic form was developed by the The population of this study was the patients three weeks researchers asking about the characteristics of the postmastectomy at the Breast Surgical Oncology Ward in respondents, such as age, marital status, occupation, the Oncology Hospital in Ho Chi Minh City, South of education, income, and mastectomy type. Vietnam. Convenient sampling was used to select the The QOLI_V was a 26-item questionnaire composed of respondents. The inclusion criteria of the respondents five domains: physical well-being, psychological well- were aged 30-60, could read and write Vietnamese, no being, social concerns, body image concerns, and other diseases, and normal surgical recovery process at treatment response. Data were indicated by marking an X seven days. on the visual line equal from 0 to 10 score. Scores were The literature suggests the estimated sample size of presented as numeric rating scales. QOL was calculated CFA should not be less than 200 to avoid violating the by the sum of the scores divided by the sum of items with thumb rule of “too few degrees of freedom” (Hair et al., a low score indicating a low QOL. The original QOLI with 2010). Other assumptions requested that the sample was 23 items retained with five domains. In reference to the > 200 for the theoretical model or ≥ 300 for the population concept of QOL in a mastectomy group, four items related
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238 Xuan, H . T . N., & Thanasilp, S. (2021) to the symptoms of patients with breast cancer Hospital. This study was an instrument development part postmastectomy, including swollen arms, the ability to of the Dissertation project for PhD education in the Faculty raise hands, the sensitivity of breast incision was added to of Nursing, Chulalongkorn University, Thailand. After IRB the section on treatment response and perceived approval, the researchers met patients and presented the femininity was added to the section on body image objectives, procedures to collect data, and approximate concerns. length of time for data collection at the Surgical Oncological Then the 27-item QOLI was sent to five experts for Ward. Patients who matched the inclusion criteria and testing its content validity index following the wished to volunteer signed the consent form to prove that recommendation of Polit et al. (2007): two surgeons with they agreed to answer the whole questionnaire. ten years of experience in the mastectomy process, two Ph.D. nursing lecturers, and one head nurse in the Breast Data Analysis Surgical Department. The results showed that the lowest The input data were checked for errors before entering the I-CVI was .80 and the highest was 1.00; S-CVI/Ave was analysis tests. The data were analyzed for the assumption .95, and S-CVI/UA was .76, which implied good validity for of normal distribution and descriptive demographic data this instrument (Osanloo & Grant, 2016; Polit et al., 2007). and reliability of the measurement by the SPSS program The CVI testing of 5 experts confirmed that for 26 items, version 16.0. Then the confirmatory factor analysis was most of all item was rated from 3 (relevant) to 4 (very conducted by using the AMOS version 20.0. The process relevant). The sum agreements of each item related to the of conducting the CFA conducted by following quality-of-life postmastectomy were calculated. The result standardized recommendations: (a) Initial data analysis to confirmed that most of the items correlated well with the identify any problem of missing data or input errors, (b) Fix quality-of-life postmastectomy, except the item of sufficient one-factor loading on each sub-construct to a specific sexual satisfaction (.40). Experts rated this item with a value as equal to 1, (c) Factor loading higher .5 to .7, (d) lower score of relevancy and recommended researchers Construct reliability .6 was accepted, (e) Standardize consider the meaning of this item on Vietnamese culture. residual accepted (from 2.5 to 4.0), (f) Not using modification indices to adjust the model fit (Hair et al., Instrument Translation 2010). The 26 item-modified QOLI was translated into Vietnamese using Brislin’s model. It was translated from Results English into Vietnamese and back-translated by two different bilingual experts at the Language Center, Characteristics of the Respondents University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam. Two translated versions were reviewed by a Table 2 Characteristics of participants (N = 265) Vietnamese nurse responsible for teaching English to nursing students in the university, identifying ambiguous Characteristic f % words and confirming the symmetry. The Quality-of-Life Age Index Vietnamese version (QOLI-V) was then assessed for 30-39 60 22.6 its intelligibility in the Vietnamese context and culture with 40-49 125 47.2 50-59 80 30.2 5 cases of patients in the Surgical Oncology Ward. The Marital status piloting of QOLI-V also showed that most patients skipped Married 209 78.9 the question asking about sufficient sexual satisfaction Widowed 29 10.9 after mastectomy. When researchers discussed the Divorced 12 4.6 reason with patients, the answer was that mastectomy Singled 15 5.7 treatment was terrifying and tiring. They and their partner Education did not want to have sex, or it was of no meaning in the Primary school 75 28.3 postmastectomy period. Based on the Vietnamese culture, Secondary school 84 31.7 High school 63 23.8 women often feel shame and become uncomfortable when University or higher 43 16.2 asked about sexual activities, or they could not express the Occupation meaning of sexual satisfaction. In the stage of three weeks Housework 112 42.3 postmastectomy, sufficient sexual satisfaction was felt Small business 52 19.6 completely irrelevant to ask because patients were usually Worker 57 21.5 concerned with other aspects of their life than sexual Officer 31 11.7 satisfaction. Therefore, this item was deleted from the Retire 13 4.9 questionnaire. Monthly income (VND) < 3 million 137 51.7
3-5 million 107 40.4 Ethical Consideration 5-10 million 21 8.0 This study was approved by the Board of Ethical in Mastectomy type Biomedical Research at the University of Medicine and Simple 94 35.5 Pharmacy and the Research Ethical Board of Oncology Radical 171 64.5
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The demographic data of the respondents showed that Square Error of Approximation (RMSEA ≤ .08), most of them were in middle age (47%). Many of the Standardized Root Mean Square Residual (SRMR ≤ .05), women were married and living together as a family Comparative Fit Index (CFI ≥ .90) (Hair et al., 2010). The (78.9%). However, the respondents had low education researchers also used other evidence to concern the (primary and secondary school, 60.5%), and income from appropriate model fit. the main family members was still low (<3 million The initial model 1 was drawn up in the AMOS graphic and/month, 51.7%). The majority of the respondents were program and run CFA with the data set. The first analysis housewives (42.3%), farmers, or doing small business at showed that with 26 items based on the construct of 5 home (19.6%). Only one-third of them were office workers dimensions, model 1 was not an ideal fit with the data. The or executives; 64.5% of the respondents received radical findings in detail were reported as Chi-Square/df 623/289 mastectomy (see Table 2). = 2.15, CFI =.815, RMSEA =.066. The model was presented in (Figure 1). Reliability of the QOLI-V The reliability of the revised translation version, 26-item QOLI-V, was tested for its reliability with 265 Vietnamese patients three weeks postmastectomy. Cronbach's alpha of QOLI-V was .84, which was considered acceptable for the modified instrument (Polit & Beck, 2003). Most of the 26 items featured the correct item-total correlation .3 to .6. There were only two items correlated with the total scale at .18. Regarding the last item, "general quality of life," the total correlation was only .06, and Cronbach's alpha increased when it was deleted. Thus, it was considered that this item should be deleted from the item set or not (see Table 3).
Table 3 Item correlation of Quality-of-Life Index Vietnamese Version
Items Scale Corrected Cronbach's Mean if Item-Total Alpha if Item Correlation Item Deleted Deleted Strength 172.82 .525 .832 Tired 171.63 .209 .841 Sleep 172.22 .469 .833 Weight 171.22 .185 .842 Appetite 171.96 .557 .829 Food amount 171.71 .521 .831 Daily work 173.94 .514 .831 Current health 172.82 .603 .827 Fun 173.26 .393 .836 Useful 171.99 .552 .829 Figure 1 CFA Model 1 Happiness 171.36 .556 .830 Worry of future 171.32 .236 .841 Life satisfaction 171.97 .525 .830 Note: Pain 172.06 .284 .839 PS: Psychological well-being | Phys: Physical well-being | Tr: Treatment Frequency of pain 171.77 .396 .836 responses| BI: Body image concerns| SO: Social concerns Arm swollen 170.28 .284 .839 Raise hand 171.82 .165 .842 For most items, the standardized estimation (factor Breast sensitive 171.53 .291 .839 loading) was from .50 to .66. There is no estimation Adjust easy 171.66 .374 .836 Scare of scar 171.50 .360 .837 indicated the cross-loading factor. However, there were Femininity 171.98 .288 .839 three items that the general quality of life, weight, and Difficult to look body 171.68 .329 .838 breast incision sensitivity were lower than .50, with the Meeting 172.22 .355 .838 Reject 170.26 .367 .837 standardized regression weight estimated as .045, .48, Private 171.99 .318 .840 .48, respectively. The residual estimation of 26 items General quality of life 171.98 .060 .847 ranked from 1.1 to 3.8 was acceptable based on the standardization rule. However, the residual estimate of e6 Construct Validity - Confirmatory Factors Analysis (general quality of life) exceeded the accepted level with The construct validity of the instrument was tested using the result at 4.2. The construct reliability of the the confirmatory factor analysis (CFA). The model validity measurement was high and exceeded the level of .6. is assessed based on exact test fit, with Chi-Square/df <2.0 As for the modification indices, the general quality of is considered good and <5.0 is acceptable, Root Mean life item is considered the cross-loading item. The
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240 Xuan, H . T . N., & Thanasilp, S. (2021) regression weight of these items was adjusted for the par model 2 was conducted. The findings showed that the change in every item or latent variable of the model. model fit improved, with the criteria Chi-Square/df =2.269, Therefore, this item was considered for deletion from the CFI=.814, and RMSEA=.069. The construct reliability of model. the Psychological dimension was improved after deleted Following the empirical evidence of the CFA in model one item. The model was presented in Figure 2. 1, the general quality of life was deleted, and the CFA of
Figure 2 CFA Model 2
Note: PS: Psychological well-being | Phys: Physical well-being | Tr: Treatment responses BI: Body image concerns| SO: Social concerns
Discussion referenced (Boateng et al., 2018). When we considered the Chi-Square/df in both models, the result was 2.15-2.26, Following Hair et al. (2010) to assess the model validity, less than 3 acceptable occasionally (Hair et al., 2010). The we need the key value of Chi-Square/df, CFI, and RMSEA CFI, GFI, TLI of these models was over 8 compared to the and other evidence to concern the appropriate model fit. standard of >.9 (Hair et al., 2010). Although it was not a Firstly, the confirmed factor analysis showed that the perfect fit, the model was considered good for measuring model of quality of life was acceptable as consistent with the quality of life. Regarding RMSEA, both models were the concept. Although the Chi-square value was .00 (< .05) acceptable, with RMSEA were .06 (< .08) suggested the implied that the model might not fit. However, the Chi- adaptable criteria for model fit. square value may be influenced by the number of samples. Secondly, from model 1 to model 2, there was a slight In this study, 265 cases were higher than 250, as decrease of CFI, GFI, TLI with increased Chi-Square/df.
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RMSEA increase proved that the deleted item " general Authors’ Biographies quality of life" was not contributed to the quality of life or Dr. Ha Thi Nhu Xuan, PhD, ANP, RN is a Vice Head of Nursing considered redundant. Therefore, this item was deleted Department, Faculty of Nursing and Medical Technology, University of Medicine and Pharmacy (UMP) at Ho Chi Minh City, from the model. Thirdly, although model 2 was not also Vietnam. She manages and contributes to updating the curriculum highly fit with the result of Chi-Square/df =2.269, CFI=.814, training for Bachelor and Master program of Nursing at UMP. She and RMSEA=.069. The researcher did not try to rerun the has experiences doing research in adult nursing care, nursing model because this model was consistently based on CVI, education, leadership and management. Cronbach’s alpha, and experts from a clinical view. Assoc. Prof. Sureeporn Thanasilp, DNP, MSN, RN is A Former Therefore, deleted more items did not help improve the Dean and Lecturer at the Faculty of Nursing, Chulalongkorn model but ruin the construct of the quality of life in patients University. She is an expert in cancer nursing caring and with breast cancer. contributes many articles for nursing science. This study proposed the model for concept quality of Data Availability Statement life three weeks postmastectomy. The original model has The datasets of this study are available from the corresponding been modified with four items and deleted two items author on reasonable request. The final instrument is available in through the process of developing the scale. The final 25- appendix. item QOLI should be tested in another group of patients with breast cancer in the early stage of treatment to References conclude the validity and reliability of this scale. In addition, Aaronson, N. K., Ahmedzai, S., Bergman, B., Bullinger, M., Cull, A., Duez, N. J., . . . de Haes, J. C. J. M. (1993). The European the construct of social concerns needs to be adjusted by Organization for Research and Treatment of Cancer QLQ- adding the new constraints for increasing the decrease of C30: A quality-of-life instrument for use in international clinical freedom set up the tau-equivalent between each construct trials in oncology. JNCI: Journal of the National Cancer in the model following the suggestion of (Hair et al., 2010). Institute, 85(5), 365-376. https://doi.org/10.1093/jnci/85.5.365 Barolia, R. (2008). Caring in nursing from an Islamic perspective: The modification indices also suggested a high correlation A grounded theory approach. International Journal of Human between the appetite and food amount that may imply the Caring, 12(1), 55-63. https://doi.org/10.20467/1091- redundancy of the item. This model should be considered 5710.12.1.55 Boateng, G. O., Neilands, T. B., Frongillo, E. A., Melgar-Quiñonez, for testing on a larger sample size to satisfy the assumption H. R., & Young, S. L. (2018). Best practices for developing and of the test and not violate the thumb rule of few degrees of validating scales for health, social, and behavioral research: A freedom. primer. Frontiers in Public Health, 6, 149. https://doi.org/10.3389/fpubh.2018.00149 Brady, M. J., Cella, D. F., Mo, F., Bonomi, A. E., Tulsky, D. S., Conclusion Lloyd, S. R., . . . Shiomoto, G. (1997). Reliability and validity of the Functional Assessment of Cancer Therapy-Breast quality-of-life instrument. Journal of Clinical Oncology, 15(3), The findings of this study provided good reliability and 974-986. https://doi.org/10.1200/jco.1997.15.3.974 validity of the QOLI-V among postmastectomy patients. Carlsson, M., & Hamrin, E. (1996). Measurement of quality of life The QOLI-V consisted of 25 items with five dimensions: in women with breast cancer. Development of a Life Satisfaction Questionnaire (LSQ-32) and a comparison with physical well-being, psychological well-being, social the EORTC QLQ-C30. Quality of Life Research, 5(2), 265- concerns, body image concerns, and treatment response. 274. https://doi.org/10.1007/BF00434748 Nurses and midwives can use this instrument to measure Cella, D. F. (1994). Quality of life: Concepts and definition. Journal the quality of life of the patients with breast cancer of Pain and Symptom Management, 9(3), 186-192. https://doi.org/10.1016/0885-3924(94)90129-5 postmastectomy, and the patients could use it for self- Champion, V. L., Wagner, L. I., Monahan, P. O., Daggy, J., Smith, assessment. L., Cohee, A., . . . Pradhan, K. (2014). Comparison of younger and older breast cancer survivors and age‐matched controls on specific and overall quality of life domains. Cancer, Declaration of Conflicting Interest 120(15), 2237-2246. https://doi.org/10.1002/cncr.28737 There is no conflict of interest in this study. Coates, A. S., Hurny, C., Peterson, H. F., Bernhard, J. r., Castiglione-Gertsch, M., Gelber, R. D., . . . International Breast Funding Cancer Study, G. (2000). Quality-of-life scores predict This study was funded by the 90th Anniversary of Chulalongkorn outcome in metastatic but not early breast cancer. Journal of University Scholarship, Chulalongkorn University, Thailand. Clinical Oncology, 18(22), 3768-3774. https://doi.org/10.1200/ JCO.2000.18.22.3768 da Silva Lima, A. F. B., Fleck, M., Pechansky, F., De Boni, R., & Acknowledgments Sukop, P. (2005). Psychometric properties of the World Health The first author would like to send the gratefulness to her Organization quality of life instrument (WHOQoL-BREF) in supervisor from Chulalongkorn University, who had supported her alcoholic males: A pilot study. Quality of Life Research, 14(2), in the studying process during the PhD program. 473-478. https://doi.org/10.1007/s11136-004-5327-1 Denford, S., Harcourt, D., Rubin, L., & Pusic, A. (2011). Authors’ Contribution Understanding normality: A qualitative analysis of breast HTNX designed the study, collected data, analyzed the data, cancer patients concepts of normality after mastectomy and reconstructive surgery. Psycho‐oncology, 20(5), 553-558. wrote and revised the manuscript. ST designed the study, wrote https://doi.org/10.1002/pon.1762 and revised the manuscript. All authors contributed and agreed Denieffe, S., Cowman, S., & Gooney, M. (2014). Symptoms, with the final version of the manuscript. clusters and quality of life prior to surgery for breast cancer. Journal of Clinical Nursing, 23(17-18), 2491-2502. https://doi.org/10.1111/jocn.12430
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Failde, I., & Ramos, I. (2000). Validity and reliability of the SF-36 Creating the blueprint for your “house”. Administrative Issues Health Survey Questionnaire in patients with coronary artery Journal: Connecting Education, Practice, and Research, 4(2), disease. Journal of Clinical Epidemiology, 53(4), 359-365. 12-26. https://doi.org/10.5929/2014.4.2.9 https://doi.org/10.1016/S0895-4356(99)00175-4 Padilla, G. V., & Grant, M. M. (1985). Quality of life as a cancer Ferrans, C. E. (1990). Quality of life: Conceptual issues. Seminars nursing outcome variable. Advances in Nursing Science, 8(1), in Oncology Nursing, 6(4), 248-254. https://doi.org/10.1016/ 45-60. https://doi.org/10.1097/00012272-198510000-00007 0749-2081(90)90026-2 Paraskevi, T. (2012). Quality of life outcomes in patients with Ferrell, B. R., Grant, M., Funk, B., Otis-Green, S., & Garcia, N. breast cancer. Oncology Reviews, 6(1), e2. https://doi.org/ (1998). Quality of life in breast cancer: Part II: Psychological 10.4081/oncol.2012.22 and spiritual well-being. Cancer Nursing, 21(1), 1-9. Perry, S., Kowalski, T. L., & Chang, C.-H. (2007). Quality of life https://doi.org/10.1097/00002820-199802000-00001 assessment in women with breast cancer: Benefits, Fobair, P., Stewart, S. L., Chang, S., D'Onofrio, C., Banks, P. J., acceptability and utilization. Health and Quality of Life & Bloom, J. R. (2006). Body image and sexual problems in Outcomes, 5(1), 1-14. https://doi.org/10.1186/1477-7525-5- young women with breast cancer. Psycho‐Oncology: Journal 24 of the Psychological, Social and Behavioral Dimensions of Plummer, M., & Molzahn, A. E. (2009). Quality of life in Cancer, 15(7), 579-594. https://doi.org/10.1002/pon.991 contemporary nursing theory: A concept analysis. Nursing Hair, J. F., Black, B., Babin, B. J., & Anderson, R. E. (2010). Science Quarterly, 22(2), 134-140. https://doi.org/10.1177/ Multivariate data analysis (7th ed.). London: Pearson. 0894318409332807 Hays, R. D., Sherbourne, C. D., & Mazel, R. M. (1995). User's Polit, D. F., & Beck, C. T. (2003). Nursing research: Principles and manual for the Medical Outcomes Study (MOS) core methods. Philadelphia: Lippincott Williams & Wilkins. measures of health-related quality of life. Santa Monica: Rand Polit, D. F., Beck, C. T., & Owen, S. V. (2007). Is the CVI an Corporation. acceptable indicator of content validity? Appraisal and Hjermstad, M. J., Fossa, S. D., Bjordal, K., & Kaasa, S. (1995). recommendations. Research in Nursing & Health, 30(4), 459- Test/retest study of the European Organization for Research 467. https://doi.org/10.1002/nur.20199 and Treatment of Cancer Core Quality-of-Life Questionnaire. Razdan, S. N., Patel, V., Jewell, S., & McCarthy, C. M. (2016). Journal of Clinical Oncology, 13(5), 1249-1254. Quality of life among patients after bilateral prophylactic https://doi.org/10.1200/jco.1995.13.5.1249 mastectomy: A systematic review of patient-reported Janz, N. K., Mujahid, M., Chung, L. K., Lantz, P. M., Hawley, S. outcomes. Quality of Life Research, 25(6), 1409-1421. T., Morrow, M., . . . Katz, S. J. (2007). Symptom experience https://doi.org/10.1007/s11136-015-1181-6 and quality of life of women following breast cancer treatment. Richardson, L. C., Wang, W., Hartzema, A. G., & Wagner, S. Journal of Women's Health, 16(9), 1348-1361. https://doi.org/ (2007). The role of health‐related quality of life in early 10.1089/jwh.2006.0255 discontinuation of chemotherapy for breast cancer. The King, M. T., Kenny, P., Shiell, A., Hall, J., & Boyages, J. (2000). Breast Journal, 13(6), 581-587. https://doi.org/10.1111/ Quality of life three months and one year after first treatment j.1524-4741.2007.00512.x for early stage breast cancer: Influence of treatment and Rukholm, E., McGirr, M., & Potts, J. (1998). Measuring quality of patient characteristics. Quality of Life Research, 9(7), 789- life in cardiac rehabilitation clients. International Journal of 800. https://doi.org/10.1023/A:1008936830764 Nursing Studies, 35(4), 210-216. https://doi.org/10.1016/ Lindwall, L., & Bergbom, I. (2009). The altered body after breast S0020-7489(98)00032-7 cancer surgery. International Journal of Qualitative Studies on Spagnola, S., Zabora, J., BrintzenhofeSzoc, K., Hooker, C., Health and Well-being, 4(4), 280-287. https://doi.org/10.3109/ Cohen, G., & Baker, F. (2003). The satisfaction with life 17482620903106645 domains scale for breast cancer (SLDS‐BC). The Breast Mandelblatt, J., Figueiredo, M., & Cullen, J. (2003). Outcomes and Journal, 9(6), 463-471. https://doi.org/10.1046/j.1524- quality of life following breast cancer treatment in older 4741.2003.09603.x women: When, why, how much, and what do women want? Spitzer, W. O., Dobson, A. J., Hall, J., Chesterman, E., Levi, J., Health and Quality of Life Outcomes, 1(1), 1-11. Shepherd, R., . . . Catchlove, B. R. (1981). Measuring the https://doi.org/10.1186/1477-7525-1-45 quality of life of cancer patients: A concise QL-index for use McCorkle, R., Benoliel, J. Q., Donaldson, G., Georgiadou, F., by physicians. Journal of Chronic Diseases, 34(12), 585-597. Moinpour, C., & Goodell, B. (1989). A randomized clinical trial https://doi.org/10.1016/0021-9681(81)90058-8 of home nursing care for lung cancer patients. Cancer, 64(6), Sprangers, M. A., Groenvold, M., Arraras, J. I., Franklin, J., te 1375-1382. https://doi.org/10.1002/1097-0142(19890915)64: Velde, A., Muller, M., . . . Hopwood, P. (1996). The European 6<1375::aid-cncr2820640634>3.0.co;2-6 Organization for Research and Treatment of Cancer breast McLachlan, S. A., Devins, G. M., & Goodwin, P. J. (1998). cancer-specific quality-of-life questionnaire module: First Validation of the European Organization for Research and results from a three-country field study. Journal of Clinical Treatment of Cancer Quality of Life Questionnaire (QLQ-C30) Oncology, 14(10), 2756-2768. https://doi.org/10.1200/jco. as a measure of psychosocial function in breast cancer 1996.14.10.2756 patients. European Journal of Cancer, 34(4), 510-517. Taghian, N. R., Miller, C. L., Jammallo, L. S., O’Toole, J., & Skolny, https://doi.org/10.1016/S0959-8049(97)10076-4 M. N. (2014). Lymphedema following breast cancer treatment Mols, F., Vingerhoets, A. J. J. M., Coebergh, J. W., & van de Poll- and impact on quality of life: A review. Critical Reviews in Franse, L. V. (2005). Quality of life among long-term breast Oncology/Hematology, 92(3), 227-234. https://doi.org/10. cancer survivors: A systematic review. European Journal of 1016/j.critrevonc.2014.06.004 Cancer, 41(17), 2613-2619. https://doi.org/10.1016/j.ejca. Toriy, A. M., Krawulski, E., Viera, J. d. S. B., da Luz, C. M., & 2005.05.017 Sperandio, F. F. (2013). Perceptions, feelings and physical Morrow, G. R., Lindke, J., & Black, P. (1992). Measurement of and emotional experiences of woman after breast cancer. quality of life in patients: Psychometric analyses of the Journal of Human Growth and Development, 23(3), 303-308. Functional Living Index-Cancer (FLIC). Quality of Life https://doi.org/10.7322/jhgd.69505 Research, 1(5), 287-296. https://doi.org/10.1007/BF004349 Ware, J. E., Snow, K. K., Kosinski, M., & Gandek, B. (1993). SF- 42 36 health survey: Manual and interpretation guide. Boston: Nguyen, J., Popovic, M., Chow, E., Cella, D., Beaumont, J. L., The Health Institute, New England Medical Center. Chu, D., . . . Bottomley, A. (2015). EORTC QLQ-BR23 and Watson, R., & Thompson, D. R. (2006). Use of factor analysis in FACT-B for the assessment of quality of life in patients with Journal of Advanced Nursing: Literature review. Journal of breast cancer: A literature review. Journal of Comparative Advanced Nursing, 55(3), 330-341. https://doi.org/10.1111/ Effectiveness Research, 4(2), 157-166. https://doi.org/10. j.1365-2648.2006.03915.x 2217/cer.14.76 WHOQOL Group. (1998). Development of the World Health Osanloo, A., & Grant, C. (2016). Understanding, selecting, and Organization WHOQOL-BREF quality of life assessment. integrating a theoretical framework in dissertation research:
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Psychological Medicine, 28(3), 551-558. https://doi.org/10. Cite this article as: Xuan, H . T . N., & Thanasilp, S. (2021). 1017/S0033291798006667 Psychometric properties of Quality-of-Life Index for Vietnamese Wilson, R. W., Hutson, L. M., & VanStry, D. (2005). Comparison women with breast cancer three weeks postmastectomy. of 2 quality-of-life questionnaires in women treated for breast Belitung Nursing Journal, 7(3), 235-245. https://doi.org/10. cancer: The RAND 36-item health survey and the Functional Living Index–Cancer. Physical Therapy, 85(9), 851-860. 33546/bnj.1332 https://doi.org/10.1093/ptj/85.9.851 Wronska, I., Stepien, R., & Dobrowolska, B. (2007). Satisfaction of women after mastectomy for nursing care. Advances in Medical Sciences (De Gruyter Open), 52(Suppl 1), 34-36.
Appendix
The Quality-of-Life Index for patients with breast cancer three weeks postmastectomy Modified from Quality-of-Life Index of Padilla and Grant (1985)
Instructions: Please read each question and place an “X” on the line that most closely measures how you feel during the past weeks. The line level is measured from “Not at all” to “Completely/Extremely”, with the score from 1 to 10. Please answer every question.
1. How much strength do you have?
Not at all A great deal 2. Is the amount of sleeping time sufficient to meet your needs?
Not sufficient Completely sufficient 3. Do you feel tired easily?
Not at all A great deal 4. Do you feel your current weight is a problem?
Not at all A great deal 5. Do you find eating a pleasure?
Not at all A great deal 6. Is the amount of food you eat sufficient to meet your needs?
Not at all Completely sufficient 7. How much can you do your usual tasks (homework, office work, and gardening)?
Not at all A great deal 8. How is your present stage of health?
Extremely poor Excellent 9. How much fun do you have (hobbies, recreation, social activities)?
Not at all A great deal 10. How useful do you feel?
Not at all Extremely useful 11. How much happy do you feel?
Not at all A great deal 12. How satisfying is your life?
Not at all Extremely satisfying
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244 Xuan, H . T . N., & Thanasilp, S. (2021)
13. How much pain do you feel in your arm and shoulder?
Not at all Excruciating 14. How often do you feel pain?
None All the time 15. Do you have the arm or hand swollen?
Not at all Extremely 16. Is it difficult to raise your arm or move it sideways?
Not at all Extremely difficult 17. Is your devastated breast over-sensitive like tingling, itching, formication?
Not at all Extremely sensitive 18. How worried are you about your future after mastectomy?
Not at all A great deal 19. How easy is it to live with your devastating breast?
Not at all Extremely fearful 20. How difficult is it for you to look at your body postmastectomy?
Not at all Extremely difficult 21. How fearful are you from the scar of devastating breast?
Not at all Extremely fearful 22. Do you feel less feminine as a result of mastectomy surgery?
Not at all Extremely 23. Is the level of contact with your friends and family sufficient to meet your needs?
Not at all Completely sufficient 24. Do you feel rejected by your family or loved one?
Not at all Extremely 25. Is the amount of privacy you have sufficient to meet your needs?
Not at all Completely sufficient
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245 Perspective BNJ
Belitung Nursing Journal Common ethical dilemmas of family Volume 7(3), 246-250 © The Author(s) 2021 https://doi.org/10.33546/bnj.1457 caregivers of palliative patients in
Indonesia
Martina Sinta Kristanti1* , Kusmaryanto2 , and Christantie Effendy3
Abstract Family caregivers, especially in Asian countries, have a profound role in caring for a sick family member. However, there are wide variations between the Asian and western world in terms of culture and facilities. Therefore, the problems and needs of family caregivers between those two regions may also be distinct, and it is important to explore and elaborate based on our empirical evidence. In Indonesia, motives and values in caregiving and religion become the wheel-power of the family caregivers in providing care. This affects action and consequences for caregivers. This paper attempts to elaborate on common ethical dilemmas that usually face by family caregivers in Indonesia. Unfortunately, family caregivers typically are not prepared to make those challenging decisions. Therefore, we recommend not only that family caregivers need to be involved in the caring process, but also their issues and ethical dilemmas should be assessed and addressed by health care professionals, especially nurses, who have the most frequent contact with patient and family caregiver.
Keywords Asia; caregivers; religion; health personnel; caring; ethics; nursing; Indonesia
Prolog He took it hard when we asked what his life activity was. Finally, he said: ‘Well, I was a happy newly graduate Without a good understanding of what it is like to be entering my first day of work, but then mom called me overwhelmed by the experience of illness - one’s own or almost every hour that day. She asked what time would I that of a loved one - how can the doctor or ethicist (or other be home. That night I could not sleep. I thought it should be health care professionals) appreciate the human situation fine to postpone my life for 1-2 years to be her caregiver. the doctor must address?” (Dresser, 2011). My life can wait, but my mother’s treatment cannot. I then submitted a resignation letter at the end of that week.’ This implies that understanding the lived experiences of patients and family caregivers is an essential key to take Case two care of patients with a terminal illness. Accordingly, we Celine, 34 years old, who has been married for ten years, would start this perspective essay by presenting three real was looking forward to having a child of her own. She used cases. to live in Singapore, but since last year, she moved back to Jakarta to take care of her mother, diagnosed with tongue Case one cancer, and her father, a diagnosed Alzheimer's patient. Roy, 25 years old, a young man we interviewed in a Celine has an older sister who lives nearby; however, she chemotherapy clinic in Yogyakarta, Indonesia, was said she was already too busy to take care of her own three accompanying his mother, diagnosed with breast cancer. kids. Therefore, it should be Celine who becomes their
1 Department of Basic and Emergency Nursing, Faculty of Medicine, Article Info: Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Received: 1 April 2021 Revised: 1 May 2021 Indonesia Accepted: 2 June 2021 2 Faculty of Philosophy – Divinity, Sanata Dharma University, Indonesia 3 Department of Medical Surgical Nursing, Faculty of Medicine, Public This is an Open Access article distributed under the terms of the Creative Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia Commons Attribution-NonCommercial 4.0 International License, which allows others to remix, tweak, and build upon the work non-commercially as long as
the original work is properly cited. The new creations are not necessarily Corresponding author: licensed under the identical terms. Martina Sinta Kristanti, S.Kep, Ns, MN, PhD Department of Basic and Emergency Nursing, Faculty of Medicine, E-ISSN: 2477-4073 | P-ISSN: 2528-181X Public Health and Nursing, Universitas Gadjah Mada Gedung Ismangoen lt.2 Sekip Bulaksumur Yogyakarta Indonesia 55281 Phone: +6281227811976 Email: [email protected]
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246 Kristanti, M. S., Kusmaryanto., & Effendy, C. (2021) mom’s caregiver since Celine has no kids. Coming from a financial compensation from the care recipient to this family wealthy family, they set up a proper home care plan fully caregiver. equipped with nurses and a visiting doctor. However, it has Family caregivers’ circumstances are varied between been three months since she could go anywhere. One time Western and Asian regions. In the Western world, she went to the gym, but she received a phone call from independence (or lack of dependency) is highly her husband asking how she could leave their parents at appreciated. The government responds by providing home in that condition. She was then stuck at home, bored various formal facilities such as long-term, hospice care, and depressed. nursing homes, and many other institutions in order to maintain the individual sense of independence for people Case three with chronic and terminal illnesses. On the other hand, in Maria, almost 50 years old, decided to be her sister’s Asian countries, including in Indonesia, taking care of caregiver, Anna, since five months ago. In doing so, she family members is part of the culture. In this setting, there needed to leave her family and job in Kalimantan, are many important lessons that we have learned from Indonesia, which was such a tough decision to make. Anna, generation to generation—taking care of our family, 36 years old, was diagnosed with breast cancer around especially our parents, may be the only way we know how three years ago. She has fought bravely, and now she to appreciate life and our inheritance. In Javanese culture, suffered from constant pain and a large malignant wound for example, tabon is a term that refers to a child that is on both of her breasts. She also suffered from anemia and assigned to take care of a parent (Keasberry, 2001). needed to go to the hospital for a transfusion. Nevertheless, According to this culture, tabon will be granted ownership Anna is a cheerful lady with a bright personality. She knew of the house once the parents are passed away exactly what is going on with her condition and was ready (Keasberry, 2001). for the worst scenario. Her concern was only for her In relation to financial compensation, some developed daughter, Lia (16 years old). Lia never knew who her father countries have various schemes. For example, in the is since she was born. Since Lia goes to school and Anna Netherlands, people are able to self-assign a ‘mantelzorg’ was bound to bed rest, Maria’s heart was moved. Actually, (family caregiver in Dutch). They put this information on Maria and Anna had such opposite characters; they had legal government documentation. When something argued in many ways since they were little. Maria decided happens to their health, this mantelzorg will provide direct to be Anna’s caregiver because she could not be on her care, including taking the patient to the hospital, facilitating mother’s side during her last moment in life. This guiltiness their groceries, and other daily activities. The Dutch haunted her for many years. She was expecting that by government offers a financial scheme to compensate for becoming one of Anna’s caregivers, her guiltiness would the time spent by the mantelzorg in providing this care. fade away. When we asked: “With whom would Lia stay There is a limited amount of Euros per day that can be with when something happens to Anna?” With her soft accessed by the mantelzorg and applied as an invoice voice, she said that this is the most important topic, but she (Alice, Inger, & Mirjam, 2019). could not initiate it with Anna. She does not know how and Considering the wide variations in the Western and when to start this discussion. Asian cultures, this implies that we need be careful about These cases illustrate that caring for the loved ones directly or thoughtlessly adapting ideas or interventions (who are ill) affects the patients and may also change the from the Western countries to Asian ones. Cultures are a family caregivers’ life. Accordingly, the World Health form of intergenerational heritage that actively shapes Organization (2010) defines palliative care as an approach people’s lives, including the family caregiving condition. to enhance not only the quality of life (QOL) of patients but Since one of the most suitable policy types is supported by also their family caregivers. This definition relates to the empirical evidence, research on family caregivers in Asia, Indonesian situation where caring for the family member is including Indonesia, is essentially needed. considered part of Asian culture (Funk, Chappell, & Liu, 2013). Family Caregivers in Indonesia This perspective paper aims to elaborate experiences of family caregivers in Indonesia and to identify some When one of the authors (MSK) started PhD study in 2015, common ethical dilemmas in their palliative experiences. funded by the Dutch government, evidence was limited concerning family caregivers in Indonesia. Fortunately, Family Caregivers research on this topic has been growing progressively in the past five years. A study revealed that family caregivers The family caregiver has various definitions. The most have a profound role in patient care even during common meaning refers to people who provide care to their hospitalization (Effendy et al., 2015). This finding implied loved ones with or without blood relations, including in-laws that family caregivers must have important tasks at home. and neighbors (Kilic & Oz, 2019). This person may or may They should be supported. They should be part of the care. not live with the care recipient, but they provide care for at The next question is, how can we provide the support and least 6 hours a day. However, the most common care that they need? differentiation with the formal caregiver is that there is no
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247 Kristanti, M. S., Kusmaryanto., & Effendy, C. (2021) This initiated me to start my first study by comparing the network, by considering their values, uniqueness, dignity, experiences of family caregivers of patients with cancer and inherent human rights (Yildiz, 2019). and patients with dementia. We found more similarities In the case of the family caregivers’ journey, based on than differences in the problems in caregiving, actions of our empirical data (Kristanti et al., 2019; Kristanti et al., caregivers, and beliefs in caregiving. Some differences 2018), one of the most frequent dilemmas was ‘hiding’. were also identified (Kristanti, Engels, Effendy, Utarini, & Family caregivers tend to hide their emotions and burdens Vernooij-Dassen, 2018). Family caregivers of people with in front of the patient. They thought that their feelings were dementia revealed that direct contact with health care not relevant and should stay hidden. They would pose a professionals was highly appreciated. People with cheerful, brave, and tough face in front of the patient. dementia are usually cared for by either gerontologists or Another hiding is about revealing diagnoses. When the neurologists, then the communication and coordination can patient is younger (below 50 years old), the doctor mostly be much simpler. On the other hand, care for most patients revealed diagnoses directly. However, when the patient is with cancer is done by multi-disciplines, including older and maybe illiterate (unable to understand), the family oncologists, internists, surgeons, and many other parties, caregiver is the first to receive the diagnosis. The doctor depending on their needs. This lack of simple, one-to-one then would request the family to inform the patient, or in involvement increases the risk for friction and some cases, the family would ask the doctor and nurses miscommunication issues. not to reveal the diagnoses until the patient is ready. When However, family caregivers of people with dementia the patient was not aware of their diagnoses, the condition revealed that they sometimes felt a loss of connection with became the most problematic situation for the family the patient even when the patient was still beside them. caregivers. One of the participants in our study revealed “She doesn’t know me anymore; she doesn’t know anyone that once she broke the news of the diagnosis to her anymore” [Husband]. mother, it felt like ‘a mountain had been removed from her Meanwhile, family caregivers of patients with cancer shoulders’ (Kristanti et al., 2019). often described a stronger family cohesiveness. For The second ethical dilemma was the perception of example, one participant said that she (55 years old) had voluntary vs. obligatory actions in the caregiving tasks. In only talked to her older brother (57 years old), who lived in many Western publications, Asian countries are framed a different city once or twice a year since they were busy negatively that caregiving is a mandatory action. Our study with their own life, family, and work. But since she has been in Indonesia showed that we framed ‘this obligation’ in a looking after their mother, they keep in touch on a daily positive way so that we see this as a chance to make some basis, sometimes just to ask how they are doing. As a payback to our loved ones. It is described as ‘a chance in result, they found a reconnection during this caregiving disguise’ or some opportunities and benefits while facing process (Kristanti et al., 2018). some challenges (Kristanti et al., 2019). The next study then elaborates on the experiences of The third dilemma was that most caregivers were the family caregivers of patients with cancer (Kristanti, Effendy, so-called ‘first-time players’ with no training (Dresser, Utarini, Vernooij-Dassen, & Engels, 2019). Data were 2011), meaning that they are ‘newbies’ (in caregiving role), collected from three major cities in Indonesia: Jakarta, and they may need time to grasp information, to have Surabaya, and Yogyakarta. Belief in caregiving is the core second or third opinions, to make (some immature) phenomenon (Kristanti et al., 2019). It is the wheel-power decisions and/or to change their decision. It is because of caregivers. It consists of spiritual and religion, values, nothing is harder than making decisions about treatment and motives in caregiving. This wheel-power influences the and caring, resulting in life and death consequences. actions of family caregivers and the consequences they Family caregivers also felt like living as a shadow. Their received. The more constructive their belief in caregiving, presence was mostly overlooked by healthcare the better the consequences it impacted on them. Those professionals or other family members. While all the with this spirit eventually found themselves as a better spotlight is on the patient, the family caregiver is also the person and vice versa. one who needs to be taken care of. The decision-making process is another dilemma that Common Ethical Dilemmas we identified. Some caregivers need to decide to continue or stop treatment when the patient can no longer participate These empirical data can help us reflect on ethical in this decision. The decision for resuscitation can be a life- dilemmas that the family caregivers must face in the long traumatic memory for them. The guilty feeling to stop caregiving process or their relationships with patients and the treatment can also become their burden of guilt for the other family members. In general terminology, extensive rest of their life. In order to reduce unnecessary guilty medical literature used ethics, dilemma, and moral distress feeling, British Medical Association reminds us to apply the interchangeably (Yildiz, 2019). In the nursing profession, an ethical principles of ordinary and extraordinary. The ethical dilemma may be alleviated by utilizing a scientific obligation of healthcare workers is to provide ordinary care, ethic, that is, by placing people (or the care recipient) at the while extraordinary care is not an obligation (British Medical center and interacting with family members and their Association, 2007). One is not obliged to use all resources to defend human life. Extraordinary care is a situation in
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248 Kristanti, M. S., Kusmaryanto., & Effendy, C. (2021) which we have to say “enough” and not prolonging The third prima facie is justice. Traditionally justice treatment or care. means that equals must be treated equally, and unequal The last dilemma is the appreciation concerning the must be treated unequally. This traditional definition is formal facilities. Some palliative care experts in Indonesia attributed to Beauchamps and James (2019) added an are still discussing if hospice care is suitable for our culture. important notion, justice means fair, equitable, and Would we dare to let our loved ones stay in the hospital at appropriate treatment in light of what is due or owed to the end of their life? Can we ignore what people say to us affected individuals and groups. This implies that services if we put our loved ones in a nursing home? or do we prefer offered by nurses for caregivers should have the same to have them stay with peace in their familiar place: at quality and standard. We should provide the support that is home? What is the formal facility to support both patients systematic and structured. Intervention such as providing and caregivers that suits our economic condition, social basic care training is effective to maintain the QOL of status, and culture? patients in terminal illness (Kristanti, Setiyarini, & Effendy, 2017). Also, interventions offered should not only be for the Ethical Considerations in Involving the patient’s QOL but also maintain the caregivers’ well-being. Family The last principle is respect for autonomy. Respect for autonomy is to acknowledge patients’ right to hold views,
make choices, and take actions based on their values and As nurses, sometimes we need to decide to involve or not beliefs. It means that nurses or other healthcare workers involve family caregivers as part of our caring team. have to respect the autonomous decision of patients. The Becoming part of the team means that we may have an opposite is true: the decision by a non-autonomous person equal number of tasks and responsibilities. One of the should not be respected. Respecting the autonomous important tasks of healthcare workers (including nurses) is decision of patients means that nurses should obtain to foster autonomous decision-making of the patients or people’s agreement for any decision and any medical their proxy (Beauchamps & James, 2019). As healthcare interventions relate to them, keep confidentiality and workers, nurses have an ethical obligation to give all promises, and not deceive others (Gillon, 1994). This necessary information so that patients or their prox may principle may relate to the decision-making process in make autonomous decisions. In many cases, the final palliative care. Knowing how challenging the decision- decision is a shared-decision making between family making process in palliative care could be, advanced care caregivers and nurses. We may refer to the four prima facie planning (ACP) should be implemented soon in Indonesia. principles in making the decision: respect for autonomy, ACP is a discussion between the doctor, patient, and family beneficence, non-maleficence, and justice (Beauchamps & (and nurses) for planning the treatment and future James, 2019). decisions. The patient should be in good condition Principles of beneficence must take positive steps to physically and psychologically following a procedure. The help others, not merely refrain from harming them discussion during ACP may include if the patient accepts or (nonmaleficence). It is an ethical obligation to do good for refuses resuscitation when it is needed. ACP will make the patients and their families, including family caregivers. treatment and next step in the process easier for everybody Involving family caregivers in patient care will enhance the and prevent a traumatic event due to the obligation to collaborative aspect. We then need to identify who is the provide a decision in a short moment for family caregivers. daily ‘family caregiver’ and who is the ‘key person to make a decision for the patient’ because their roles are different. They can be the same person. But in Indonesia, this is not Implication for Nursing Practice always the case. There are cases where the main decision- maker is living in another part of the world. They can be the Nurses are part of health care professionals who have the one who is funding the treatment or the eldest ones in the most frequent contact and interaction with patients and family. Nurses need to identify this hierarchy so that they families. Therefore, nurses have an important task to can speak the right topic to the right person. observe patient's and family’s situations and needs. In Non-maleficence relates to the previous principles. The addition, knowing some of the ethical dilemmas that may principle of nonmaleficence obligates us to abstain from be faced by the family caregivers, nurses need to assess causing harm to others. This principle is identical to the and provide sufficient support for them. Patients and famous maxim Primum non nocere: “Above all [or first] do families are one unit in caregiving. By providing care to the no harm.” Although this principle does not appear in family caregivers, we support the patients in facing difficult Hippocratic writings, it is regarded as a fundamental moments in life due to their illness. principle in the Hippocratic tradition. It was found that that the most dilemmatic problem in family caregivers is their Conclusion unbounded tasks (Dresser, 2011). They do everything every time. In some cases, family caregivers of dementia Family caregivers have profound roles in caregiving for passed away when the patient was still alive. Nurses patients with chronic and terminal illnesses. Some ethical should assist them in setting up targets and boundaries to dilemmas along the journey were identified as signposts. maintain the family caregivers’ own QOL. Accordingly, nurses can utilize the four primary ethical
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249 Kristanti, M. S., Kusmaryanto., & Effendy, C. (2021) principles of caregiving to provide support for family caregivers' involvement in caring for a hospitalized patient with caregivers and enhance the family caregivers’ sense of cancer and their quality of life in a country with strong family well-being. bonds. Psycho‐Oncology, 24(5), 585-591. https://doi.org/10. 1002/pon.3701 Funk, L. M., Chappell, N. L., & Liu, G. (2013). Associations Declaration of Conflicting Interest between filial responsibility and caregiver well-being: Are there None declared. differences by cultural group? Research on Aging, 35(1), 78-
95. https://doi.org/10.1177/0164027511422450 Funding Gillon, R. (1994). Medical ethics: Four principles plus attention to None. scope. British Medical Journal, 309(6948), 184. https://doi.org/
10.1136/bmj.309.6948.184 Authors’ Contributions Keasberry, I. N. (2001). Elder care and intergenerational MSK was responsible for initiating the concept, writing, and relationships in rural Yogyakarta, Indonesia. Ageing & Society, drafting and had the ownership of data. K and CE provided 21(5), 641-665. https://doi.org/10.1017/S0144686X01008431 important intellectual content and contributed feedback while Kilic, S. T., & Oz, F. (2019). Family caregivers’ involvement in writing a manuscript draft. All authors have provided final approval caring with cancer and their quality of life. Asian Pacific Journal and agreement to be accountable for all aspects of the work of Cancer Prevention: APJCP, 20(6), 1735. https://doi.org/10. regarding content. 31557/APJCP.2019.20.6.1735
Kristanti, M. S., Effendy, C., Utarini, A., Vernooij-Dassen, M., & Authors’ Biographies Engels, Y. (2019). The experience of family caregivers of Martina Sinta Kristanti, S.Kep, Ns, MN, PhD is an Assistant patients with cancer in an Asian country: A grounded theory Professor at the Department of Nursing, Faculty of Medicine, approach. Palliative Medicine, 33(6), 676-684. https://doi.org/ Public Health and Nursing Universitas Gadjah Mada Yogyakarta. 10.1177/0269216319833260 Her research interest is on family caregiving in palliative care. Kristanti, M. S., Engels, Y., Effendy, C., Utarini, A., & Vernooij- Dr. C.B Kusmaryanto is an Assistant Professor at the Faculty of Dassen, M. (2018). Comparison of the lived experiences of Philosophy – Divinity, Sanata Dharma University, Indonesia. He family caregivers of patients with dementia and of patients with has written several textbooks on Medical Ethics and Bioethics. cancer in Indonesia. International Psychogeriatrics, 30(6), Dr. Christantie Effendy, SKp, MKes is an Associate Professor at 903-914. https://doi.org/10.1017/S1041610217001508 the Department of Medical Surgical, Faculty of Medicine, Public Kristanti, M. S., Setiyarini, S., & Effendy, C. (2017). Enhancing the Health and Nursing Universitas Gadjah Mada Yogyakarta. Her quality of life for palliative care cancer patients in Indonesia areas of interest are adult nursing, oncology, and palliative care. through family caregivers: A pilot study of basic skills training.
BMC Palliative Care, 16(1), 1-7. https://doi.org/10.1186/s1 References 2904-016-0178-4 Alice, d. B., Inger, P., & Mirjam, d. K. (2019). Werk en mantelzorg World Health Organization. (2010). WHO definition of palliative [Work and informal care]. Retrieved from https://www.scp.nl/ care. Retrieved from http://who.int/cancer/palliative/definition publicaties/publicaties/2019/02/13/werk-en-mantelzorg /en/ Beauchamps, T. L., & James, F. C. (2019). Principles of biomedical Yildiz, E. (2019). Ethics in nursing: A systematic review of the ethics. Oxford: Oxford University Press. framework of evidence perspective. Nursing Ethics, 26(4), British Medical Association. (2007). Withholding and withdrawing 1128-1148. https://doi.org/10.1177/0969733017734412 life-prolonging medical treatment guidance for decision
making. Oxford: Blackwell Publishing.
Dresser, R. (2011). Bioethics and cancer: When the professional Cite this article as: Kristanti, M. S., Kusmaryanto., & Effendy, becomes personal. The Hastings Center Report, 41(6), 14. C. (2021). Common ethical dilemmas of family caregivers of https://doi.org/10.1002/j.1552-146X.2011.tb00152.x palliative patients in Indonesia. Belitung Nursing Journal, 7(3), Effendy, C., Vernooij‐Dassen, M., Setiyarini, S., Kristanti, M. S., 246-250. https://doi.org/10.33546/bnj.1457 Tejawinata, S., Vissers, K., & Engels, Y. (2015). Family
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Belitung Nursing Journal Developmental assessment and Volume 7(3), 251-259 © The Author(s) 2021 early intervention for children with https://doi.org/10.33546/bnj.1480 developmental delays: A case study in South Australia
Mardiyanti1* and Amanda Case2
Abstract Background: Child development monitoring and screening have been mandated as a national health service worldwide, including Indonesia; however, a recent study found that Indonesian community health nurses experienced difficulties detecting and stimulating a child suspected of a developmental delay. Objective: To explore and provide an example of how Australian community health nurses, along with other professionals, contribute to a Universal child and family health service (UCFHS), a similar programme name in Indonesia is child developmental stimulating, detecting monitoring and early intervention programme or SDIDTK. Case study: This is a case study of a young Australian boy (4 years old) whom the mother reported that her son has unclear speech and he was not speaking as much as other children at his age. The researcher, as a nurse, delivered the child developmental assessment and play skills assessment and found that the child has subtle developmental gaps and was at risk for developmental delay. Several goal setting and programming ideas have been developed to meet the child developmental milestones. These include goals in fine motor skills, communication, problem-solving and personal-social skills which have been regarded as early intervention for the child. Together with the therapy from a Speech Pathologist, these goal settings and programming ideas have been collaborated with the kindergarten teachers and the family as well as the UCFHS nurses as part of the child developmental monitoring programme. Conclusion: Developmental delays can be detected through developmental and play assessments and can be followed by developmental stimulation and early intervention programme by developing goal settings and programming ideas around the delays or gaps in play or development.
Keywords child development; nurses; Indonesia; early intervention; play assessment
Child development monitoring and screening have been Ministers' Advisery Council, 2011; Macy et al., 2014; mandated as a national health service worldwide, including Ministry of Health of Indonesia, 2021). Indonesian Ministry in Indonesia. Examples of the service are Child Find and of Health has regulated SDIDTK’s Law number 66 by 2014 Oregon Healthy Start in the US; Universal Child and Family (Ministry of Health of Indonesia, 2021). This means that Health Service (UCFHS) in Australia, and Stimulasi, child developmental screening, stimulation, and early Deteksi Intervensi Dini Tumbuh Kembang (SDIDTK, stands intervention should be provided regularly in Indonesian for growth and developmental assessment, stimulation and community health centres (Puskesmas). However, a recent early intervention) in Indonesia (Australian Health study found that Indonesian community health nurses
1 Department of Pediatric Nursing, School of Nursing, Faculty of Health Article Info: Science, Islamic State University UIN Syarif Hidayatullah Jakarta, Received: 14 April 2021 Revised: 12 May 2021 Indonesia Accepted: 10 June 2021 2 College of Nursing and Health Sciences, Flinders University, Adelaide, Australia This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which allows Corresponding author: others to remix, tweak, and build upon the work non-commercially as long as the original work is properly cited. The new creations are not necessarily Ns. Mardiyanti, MKep., MDS licensed under the identical terms. Faculty of Health Science, Islamic State University UIN Syarif Hidayatullah Jakarta. Jl. Kertamukti no.5 Ciputat, Tangerang Selatan, E-ISSN: 2477-4073 | P-ISSN: 2528-181X Banten, Indonesia. Phone: +62217401925 Email: [email protected]
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251 Mardiyanti, & Case A. (2021) experienced difficulties detecting and implementing early planning component becomes the issue to his imprecise intervention of a child suspected of a developmental delay speech. There were no other issues in developmental skills (Mardiyanti et al., 2020). Meanwhile, other countries have at the time, as she found Evan’s play, attention and social delivered the programme successfully and may become an skills, and receptive language were appropriate to age. example for Indonesian health professionals, especially Evan will become a successful verbal communicator if he nurses. This article provides an example of how a child has regular exercise on speech motor tasks, such as suspected of developmental delays has been screened, teaching precise movements for different speech sounds assessed, stimulated and intervened earlier so that the and sequencing sounds together to form words and delay can be minimised or corrected before the child enters sentences. In addition, she also recommended referring the primary school where the delays may become Evan to Ear, Nose and Throat (ENT) specialist to find out problems. any structural issue which may impact his oral motor skills. The Speech Pathologist advised having a hearing test with Australian Context an audiologist to find any hearing issues that may be The Australian education system provides primary, impacting his processing of speech sounds. She also secondary and tertiary education. Primary education starts advised the mother to include Evan in the Early Entry from the foundation level (kindergarten or preschool from Preschool Programme where he attended in July 2013 until age 3.5 to 5 years) through year 6 or 7 (Department of now, in one of the well-known Adelaide Kindergartens. Foreign Affairs and Trade, n.d.). Kindergarten or preschool The kindergarten principal said that she had made a are part of early childhood education which responsible for referral to the Department of Education and Child providing care and supervision for young children, Development to get support service, but to date, there has preparing them for school, and ensuring that the children been no response. The family paid for private therapy as a are able to effectively participate in subsequent learning result. After following all the recommendations from the opportunities (Department of Foreign Affairs and Trade, speech pathologist, it concluded that he had not had any n.d.). This case study took place in South Australia issue with hearing or structure disorder in his mouth. kindergarten. Currently, one teacher participates regularly in teaching different speech sounds as suggested by the speech Case Presentation pathologist. Since February’14, the focus has been on the speech of words ending with n, ch, f and c/k. Evan shows many improvements in his speech, as reported by the Evan (not his real name), a 50-month-old male, was born teacher and his mother. prematurely on March 2010 at 36-week of gestation, with During observation in the kindergarten, it was noted the his birth weight of 3600 grams. During his first week of life, teachers and his best friend (Nivedh) relatively understand he experienced jaundice. He was breast-fed and formula- what Evan’s says, but it is likely difficult for other friends or fed during the first 6-month of life because of reduced adults who are unfamiliar with him. During free play, he breast milk supply, then ceased breastfeeding completely pretended to be a spiderman with Nivedh excitedly. He can at around 6-months. No feeding difficulties were reported show others something that interested him, imitates others, during the infant period or at his current age. Physically, his join in a group if requested, seek adult assistance, and weight and height are appropriate for his age, and he also respond to questions. He also plays like others either inside looks taller than other children at his age. The only concern (craft, puzzle, draw, and storytelling) or outside (climb the that his mother and teacher reported was his unclear rungs, swing and slide). However, his unclear speech speech. Dribbling sometimes occurs involuntarily during his made the play assessment to some point hard for the speech. Mom reported a speech delay of 6-months, as assessor. For example, his verbalisation about the play diagnosed and assessed by the speech pathologist. scenario is hard to understand. In addition, the mother In March 2013 (aged 3), Evan’s mother had referred reported that he does not have any friends at home him to a speech pathologist due to unclear speech as he because there is no other child his age nearby. He usually was not speaking as much as other children at his age. plays with his little sister (Asley, 15-month-old) and his Evan was assessed using the Diagnostic Evaluation of mother, who was not working at that time. Since starting Articulation and Phonology (DEAP) (Dodd et al., 2006). It Kindergarten, Evan was not attending other settings for was found that his speech is relatively clear at the single early childhood programme, such as child care. word level, but when he tries to sequence sounds to say longer words and put words together, the clarity of his Methods speech diminishes and becomes very difficult to understand. For example, he said: “hou” for a house, “sli” Structured observation has been performed two times; for slide and “muni” for “monkey”. Dribbling and low oral once at the kindergarten class and playground, and muscle tone result in difficulty to precisely make and secondly observation at the child home. Informal interviews sequence the tiny movements necessary for connected were also performed with the mother and the kindergarten speech (Rosemary & Usha, 2021). The speech pathologist teacher. reported that poor motor control in his mouth and motor
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1. Child developmental assessment Guevara et al., 2013). The ASQ-3™ also utilised by the Evan’s developmental skills have been assessed using the Child and Family Health Service (CaFHS) in the Adelaide Australian Developmental Screening Checklist (ADSC), region, which will subsequently be used if families or child Age and Stage Questionnaire (ASQ-3™) and Play skills health nurses are concerned about the child’s development checklist (Heidemann & Hewitt, 2010). ADSC is a (Arrowsmith, May 28, 2014). Evan’s ASQ-3™ results have professional-completed checklist developed by (Burdon., been reviewed by Arrowsmith (May 28, 2014) from one 1994), whereas ASQ-3™ is a parent-completed checklist local CaFHS in the Adelaide region. She suggested some developed by Squires et al. (2009). The play skills checklist sources and materials for developing Evan’s stimulating is adapted from Heidemann and Hewitt (2010) and is an programme. observational tool. The use of these tools combines both Play assessments are often taken in screening children, points of view (parents and professionals), which may differ as play is the central occupation for children (Lynch & in how they judge the child’s ability. ASQ-3™ has been Moore, 2016). Play is complex and may reveal many things recommended widely in English-speaking countries about the child’s development relative to others, including because of its sensitivity and specificity (85% and 86%, developmental status and functional skills (Casby, 2003) respectively) (Mackrides & Ryherd, 2011). Many studies and cognitive ability (Fink et al., 2012). recommend ASQ as a standardised screening tool to be used during well-child visits in any clinical settings either in 2. Observation urban or rural settings (Hamilton, 2006; Rydz et al., 2006; The observation records can be seen in Table 1. Rybski & Wilder, 2008; Burns et al., 2009; King et al., 2010;
Table 1 Observation records
Date: 12/5/2014 Observer: Yanti Child’s name & Age: Evan (49 month) Background info: every morning, the one starts with a group Time: 09.15 session, singing, checking, and greeting each other’s (±20 Setting: Morning session in kindergarten minutes). Who is present: one group (23 children), one teacher (leader), Other involved: one parent whose daughter was unwell. and four facilitators Time Observation 09.15 T/ asking all students to come to the playroom for the group morning session. E/ follow the instruction and sit down at the front corner closed to his best friend Nivedh. T/ greeting and student too, T/ asked all students to greet all teachers using other languages such as Spanish, French, Chinese, Vietnamese, and Indonesian. Some students follow the greetings; some were not. E/ does too. T/ then asked about the weather today, some students answered correctly, and some were quiet. E/ tried to give his opinion by raising his hand, but the T/ did not look at him as he sat down at the corner. Finally, he said something, but it was not clear. When another student gave a comment to the T/, Nivedh laughed and E/ laughed excitedly, T/ reminded them that there was not something funny, and they stopped laughing. 09.35 Small group session (Reading story/storytelling) One facilitator with four students (two boys and two girls) sat down in the corner. F/ asked which book they wanted to read. The boys argued as they wanted to read different books, but finally, E/ agreed with his friend and chose to read his book later. F/ read a book about Charlie and Lola with the title “I like tomato” in front of the students. The boys actively questioned and answered with the F/, and the other two girls’ students were very quiet. E/ sat beside the F/, which was not a good position as he needed his head to keep turn right to see the book. While being suggested to move, E/ was still in the same position. During the conversation, sometimes F/ understood what E/ said, sometimes not. It was noticed that E/ saliva sometimes splashed while he was talking. E/ looked frequently opened his mouth during storytelling. He pointed to specific pictures frequently and said some words such as “to..a..too” for “tomato”; “..at..is..nge” for “eat fish finger” etc. He asked for a specific picture in the book, and F/ explained it and replied with a question and E/ answered it correctly. It was noticed that his mouth sometimes kept open with the tongue coming out a little bit. 09.50 Fruit time. E/ walked and grabbed his lunch book. Opened the bag’s zipper with his left hand. He took the apple and brought it to the T/ asked for help to cut it and brought it back to the previous place where he left his bag. Together with Nivedh, he enjoyed his apple. I noticed again that E/ could not control his saliva while eating. Date: 13/5/14 Observer: Yanti Child’s name and age: Evan (49 months) Background info: every Tuesday (once a week), S stimulated E Time: 09.40 with a words card, asked E to mention the word and arranged it Setting: Kindy’s office in the same group with other words with the letter ends with Ch, Who is present: One teacher (S) and Evan N, F and C/K. The programme has started on 26 February 2014. The cards consist of a picture of a word and its letters. Time Observation 09.40 E/ came to the office room in the kindy as the T/ asked him to do so. E/ sat down in a chair, and S/ asked him to sit on the floor because it was for the observer. E/ asked why the observer came to the office, and S explained it simply, and E/ asked again, but the observer could not understand what he’s talking about. S looked to understand what E/ said, and she explained and then shifted the focus to the activity. S started the intervention by explaining about talking at the right speed. She explained using a picture of three types of speed talking: slow (snail), just right and too fast (running people). She asked E/ to speak at the right speed. E/ looked at the cards and answered every question. S asked E/ to classify
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Table 1 (Cont.) the card based on its sound. There were four groups for words ending with the sound n—ch—f—c/k. Examples of the word card are: ▪ Bee-Bean-Beach-Beak ▪ Win-witch-whiff-weck ▪ Lee-lean-leech-leak ▪ Tif-teen-teak-teach S asked E/ to sound the words correctly, and E/ did it sometimes clear and sometimes unclear. E/ looked excited with these games, and he tried to sound the words and to put them in the correct group. Sometimes he kept busy on where to put the cards to the correct group and not follow S instruction; he sometimes asked “where to put this on?” and S kept remain E/ to sound it correctly and said, “you know where to put don’t you” E/ looked enjoy if S looked a bit disturbed with his questions. S looked patient and asked E/ to “click them out” every time he finished grouping the cards. There was one word, “tea”, which did not fit with those four groups, and E/ noticed that correctly. The second games started. S asked E/ to close his eyes while she hid some words. After finished, S asked E/ to open his eyes. S asked E/ to find all the words and to pronounce them correctly. E/ could find most of the words, and when he looked difficult to find, S gave some clue of where the word was. S sometimes reminded E/ to speak just at the right speed if she could not understand what E/ said. T/: Teacher S/: teacher responsible for Evan language therapy E/: Evan F/: Facilitator
Results from the developmental assessment A summary of Evan developmental skills can be seen in Table 2.
Table 2 Summary of Evan developmental skills from ADSC and ASQ-3
No Domain ADSC ASQ-3™ 1. Communication Evan is able to name particular An overall score is 45, which is above the cut-off (30.72). Evan is objects, join in songs/nursery able to answer common questions and act to three commands rhymes, identify “same/different”, ask without pointing or repeating (give me the pen, open the book and WH- questions, respond appro- stand up). Sometimes, he is able to name at least three items for priately to questions, and understand common questions, such as “tell me the names of some animals”. or verbalise physical needs. Sometimes, he is able to mention the ending of words (-s, -ed, - Apparently, his language skills are ing: such as I see two cats, I kicked the ball, I am playing) and around the age of 44-49 month. uses all of the words in a sentence (“a”, “the”, “am”, “is” and “are”). 2. Fine motor Evan is able to pincer grasp, holds a An overall score is 35, above cut-off (15.81) but close to grey pencil in hand, not a fist, draws areas. He is able to draw three shapes and a picture of people horizontal and vertical lines, turns with at least three features (head, eyes, arms, legs). Sometimes doorknob to open the door, cut paper he is able to put together a 5 to 7-pieces puzzle, cut a piece of with scissors, and draw a circle. paper using a scissor or unbutton one or more buttons of his Apparently, his fine motor skills are clothes. However, he has not yet drawn or colour in within line. around the age of 44-49 month. 3. Gross motor Evan is able to jump forwards: feet An overall score is 60, which is above the cut-off (32.78). Evan is together, hops on foot: on the spot, able to catch a ball, climb, throw a ball, hop up and down, jump balances on 1 foot for a few seconds, forward and stand on one foot for 5 seconds, which are can sit on the floor cross-legged, appropriate to his age. walks a straight line. Apparently, his gross motor skills are around the age of 50-55 months. 4. Problem Evan is able to tell the name of a An overall score is 50, which is above the cut-off (31.30). He is solving/cognitive friend or playmate, maintain interest able to repeat three numbers in order without repeating the or involvement for few minutes, request, distinguish items by their size, name five different refers to own gender accurately, colours, and count items. Sometimes he understands the understands 2: picks two objects, concept of “under”, “between” and “middle” and does pretend tries to count and understands 3: play. picks three objects. Apparently, his cognitive skills are around the age of 44-49 months 5. Personal-social Evan is able to ask for help if needed, An overall score is 45, which is above the cut-off (26.60). He is can tell his own first name, can wash able to serve himself, wash his hands, and brush all his teeth and dry hands, recognise the gender without any help. Sometimes he is able to mention the names of of his friend Nivedh and himself, is two or more playmates and recognises his identity, such as his able to go to the toilet by himself, first and last name, age and sex. sometimes joins in play with others. Evan is around 44 months development in this area.
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Table 2 (Cont.) 6. Overall Evan has strengths in the area of No problems in hearing, vision, behaviour and medical problems Gross Motor and is just under age in the last several months. Evan’s mum worries about two things: appropriate for most other areas. “not talks like other children at his age” and “Others do not There are some impacts of understand most of what your child says”. Since under speech communication difficulties in his therapy last year, Evan’s speech now shows many social and communication skills. improvements. There are also some slight delays in fine motor development.
Play assessment checklist When looking at each domain in the checklist, more Based on the play checklist, which looked at areas of social focus should be taken on the fine motor area, play, communication, pretence and problem solving, Evan communication, problem-solving and personal-social. This does pretend play by using imaginary objects and uses means that more activities in these areas should be verbal declaration approximation (“I am a Spiderman”). supported and created. His dislike to colour in should be During observation, he enjoys and interacts with Nivedh, addressed. In addition, given his unclear speech, this may and they play together as they are Spiderman and others lessen his motivation to participate in play with others or are the bad people. He enjoys playing in a group if an adult lessen his social interaction later when others respond requests it. He is able to show others an interesting object unexpectedly or when he realises that his speech is by pointing, bringing the object or express verbally, and different from other children. This can be seen during engaging in the activities for several minutes or until the observation in the kindergarten; Evan spent his time mostly activity finishes. He is able to negotiate with a peer about play with Nivedh and not with other children, though he is which book should be read during the storytelling group, an active person and show excellent enthusiasm during although then he accepted the adult suggestion without group sessions and story-telling. He tries to participate and arguing. There are some difficulties in his communication connect with others, but sometimes others do not respond during a play episode, verbalising about the play scenario to him due to his unclear speech. Therefore, we need to to his play partner, and being understood. He also tends to develop strategies not only for building his articulation play with one (the same) play partner. However, due to speech but also for encouraging him to interact with other parents’ permission, the observation settings only children. happened in the kindergarten. Therefore, there is a need to Moreover, support should also be provided to help him observe the child’s play skills in his house, where he achieve the kindergarten’s learning outcomes so that he spends most of his time. can build a strong sense of identity, feel connected and contribute to the world, a strong sense of well-being, feel Analysis confident, independent and involved learner as well as an Overall, Evan’s developmental level is relatively active communicator (Pasaneda Kindergarten, 2012). appropriate for his age. He still has many opportunities to Perhaps providing a positive experience will help him improve the “sometimes” skills into his “routine” skills to construct his strong identity, confidence and indepen- help him reach his full potential. Evan’s mother and the dence. teachers are very good sources in shaping his development. During observation, the mother is very active Goals setting in questioning and clarifying Evan’s progress with the Goal setting aims to provide assistance for Evan and his teachers. The teachers also persistently delivered the family to optimise his child development. The goals have activity suggested by the speech therapist. It is believed been created based on Evan’s developmental level and his that at the end of the kindergarten programme, Evan will be emerging skills that need to be strengthened to achieve his more than ready for his next primary school. full potential. Please see Table 3 (Goals for Evan) and Table 4 (Goals and activities for the families).
Table 3 Goals for Evan
Fine Motor Goals Goal 1. Evan will colour a picture in a colouring book mostly within the lines minimally three times a week in his time at home by July 30. Goal 2. Evan will unbutton one or more buttons while undressing his clothes every time he comes back from school or playing with a cloth buttoning strip by June 30. Goal 3. Using a child-safe scissor, Evan cuts papers in half on a more or less straight line 3 times a week at home by June 30. Goal 4. Using a minimum five- to seven-piece interlocking puzzle, Evan puts them together correctly three times a week by June 30. Communication Goals Goal 7. (Collaboration with the intervention from Speech therapy). Then requested to sound the words provided, 50 % of Evan’s speech sounds are correct and clear by July 31.
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Table 3 (Cont.) Problem-Solving Goals Goal 8. When requested, Evan pretends to play with one different/new child partner (not Nivedh or his little sister) in the playground or during kindergarten free play minimally once a week by July 30 (collaboration with the teachers). Goal 9. When requested to participate in socio-dramatic play, Evan can play with two or three children and interact with each other in the kindergarten play sessions 50% by July 31. (Collaboration with the teachers). Personal-Social Goals Goal 10. When asked by his mum after finish his school session, Evan mentions the names of two or more playmates (not including his little sister) by July 31.
Table 4 Goals and activities for the families
No Goals Items Activities Description 1. Evan family will look for and use Explain the CaFHS services in South Australia that family may gain benefits. the services from one of the local Provide the website address (www.cyh.com) or the CaFHS local address and contact CaFHS in Adelaide by June 30 number close to their area (Edwardstown CaFHS; 2 Vurness Avenue 5039, Call number (e.g., Kid’s health and child 1300 733 606 between 9 am and 4.30 pm, Monday to Friday to make an appointment). developmental monitoring pro- Explain that Evan needs an-ongoing services from CAFHS to monitor his development gramme). closely (e.g., using ASQ-3™ developmental monitoring until 60-month-old), including the early childhood intervention programme and parenting support. 2. Evan family will look for and use Explain the Forbes Children’s Centre services that the family may gain benefits, such as: the services at Forbes children’s • Sessional preschool for children for five sessions a week in the year prior to starting centre for Early Childhood school. Development and Parenting by • Long daycare child care for Evan or Asley. So, the mother will be helped in raising the June 30. children. • Many programmes will benefit the family, such as Dad engagement, developmental play sessions, Saturday playgroup, Family service coordinator, Circle of Security, Premier’s be active challenge, Mums of toddler group). 3. Evan’s family will read to Evan Offer article to the family about the risk for reading problems in children with speech sound every day. disorders (Anthony et al., 2011). The Forbes Children’s Centre also creates a programme, Let’s Read, to support families reading with their children. Motivate the family to create a reading programme every twice a week at home.
Programming Ideas and ongoing activities, although he might avoid these (e.g. Programming ideas aim to achieve those goals that are colour in) (Johnson-Martin et al., 2004). The strategy could created based on Evan’s emerging skills and the be to rearrange the environment (e.g. remove the materials availability of resources. Play is extremely important for the child persists in using for a period during the day and children’s learning. It is regarded as an activity that helps offer other activities) or to become more directed (e.g. “We develop the child’s cognition, communication, socialisation, need to spend some time colour in first, and then you can sensory-motor functions, problem solving and self- play with trampoline”). One activity can be used for some awareness (Canadian Association of Occupational or all domains of development; for example, storytelling in Therapist, 1996 cited in Stagnitti, 2004). The activities a group of children may involve cognitive, fine motor, gross should be integrated into the child’s immediate interests motor, communication and social skills (Table 5).
Table 5 Activities for Evan
Goals Activities Description Fine motor’s goals Colour in games Provide “Spiderman colouring books” and colour pencils. Ask him to colour in. If he does not show interest, he will be attracted by modelling first and saying, “I am busy with Spiderman”. Alternatively, guide his hand and later let him do it independently. Encourage him by stating, “can you cover all the white?” and “try and stay inside the lines.” Unbutton games Ask him to unbutton his cloth or another cloth strip from the dressing vest or doll, which has large, medium and small buttons. If he does not know how to approach this task, slowly demonstrate for him. Then try to assist him physically. He should hold and lightly pull the cloth next to the hole with one hand, grasp the button and push it through the hole with the other hand. Adapted from “The Carolina Curriculum for Pre-schoolers with Special Needs” (Johnson- Martin et al., 2004)
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Table 5 (Cont.) Cut and draw Place a piece of paper and the safety scissors in front of the child. Draw a line from the games left to the right side of the paper. Ask him to cut the paper in half or to cut all of the ways across the paper. Give him verbal cues if needed (e.g., “follow the line”). Or use tape by placing it on either side of the line to encourage the child to stay on the line. If he is able to do this, expand the games by cutting a circle, square or pictures that he made and coloured in. It may be helpful to trace around the outline of the picture with a marker before cutting it out. Encourage the child to stay on the line and not cut into a picture. Select pictures easily to cut, then stick them into a paper board. Ask him to put his name and date on it. At the end of June, the families can know how far his progress is. Adapted from “The Carolina Curriculum for Preschoolers with Special Needs” (Johnson- Martin et al., 2004) Puzzles Choose a puzzle that has minimally 5 to 7-pieces. Encourage him to finish the puzzle. If he cannot do it, try to work together or one-by-one or backchain - do all but the last one and ask him to add the last piece. Next time do two last pieces, etc. Communication 3-related items Choose three pictures from common categories (fruit, school items, food), then write the games name of the picture on a piece of paper, place it close to the picture. Ask him to answer your question: “things that we eat”, “things in the school”, “things that are yellow”. Encourage the child to choose three pictures and bring them together with the name. If he is able to do this, expand the games by only stating the name of the item. Encourage him to be familiar with the letters. Encourage him to verbalise the name correctly. Model the correct articulation of the words, then ask him to sound them out. Identifying the Use the word cards from speech therapy or download the new one from sound of words www.busybugkits.com.au/freebiesarticulation/. Choose the letter of words that Evan needs to practice. Expand the games to “hungry for K’s”. Tell him and other children in a group that they are on a special diet and can only eat things that start with the /K/ sound. Ask them to put the things into their lunch box (e.g., carrots, corn, cucumber, ketchup). To make it more complex, add other objects that start with /k/ but cannot be eaten (e.g., cards, cat, key, cow). Alternatively, put some words that do not have any /k/ sound. Count to see how much they can put in their lunch box. Adapted from www.phonologicalawareness.org/ #!phoneme/cr2d Problem-solving Spiderman Ask Evan to play “Spiderman shopping”. Creates the situation like a shop. Evan becomes shopping a Spiderman (provide Spiderman costume), and his friend pretends to be a clerk. Provide pictures as a cue to prompt, and ask Evan to buy things that start with the letter /f/. Encourage both of them to interact with each other. Spiderman Sick Ask Evan to play “Spiderman sick” and go to a clinic and meet customer service, doctors, pharmacists, and other people who need help.
Discussion monitor the child development closely and support the family. Parent’s willingness should also be supported so Evan, who has speech delays, shows much improvement that they can participate in the programmes fully. in his communication since he started the Early Entry The case in this report might become a good sample programme in kindergarten and several session therapies where the child may show delays in the communication since last year from the Speech Pathologist. Evan will be skills that may not intervene earlier if parents had not more than ready for his next school journey if he and his sought help from the speech therapist. Early detection of family join many community-based programmes and do a the developmental problem may allow an early intervention lot of activities, as suggested above. programme to reach children’s full potential, academic Some articles show that Subtle Developmental success, independence, and confidence. Problems (SDPs) and Speech sound disorders are at high risk of academic failure, social-emotional disturbance and Nursing Implications behaviour problems (Glascoe, 1999; Williams & Holmes, Nurses in the community health centres may be inspired 2004; Anthony et al., 2011). These may be due to poor by this case study and use the information for developing motor control and motor planning inadequacy that require nursing care for children suspected of a developmental much more intensive developmental stimulation. This delay or subtle development. Evan’s goals may also be stimulation may be hard to do if the family does not have used for developing nursing outcomes, and Evan’s and enough resources and must deal with other demands such family activities used for developing nursing interventions. as work and other siblings. Therefore, it is important to The developmental screenings (either ADSC or ASQ- refer all children with high risks of developmental delays to 3™) showed Evan’s development was normal, although an early intervention programme, although they have not the mother’s concerns about Evan’s speech problem, yet any diagnosis. It also important as well for CaFHS to therefore play skills assessment may be beneficial in finding which areas of development are specifically at risk
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257 Mardiyanti, & Case A. (2021) of delay. Therefore it is recommended to use play skills Amanda (Mandy) Case, MOccTh(GradEntry) is an Associate assessment, such as the Pretend Play Enjoyment Lecturer at the College of Nursing and Health Sciences, Flinders Developmental Checklist (Stagnitti, 2017) combined with University, Australia. Her work with children with delays and disabilities as a Developmental Educator/Occupational Therapist developmental screening tools such as Kuesioner spans over 30 years. Mandy has taught the Play and Early Praskrining Perkembangan (KPSP) in the SDIDTK Intervention topic at Flinders University for the last ten years. Her programme. It is also suggested that policymakers train particular interest is play in young children with delays and community health nurses for developmental assessment disabilities. skills and play assessment skills to improve the quality of child universal health service in Indonesia. References Anthony, J. L., Aghara, R. G., Dunkelberger, M. J., Anthony, T. I., Limitations of this Study Williams, J. M., & Zhang, Z. (2011). What factors place There are several limitations to this study. Firstly, this is a children with speech sound disorders at risk for reading problems? American Journal of Speech-Language Pathology, single case study, and further studies would need to 20(2), 146-160. https://doi.org/10.1044/1058-0360(2011/10- include more subjects. Secondly, ideally, child 0053) development skills and play skills should be assessed in Arrowsmith (May 28, 2014). [Personal communication]. three different areas (house, school and other public areas Australian Health Ministers' Advisery Council. (2011). National such as playground); however, this study only conducts framework for universal child and family health services. observation in the school and public areas. And thirdly, this Retrieved from http://www.health.gov.au/internet/main/pub case study did not report on outcomes of the early lishing.nsf/Content/AFF3C1C460BA5300CA257BF0001A8D 86/$File/NFUCFHS.PDF intervention for the child, and further studies would do well Burdon., B. E. (1994). Australian Development and Screening to include both quantitative and qualitative outcome data. Checklist Examiner's manual. Sydney: Harcourt Brace Psychological Corporation. Conclusion Burns, C., Dunn, A., Brady, M., Starr, N., & Blosser, C. (2009). Pediatric primary care (4th Ed ed.). St.Louis, Missouri: Evan’s developmental skills and play are relatively Saunders Elsevier. Casby, M. W. (2003). Developmental assessment of play: A model appropriate for his age based on the tools applied, for early intervention. Communication Disorders Quarterly, although ASQ-3™ picked up parental concerns that need 24(4), 175-183. https://doi.org/10.1177/1525740103024004 to be referred into an early intervention programme, 0301 followed by monitoring his development closely. Parents Department of Foreign Affairs and Trade. (n.d.). The Australian are strongly recommended to raise any concerns about education system: Foundation level. Retrieved from their child development and seek help from professionals. https://www.dfat.gov.au/sites/default/files/australian-educatio Parents’ concern and willingness should be encouraged n-system-foundation.pdf for the success of the early intervention programme and Dodd, B., Hua, Z., Crosbie, S., Holm, A., & Ozanne, A. (2006). the well-being of the child. Diagnostic Evaluation of Articulation & Phonology (DEAP). San Antonio, TX: PsychCorp of Harcourt Assessment.
Fink, N., Stagnitti, K., & Galvin, J. (2012). Pretend play of children Declaration of Conflicting Interest with acquired brain injury: An exploratory study. The authors have no conflict of interest to declare. Developmental Neurorehabilitation, 15(5), 336-342. https:// doi.org/10.3109/17518423.2012.655798 Funding Glascoe, F. P. (1999). Using parents' concerns to detect and This study was part of a major assignment in Master of Disability address developmental and behavioral problems. Journal for Studies. The author (Mardiyanti) had funding support from AAS Specialists in Pediatric Nursing, 4(1), 24-35. https://doi.org/ (Australian Award Scholarship) and Islamic State University UIN 10.1111/j.1744-6155.1999.tb00077.x Syarif Hidayatullah Jakarta, Indonesia. Guevara, J. P., Gerdes, M., Localio, R., Huang, Y. V., Pinto- Martin, J., Minkovitz, C. S., . . . Kavanagh, J. (2013). Acknowledgment Effectiveness of developmental screening in an urban setting. We thank Pasadena Kindergarten South Australia, the Faculty of Pediatrics, 131(1), 30-37. https://doi.org/10.1542/peds.2012- Health Science UIN Syarif Hidayatullah Jakarta and Flinders 0765 University for their great supports. Also, special thanks to Evan’s Hamilton, S. (2006). Screening for developmental delay: Reliable, mother for her openness and kindness. easy-to-use tools. Journal of Family Practice, 55(5), 415.
Heidemann, S., & Hewitt, D. (2010). Play: The pathway from Authors’ Contribution theory to practice. United States of America: Read Leaf Press. All author contributes to the study’s conception and design. MM Johnson-Martin, N. M., Hacker, B. J., & Attermeier, S. M. (2004). and MC conceptualized the study. MM performed data collection, The Carolina curriculum for preschoolers with special needs MM dan MC drafted the original version of the manuscript. All (2nd ed.). Baltimore: Paul.H.Brookes Publishing Co. author accepts the final manuscript. King, T. M., Tandon, S. D., Macias, M. M., Healy, J. A., Duncan, P. M., Swigonski, N. L., . . . Lipkin, P. H. (2010). Implementing Authors’ Biographies developmental screening and referrals: Lessons learned from Mardiyanti, RN., MKep., MDS is a Lecturer at the Nursing a national project. Pediatrics, 125(2), 350-360. https://doi.org/ Programme of the Faculty of Health Science UIN Syarif 10.1542/peds.2009-0388 Hidayatullah Jakarta, Indonesia. She is also an Alumni of Master of Disability Studies, Flinders University, Australia.
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Lynch, H., & Moore, A. (2016). Play as an occupation in community child care settings. Journal of Allied health, 37(1), occupational therapy. British Journal of Occupational 34E-49E. Therapy, 79(9), 519-520. https://doi.org/10.1177/030802261 Rydz, D., Srour, M., Oskoui, M., Marget, N., Shiller, M., Birnbaum, 6664540 R., . . . Shevell, M. I. (2006). Screening for developmental Mackrides, P. S., & Ryherd, S. J. (2011). Screening for delay in the setting of a community pediatric clinic: A developmental delay. American Family Physician, 84(5), 544. prospective assessment of parent-report questionnaires. Macy, M., Marks, K., & Towle, A. (2014). Missed, misused, or Pediatrics, 118(4), e1178-e1186. https://doi.org/10.1542/ mismanaged: Improving early detection systems to optimize peds.2006-0466 child outcomes. Topics in Early Childhood Special Education, Squires, J., Twombly, E., Bricker, D., & Potter, L. (2009). ASQ-3 34(2), 94-105. https://doi.org/10.1177/0271121414525997 User's Guide. Baltimore: Paul.H.Brookes. Mardiyanti, M., Cuthbertson, L., & Jewell, P. (2020). What roles do Stagnitti, K. (2004). Understanding play: The implications for play Indonesian nurses play in the early identification and assessment. Australian Occupational Therapy Journal, 51(1), intervention of children with developmental disabilities? A 3-12. https://doi.org/10.1046/j.1440-1630.2003.0038 7.x qualitative study Belitung Nursing Journal, 6(2), 35-40. Stagnitti, K. (2017). Pretend Play Enjoyment Developmental https://doi.org/10.33546/bnj.1039 Checklist (PPE-DC). Retrieved from https://www.learntoplay Ministry of Health of Indonesia. (2021). Tumbuh kembang optimal events.com/product/pretend-play-enjoyment-developmental- dengan Stimulasi, Deteksi Dan Intervensi Dini Tumbuh checklist-ppe-dc-starter-package/ Kembang (SDIDTK) [Optimal growth and development with Williams, J., & Holmes, C. A. (2004). Improving the early detection Stimulation, Detection and Early Intervention on Growth of children with subtle developmental problems. Journal of (SDIDTK)]. Retrieved from https://kesga.kemkes.go.id/berita Child Health Care, 8(1), 34-46. https://doi.org/10.1177/ lengkap/eyJpdiI6InpCYVovb28yeXYrelNiaGxMOGZUT0E9P 1367493504041852 SIsInZhbHVlIjoiVGhhWnlBa0l6VWlVeThlNzRKcSt1dz09Iiwib WFjIjoiMzJlY2E1Yjc1OTNkOWE2MmU1ZjRlOGY2YmZlZmI 4MTJkOWI5NTcyYzY1NGM4MjZmNTk5MjM1NDNhNjdkYjh mZiJ9 Cite this article as: Mardiyanti, & Case A. (2021). Pasaneda Kindergarten. (2012). Parent information booklet. Developmental assessment and early intervention for children Retrieved from www.pasadenakgn.sa.edu.au/parentinfo.htm with developmental delays: A case study in South Australia. Rosemary, & Usha. (2021). Oral muscle tone in speech and Belitung Nursing Journal, 7(3), 251-259. https://doi.org/10.335 feeding. Retrieved from https://www.playstreet.in/2021/01/ 46/bnj.1480 18/oral-muscle-tone-in-speech-and-feeding/ Rybski, D. A., & Wilder, E. (2008). A pilot study to identify developmental delay in children in underserved urban
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Belitung Nursing Journal Reflections on International Nurses Volume 7(3), 260-261 © The Author(s) 2021 https://doi.org/10.33546/bnj.1500 Day: Current status, issues, and the future of nursing in Indonesia
Feni Betriana1 , Tetsuya Tanioka2* , Rozzano C. Locsin3,4 , and Nelwati5
Dear Editors, still not significant enough, as nurses continue to risk their May 12 is celebrated as International Nurses Day and lives ― sometimes losing their lives ― in order to save their as the birthday of Florence Nightingale, the founder of patients’ lives and the lives of other co-workers. This Modern Nursing (International Council of Nurses, 2021). appreciation points to the realization that nurses and their For nurses around the world, this is a momentous occasion practice deserve political and social actions for their reflecting on the state of nursing and how nurses are valuable work, supporting a deserved salary raise advancing the profession. Highlighted by the International (Gunawan, 2020). While the risks to nurses’ lives on the Council of Nurses are three issues; COVID-19 infections front lines is evident, the global society must finally realize and deaths among nurses and other healthcare workers; the professional mandate that frontline nurses are soldiers- stress and burnout in the nursing profession; and nurse at-war, whose lives are valuable, therefore need protection shortage and retention (International Council of Nurses, by all costs from being uselessly exposed to an invisible 2021). Regarding issues affecting the discipline and organism and become patients themselves (Chatterjee & professional practice of nursing, nurses in Indonesia are Kagwe, 2020). austerely experiencing these issues because of the Second, in Indonesia, there are various classifications pandemic; of practicing professional nursing; and of nurses based on education. The Indonesian Nursing conducting research and enhancing nursing education. Law No. 38 the Year 2014 described categories of nursing First, with the COVID-19 pandemic, nursing practice education into vocational education, academic education, has become more challenging. The invisible disease agent and professional education. Vocational education is a has caused untimely deaths of many healthcare three-year program, while the academic program prepares professionals, making nursing practice much harder nurses for a baccalaureate degree in nursing, Masters in (Chatterjee & Kagwe, 2020) and less attractive as a Nursing, and Doctor of Nursing. With an academic degree, profession. As of March 2021, the Indonesian National professional nursing education qualifies nurses through Nurses Association reported that more than 15,000 nurses internships in the nursing professional (Ners) and nursing were infected with COVID-19 and 274 have passed away specialty program (Government of Indonesia, 2014). (Guritno, 2021). Improvements in regulations related to Despite the variety of educational levels and the limited COVID-19 management in hospitals and other healthcare number of graduate school programs, nursing education in institutions were imposed, such as increasing supplies of Indonesia is steadily improving. With only 11 Professors of personal protective equipment (PPE) and prioritizing Nursing, there are now two Doctoral Programs in Nursing: benefits for healthcare workers regarding staffing, a doctoral program at the University of Indonesia and the including the nurses. This prioritized frontline healthcare other at the Faculty of Nursing, Universitas Airlangga workers, including nurses, to receive vaccinations against (Casman et al., 2020). Nevertheless, transforming the COVID-19 (COVID-19 Handling Acceleration Force, discipline to advance the professional practice of nursing 2021). requires more interdisciplinary collaboration, especially Appreciations for nurses’ dedication to their with expert nurse researchers from the international arena. professional practice during the pandemic were many, but
1 Graduate School of Health Sciences, Tokushima University, Article Info: Tokushima, Japan Received: 24 April 2021 2 Department of Nursing Outcome Management, Institute of Biomedical Revised: 10 May 2021 Sciences, Tokushima University, Tokushima, Japan Accepted: 11 May 2021 3 Institute of Biomedical Sciences, Tokushima University, Tokushima, Japan This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which allows 4 Florida Atlantic University, Boca Raton, FL 33431, USA 5 others to remix, tweak, and build upon the work non-commercially as long as Faculty of Nursing, Universitas Andalas, Padang, Indonesia the original work is properly cited. The new creations are not necessarily licensed under the identical terms. Corresponding author: Tetsuya Tanioka, RN, PhD, FAAN E-ISSN: 2477-4073 | P-ISSN: 2528-181X Professor, Department of Nursing Outcome Management, Institute of Biomedical Sciences Tokushima University, Graduate School, 18–15 Kuramoto-cho 3, Tokushima, 770–8509, Japan, Phone, and Fax +81-88-633-9021, E-mail: [email protected]
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Third, the regulations from the Indonesian Ministry of Authors’ Biographies Higher Education require faculty members in academic Feni Betriana, Ns, S. Kep, MNS is a PhD Student, Graduate positions to publish scholarly articles (Ministry of Research School of Health Sciences, Tokushima University, Tokushima, and Technology of the Republic of Indonesia, 2017), and Japan. for university students to also publish their final projects, Tetsuya Tanioka, RN, PhD, FAAN is a Professor of Nursing theses, and dissertations in key scientific journals as a Outcome Management, Institute of Biomedical Sciences, Tokushima University, Tokushima, Japan. requirement for graduation (Ministry of Education and Rozzano C. Locsin, RN, PhD, FAAN is a Professor Emeritus in Culture, 2012). These requirements are clear evidence Institute of Biomedical Sciences, Tokushima University, affirming the flourishing of nursing research and knowledge Tokushima, Japan, and Professor Emeritus in Florida Atlantic dissemination in Indonesia. Today, the requirement for University, Boca Raton, FL 33431, USA. enhancing scholarly articles authored by Indonesian Nelwati, S. Kp, MN, PhD is an Associate Professor, Faculty of nurses and nurse educators in international journals has Nursing, Universitas Andalas, Padang, Indonesia. increased manifold, instigating the establishment of more rigorous nursing journals. However, even with the References Casman, C., Ahadi Pradana, A., Edianto, E., & Abdul Rahman, L. increasing processes for knowledge dissemination as O. (2020). Kaleidoskop menuju seperempat abad pendidikan evidenced by the number of publications, journals indexed keperawatan di Indonesia [A kaleidoscope toward a quarter in reputable national and international indices are still few. century of nursing education in Indonesia]. Jurnal Endurance, As of March 2021, only three nursing journals were 5(1), 115-125. http://doi.org/10.22216/jen.v5i1.4291 indexed in reputable international databases, such as Chatterjee, S., & Kagwe, M. (2020). Health workers are the Scopus, Web of Science, and EBSCO. These journals are frontline soldiers against COVID-19. Let`s protect them. Belitung Nursing Journal, Nurse Media Journal of Nursing, Retrieved from https://www.un.org/africarenewal/web-featu and Nursing Journal of Indonesia (Jurnal Keperawatan res/coronavirus/health-workers-are-frontline-soldiers-against- covid-19-let’s-protect-them Indonesia). COVID-19 Handling Acceleration Force. (2021). Peran penting While this letter briefly highlights three current perawat Indonesia dalam menangani pandemi [Important role conditions as the basic informational needs of nursing of Indonesian nurses in handling the pandemic]. Retrieved practice, education, and research, focused attention on from https://covid19.go.id/p/berita/peran-penting-perawat- education, practice, and policies influencing scholarly indonesia-dalam-menangani-pandemi nursing endeavors in Indonesia requires more recognition Government of Indonesia. (2014). Indonesian Nursing Law No 38 and appreciation. Editors, researchers, and practitioners of Year 2014. Retrieved from https://peraturan.bpk.go.id/Home/ nursing need to be influential and establish nursing science Details/38782/uu-no-38-tahun-2014. Gunawan, J. (2020). COVID-19: Praise is welcome, but nurses journals in order to disseminate ground-breaking and deserve a pay rise. Belitung Nursing Journal, 6(5), 150-151. important nursing work. With the nursing academe, further https://doi.org/10.33546/bnj.1217 progress and recognition of nursing as a discipline of Guritno, T. (2021). PPNI: Lebih dari 15.000 perawat terpapar knowledge and a practice profession will materialize. COVID-19, 274 di antaranya meninggal [Indonesian National Reflecting on the future of Indonesian nurses during Nurses Association: More than 15,000 nurses infected by this momentous International Nurses Day leaves us to COVID-19, 274 of them died]. Retrieved from https:// realize that, while professional nursing practice in nasional.kompas.com/read/2021/03/18/13443301/ppni-lebih- Indonesia is advancing, more disciplinary and professional dari-15000-perawat-terpapar-covid-19-274-di-antaranya- meninggal ‘homework’ is needed to move nursing as a valuable and International Council of Nurses. (2021). International Nurses Day. integral health care practice. This consideration is a Retrieved from https://www.icn.ch/what-we-do/campaigns/ significant step towards growing Indonesian nursing to a international-nurses-day level of professional practice that is integral to human Ministry of Education and Culture. (2012). Publications of scientific health and well-being. papers. Retrieved from http://luk.staff.ugm.ac.id/atur/SKDir jen152-E-T-2012KaryaIlmiah.pdf. Keywords Ministry of Research and Technology of the Republic of Indonesia. International Nurses Day; COVID-19; professional practice; (2017). Technical instructions to regulation of the Ministry of delivery of healthcare; nursing; Indonesia Research, Technology, and Higher Education No 20 of 2017 concerning lecturer and professor professional honorarium. Declaration of Conflicting Interest Retrieved from https://luk.staff.ugm.ac.id/atur/Permenristek None to declare. dikti20-2017Juknis.pdf.
Funding Cite this article as: Betriana, F., Tanioka, T., Locsin, R. C., & None. Nelwati. (2021). Reflections on International Nurses Day: Current status, issues, and the future of nursing in Indonesia. Authors’ Contribution Belitung Nursing Journal, 7(3), 260-261. https://doi.org/10. Initial draft: FB, TT, RL. Writing and editing the manuscript: FB, 33546/bnj.1500 TT, RL, N. All authors approved the manuscript before submission and the final version of the manuscript.
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