HOW A COLD SITZ BATH VERSUS INFRARED THERAPY CAN REMOVE THE PAIN OF POSTPARTUM PERINEAL WOUNDS?

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Girsang, B. M., & Elfira, I. (2021) Jurnal Keperawatan Soedirman – Vol 16, No 1 page 1-5 http://jks.fikes.unsoed.ac.id/index.php/jks/index

ORIGINAL ARTICLE

HOW A COLD SITZ BATH VERSUS INFRARED THERAPY CAN REMOVE THE PAIN OF POSTPARTUM PERINEAL WOUNDS?

Bina Melvia Girsang*

¹

, Eqlima Elfira

²

1.

Department of Maternity and Child Nursing, Faculty of Nursing, Universitas Sumatera Utara, Indonesia

2.

Department of Medical Surgical Nursing, Faculty of Nursing, Universitas Sumatera Utara, Indonesia

Article Information ABSTRACT

Women who suffer perineal trauma in spontaneous labor experience pain and edema as the most common problems on the first day after delivery. Impaired mobility and a limited ability to carry out daily activities will affect the mother-baby bond. The study of the cold sitz bath intervention and infrared treatment aims to determine how these interventions can overcome the pain of perineal wounds in postpartum mothers. A quasi-experimental design was used to assess both interventions for treating pain in perineal trauma at the Madina Clinic and Sundari Hospital. The sample consisted of 40 mothers, 20 in the cold sitz bath (intervention group) and 20 in the infrared therapy (control group). The pain was measured using a numerical scale from day one to day three of the postpartum period, and then the data were analyzed using the paired t-test statistical test. The results of this study revealed that the cold sitz bath hydrotherapy had a significant effect in reducing pain (p = 0.004) and infrared therapy (0.008). Although the infrared treatment did not significantly reduce the pain level on the third day of the postpartum period, several other factors could contribute to the significant differences in pain intensity reduction, such as comfort, convenience, and the intervention's economic value.

Received: 19 July 2019 Revised: 16 October 2019 Accepted: 27 January 2021

*Corresponding Author

Bina Melvia Girsang binamelvia@usu.ac.id

DOI

10.20884/1.jks.2021.16.1.1124

Keywords: Cold; hydrotherapy; infrared; pain; perineal trauma; sitz bath

ISSN : 1907-6637 e-ISSN : 2579-9320

INTRODUCTION

The maternal mortality rate in the world is mostly led by developing countries as much as 99 percent. Nigeria has a perineal wound infection prevalence rate of 23 percent (Sule

& Shittu, 2003). In comparison, other studies have reported 2 percent in spontaneous labor (Larsson et al., 1991). The geographic health survey results in Indonesia in 2010 obtained maternal mortality ratio (MMR) data of 263 per 100,000 live births (Kemenkes RI, 2013). Complications including puerperal infection, improper treatment of perineal wounds, and bleeding (Hernawati, 2011). During pregnancy, childbirth, and the postpartum period that is not immediately addressed are the leading causes of maternal death (De Bernis et al., 2003). During postpartum recovery, mothers need proper perineal wound care to prevent infection, reducing pain in the perineal wounds. Perineal wounds can cause maternal discomfort that further can affect the mental condition and may lead to mothers experiencing ‘baby

blues’ or postpartum depression (De Bernis et al., 2003;

Yang et al., 2017).

Bathing perineal wounds with a sitz bath and having infrared therapy are both non-pharmacological treatments.

Administration of a cold compress, twice a day after each bath, can relieve the pain experienced due to perineal wounds in the first 24 hours postpartum (Ramler & Roberts, 1986). The cold soaking process should be as comfortable as possible for 10-20 minutes (Geytenbeek, 2002).

Meanwhile, infrared therapy is recommended to reduce pain through monochromatic effects emitted to improve the circulation to the perineal wound area.

This research was conducted by observing how a sitz bath intervention and infrared therapy can reduce perineal wounds' pain. These interventions can provide a sense of comfort in the early postpartum period (Enkin et al., 2001;

Jacob et al., 2007; Sleep et al., 1991). The results of wound

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Girsang, B. M., & Elfira, I. (2021)

Jurnal Keperawatan Soedirman – Vol. 16, No. 1 (2021) 2

repair using monochromatic infrared therapy are significant in reducing pain (Horwitz et al., 1999). This wound healing therapy uses monochromatic 890 nanometers (nm) infrared energy. The wound is irradiated using infrared, which results in the damage shrinking and closing after using monochromatic infrared energy. This method is possible because of an increase in local nitric oxide concentration.

Increased nitric oxide correlates with vasodilation and anabolic responses (Dewi & Ayuningtyas, 2015; Horwitz et al., 1999).

METHOD

Study design

This study is a comparative study design to assess the effectiveness of cold water bath intervention versus infrared radiation therapy in removing the pain of postpartum mothers' perineal wonds using a quasi-experimental pretest- postest method.

Participant

The sampling technique was done using purposive sampling, where 40 postnatal mothers on postpartum days 1, 2, and 3, who had normal labor with grade 2 perineal injuries were selected. There were 20 mothers in group 1 (cold sitz bath), which was performed at the Madina Clinic and home, while there were 20 mothers in group 2 (infrared radiation), performed at Sundari Hospital, Medan at home.

Instrument

This research was conducted with an instrument pain assessment tool. The pain assessment is measured using a numeric rating scale ranging from the first day to the third day of the postpartum period.

Intervention

Within this study, cold sitz bath hydrotherapy refers to the procedure of soaking the postnatal mothers' hips and buttocks with perineal wounds in a basin filled with ¼ parts of cold water (temperature 12^oC-14^oC) for 10 minutes. This procedure is carried out twice a day for three consecutive days from the puerperal day 1 to 3. As for infrared radiation therapy, it refers to the exposure of the perineal wounds to infrared radiation for 10 minutes with a distance of 50 cm from the perineum wound, twice a day for three consecutive days after birth.

Data analysis

The differences in pain levels for three consecutive days were analyzed using the paired t-test statistical test.

Ethical Consideration

Administrative approvals and ethical permits have been obtained from nursing institutions that issue ethics approval letters Number 1724 / IV / SP / 2019. Written consent was obtained after explaining the intervention undertaken by the researcher. The principle of confidentiality and anonymity was presented to the research subjects and guaranteed by the researchers.

RESULT

This study revealed several results, including univariate data and bivariate data. Univariate data, including age, religion, ethnicity, and educators, are presented in Table 1.

Table 1. Frequency distribution, mean and standard deviation of postpartum maternal characteristics Variable Group 1 (Hydrotherapy cold sitz bath) Group 2 (Infrared therapy)

Frequency Percentage(%) Frequency Percentage (%)

Age (years old)

20-25 3 15 7 35

26-31 9 45 5 25

31-35 5 25 7 35

>35 3 15 1 5

Religion

Moslem 19 95 17 85

Christian 1 5 3 15

Ethnicity

Bataknese 4 20 8 40

Malay 1 5 0 0

Minang 11 55 1 5

Java 4 20 10 50

Nias 0 0 1 5

Education

Primary 1 5 1 5

Junior high school 6 30 15 75

Senior high school 12 60 4 20

College 1 5 0 0

Occupation

Entrepreneur 1 5 0 0

Private employees 0 0 1 5

Full time housewife 19 95 19 95

Parity

Primigravida 4 20 3 25

Secundigravida 6 30 5 15

Multigravida 10 50 12 60

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The majority of postpartum mothers in group 1 (Sitz bath hydrotherapy) were 26-31 years old (45%), while in group 2 (infrared therapy), they were equally distributed between the 31-35 and 20-25 years old age groups (35% in each age category). Both groups are predominantly Muslim, with most Mining (55%) in group 1 and Javanese (50%) in group 2.

The final education level is mostly senior high school (60%) in group 1 and junior high school (75%) in group 2.

Postpartum mothers were mostly housewives in both groups (95%), with the majority of the parity was multigravida (50%

in group 1 and 60% in group 2, respectively).

Table 2. Comparison of pre and post pain level for three consecutive days in group 1 and group 2

Pre-post intervention Groups Mean ± SD t-Test P

Pre-post intervention day 1 Group 1 (Sitz bath) 4.10±1.861 2.179 0.042

3.90±1.832

Group 2 (Infrared) 5.95±2.188 2.131 0.046

5.50±1.906

3.00±1.376

Group 2 (Infrared) 4.85±1.981 4.359 0.000

4.35±1.785

1.80±1.056

Group 2 (Infrared) 3.65±1.814 2.990 0.008

3.25±1.410 Based on Table 2, it can be seen that the mean pre-post

intervention score in group 1 (sitz bath hydrotherapy) on the first day (4.10 ± 1.861) was lower than the infrared group 2 intervention (5.95 ± 2.88). On the third day of the intervention, the average reduction in the pain scale in group 1 (1.80 ± 1.056) was lower than in group 2 (3.25 ± 1.410).

The average score of pain reduction occurs significantly from day to day consecutively for three days in group 1 than group 2. It was proven that the two group interventions (sitz bath hydrotherapy and infrared therapy) were statistically significant in reducing pain after intervention until the third day. Cold sitz bath hydrotherapy has a significant effect (p = 0.004) and infrared therapy (0.008). However, changes in the mean score of pain reduction indicate that sitz bath hydrotherapy is more significant in reducing pain than infrared therapy intervention.

DISCUSSION

Both of the interventions applied in this study, i.e., cold sitz bath hydrotherapy and infrared therapy did not show a statistical difference in reducing perineal wound pain in

postpartum mothers' spontaneous birth. However, the study results prove that cold sitz bath hydrotherapy is better (1.80

± 1.05) in reducing the pain scale in postpartum wounds compared to infrared therapy (3.25 ± 1.41) for three consecutive days with levels significance p = 0.004. This result differs from some of the effects of researchers that stated that infrared rays are more effective in reducing pain in perineal wounds (Balakrishnan & Soman, 2019; El-Lassy, 2019; Dhanalakshmi, 2010; Venkadalakshmi et al., 2010).

Therapy, using the principle of hydrotherapy in the sitting position (sitz bath), has proven useful for recovery therapy.

The principal application of hydrotherapy is to stimulate the circulation of the pelvic region. This hydrotherapy uses alternative cold water because it can overcome edema in perineal wounds compared to warm water (Tejirian &

Abbas, 2005). Analysis of pain scale scores using two-way analysis of variance with replication showed that sitz baths with cold water were significantly more effective in relieving perineal pain.

The literature search results stated that sitz bath hydrotherapy with cold water at temperatures of 55^o – 75^o F

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(12^o – 24^o C) is useful in healing perineal wounds.

Hydrotherapy with mean water results in a decrease in cell metabolism and a reduction in oxygen use around the tissues that are not injured. Some studies have also shown cold water therapy causes vasoconstriction and increases venous circulation. The occurrence of venous vasoconstriction can help the drainage process in edema tissue by the lymph vessels. After vasoconstriction in the edema tissue, the retained intracellular fluid will flow slowly through connective tissue between muscle fibers into the lymph channels. The drainage process is also facilitated by a pump that occurs due to muscle contraction and relaxation (Geytenbeek, 2002; McPhee, S. J., Papadakis, M. A., &

Rabow, 2010; Netter, 2017). Therefore, hydrotherapy with cold water in spontaneous postpartum mothers who experience perineal laceration can be one type of perineal wound management to treat perineal edema.

Infrared therapy is a treatment designed to avoid infection in perineal wounds. Infrared waves can help relieve pain, cure infections, and reduce inflammation. All the light waves produced are safe enough for all layers of the skin. The uppermost epidermal layer, then the dermis layer below, contains blood vessels and the tip that is very sensitive to the bottom subcutaneous fat tissue (Helen, 2009). Infrared lights improve circulation in those areas. Therefore, vasodilation occurs when the heat is applied to the wound's Episiotomy. Blood circulation to the areas increases - blood contains the nutrient oxygen (Gale et al., 2006; El-Lassy, 2019).

The process of decreasing the level of perineal wound pain with sitz bath hydrotherapy and infrared therapy is different.

However, both of these interventions reduce the level of perineal wound pain. Chart 1 showed that the decrease in pain level in the cold sitz bath hydrotherapy intervention was more significant than the infrared therapy intervention. This result can be influenced by several sociodemographic factors, including age group, culture or ethnicity, and education level. The race is a background that shows differences in behavior, beliefs, culture, historical values, characteristics, and physical characteristics (Edwards et al., 2001). Ethnicity correlates with how someone behaves emotionally and how his behavior responds to the pain stimulus that occurs (Campbell & Edwards, 2012). Both interventions in this study are interventions that can be easily carried out at home independently by the mothers, but there are still differences in pain reduction. Some of the factors sociodemographic characteristics and the culture, religion, and beliefs of each person can influence one's perception and experience in adapting to pain (Campbell &

Edwards, 2012).

Limitation of the Study

Respondents of this study were only 20 postpartum mothers, so it was quite limited in recording the social cultural characteristics as a whole in the place of research.

This is a limitation in this study due to the Covid-19 pandemic situation, and limited time and research resources. This will be a benchmark for further research.

CONCLUSION AND RECOMMENDATION

This study's findings prove that cold sitz bath hydrotherapy and infrared therapy can significantly reduce pain intensity.

However, on the third day, the infrared treatment did not significantly reduce the pain level. Compared to infrared therapy, the cold sitz bath hydrotherapy intervention procedure is more comfortable to carry out independently at home due to ease and economic value. This method can be

recommended as a procedure for treating perineal wounds on the ward or at home.

REFERENCES

Balakrishnan, V., & Soman, S. (2019). Effect of infrared light therapy on episiotomy pain and wound healing among postnatal mothers. International Journal of Science and Research, 8(3), 1543–1548.

Campbell, C. M., & Edwards, R. R. (2012). Ethnic differences in pain and pain management. Pain

Management, 2(3), 219–230.

https://doi.org/10.2217/pmt.12.7

De Bernis, L., Sherratt, D. R., AbouZahr, C., & Van Lerberghe, W. (2003). Skilled attendants for pregnancy, childbirth and postnatal care. British

Medical Bulletin, 67, 39–57.

https://doi.org/10.1093/bmb/ldg017

Dewi, V., & Ayuningtyas, I. (2015). Infrared is more effective in perineum wound healing during postpartum than iodine. International Journal of Research in Medical

Sciences, 3(1), S6–S9.

https://doi.org/10.18203/2320-6012.ijrms20151513 Edwards, C. L., Fillingim, R. B., & Keefe, F. (2001). Race,

ethnicity and pain. Pain, 94(2), 133–137.

https://doi.org/10.1016/S0304-3959(01)00408-0 Enkin, M., Keirse, M. J., Neilson, J., Crowther, C., Duley, L.,

Hodnett, E., & Hofmeyr, G. J. (2001). Effective care in pregnancy and childbirth: a synopsis. Birth (Berkeley, Calif.), 28(1), 41–51.

https://doi.org/10.1046/j.1523-536x.2001.00041.x Gale, G. D., Rothbart, P. J., & Li, Y. (2006). Infrared therapy

for chronic low back pain: a randomized, controlled trial. Pain Research & Management, 11(3), 193–196.

https://doi.org/10.1155/2006/876920

Geytenbeek, J. (2002). Evidence for effective hydrotherapy.

Physiotherapy, 88(9), 514–529.

https://doi.org/10.1016/S0031-9406(05)60134-4 Helen. (2009). Keperawatan maternitas (maternity care) (

editor bahasa I. Y. asih alih bahasa Andry Hartono (ed.); 2nd ed.). Jakarta: EGC.

Hernawati, I. (2011). Analisis Kematian Ibu Di Indonesia Tahun 2010 (Analysis of Maternal Mortality in Indonesia, 2010). Bina Kesehatan Ibu Bakti Husada.

Horwitz, L. R., Burke, T. J., & Carnegie, D. (1999).

Augmentation of wound healing using monochromatic infrared energy. Exploration of a new technology for wound management. Advances in Wound Care : The Journal for Prevention and Healing, 12(1), 35–40.

Jacob, A., R, R., & Tarachand, J. S. (2007). Clinical nursing procedures: The art of nursing practice (1st editio).

Jaypee Brothers Medical Publishers (P) Ltd.

Kemenkes RI. (2013). Profil Kesehatan Indonesia Tahun 2012 (Indonesia Health Profile 2012). Kementerian Kesehatan Republik Indonesia.

Larsson, P. G., Platz-Christensen, J. J., Bergman, B., &

Wallstersson, G. (1991). Advantage or disadvantage of episiotomy compared with spontaneous perineal laceration. Gynecologic and Obstetric Investigation, 31(4), 213–216. https://doi.org/10.1159/000293161

(6)

McPhee, S. J., Papadakis, M. A., & Rabow, M. W. (2010).

Current medical diagnosis & treatment. New York:

McGraw-Hill Medical.

Netter, F. H. (2017). Atlas of human anatomy, plate 46.

Philadelphia, PA: Elsevier.

Ramler, D., & Roberts, J. (1986). A comparison of cold and warm sitz baths for relief of postpartum perineal pain.

Journal of Obstetric, Gynecologic, and Neonatal Nursing : JOGNN, 15(6), 471–474.

https://doi.org/10.1111/j.1552-6909.1986.tb01426.x Reem Bassiouny Mahmoud El-Lassy, A. A. E.-A. M. M.

(2019). The effect of infrared lamp therapy on episiotomy wound restorative besides pain relief among post-partum women. Journal of Nursing Education and Practice, 9(2), 20–30.

Sleep, J., Robinson, S., & Thompson, A. (1991). Midwives research and childbirth. Perineal Care: A Series of Five Randomised Trials, 2, 199–251.

Sule, S. T., & Shittu, S. O. (2003). Puerperal complications of episiotomies at Ahmadu Bello University Teaching

Hospital, Zaria, Nigeria. East African Medical

Journal, 80(7), 351–356.

https://doi.org/10.4314/eamj.v80i7.8717

Tejirian, T., & Abbas, M. A. (2005). Sitz bath: where is the evidence? Scientific basis of a common practice.

Diseases of the Colon and Rectum, 48(12), 2336–

2340. https://doi.org/10.1007/s10350-005-0085-x V Dhanalakshmi. (2010). Best remedial measure after

Episiotomy? Sitz ? Or Infrared Light Therapy?bath.

Nightingale Nursing Times, 5(12)(Mar), 6–12.

Venkadalakshmi, V., Venkatesan, L., & Perdita, H. M.

(2010). Effect of infrared therapy on episiotomy pain and wound healing in postnatal mothers. The Nursing Journal of India, 101(9), 212–214.

Yang, Y.-J., Xu, Y.-M., Chen, W.-C., Zhu, J.-H., Lu, J., &

Zhong, B.-L. (2017). Prevalence of pain and its socio-demographic and clinical correlates among heroin-dependent patients receiving methadone maintenance treatment. Scientific Reports, 7, 8840.

https://doi.org/10.1038/s41598-017-09404-w

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Tamba, D., Dharmajaya, R., & Sitohang, N. A. (2021) Jurnal Keperawatan Soedirman – Vol 16, No 1 page 6-13 http://jks.fikes.unsoed.ac.id/index.php/jks/index

ORIGINAL ARTICLE

THE EFFECT OF HATHA YOGA THERAPY ON THE BLOOD PRESSURE OF PRIMARY HYPERTENSION PATIENTS OF PRODUCTIVE AGE

Darwin Tamba

^*

, Ridha Dharmajaya, Nur Asnah Sitohang

Department of Medical Surgical Nursing, Faculty of Nursing, Universitas Sumatera Utara, Indonesia

Article Information ABSTRACT

Untreated hypertension can lead to serious complications. One of the nonpharmacological therapies for treating hypertension is hatha yoga. The study aimed to determine the effect of hatha yoga therapy on the blood pressure of those of productive age among primary hypertension patients. The research type was a quasi-experiment with pre-posttest with control group design. The number of study samples was 64 respondents consisting of 32 respondents in the intervention group (who were given 35 minutes of hatha yoga therapy and Amlodipine 5mg/day for 4 weeks) and 32 respondents in the control group who received Amlodipine 5mg/day for 4 weeks. The data analysis used the dependent test (paired t test). The results showed that the mean of systolic and diastolic of blood pressure before the therapy in primary hypertension patients in the intervention group was 161.84 / 93.25 mmHg, while in the control group it was 161.66 / 93.37 mmHg. The mean of the systolic and diastolic blood pressure after therapy in the primary hypertensive patients in the intervention group was 122.87 / 71.69 mmHg, and in the control group it was 127.66 / 73.13 mmHg. The statistical tests using paired t-test showed that the p value was <α = 0.05. In conclusion, hatha yoga therapy has the effect of lowering blood pressure for those of productive age among primary hypertension patients.

Received: 30 September 2020 Revised: 30 December 2020 Accepted: 1 March 2021

*Corresponding Author

Darwin Tamba

darwintamba08@gmail.com

DOI

10.20884/1.jks.2021.16.1.1543

Keywords: Blood pressure; hatha toga therapy; primary hypertension

ISSN : 1907-6637 e-ISSN : 2579-9320

INTRODUCTION

Hypertension is the increase of blood pressure above the normal level with a systolic and diastolic number of more than 140/90 mmHg. Increased and prolonged high blood pressure can damage blood vessels in organs such as the kidneys, heart, brain and eyes, causing complications such as stroke, coronary heart disease, kidney failure, and blindness. Hypertension is also known as the silent killer (Ministry of Health of the Republic of Indonesia, 2016).

Based on the causes of hypertension, it is divided into two, namely primary hypertension (around 90% of total cases of hypertension) and secondary hypertension (around 10% of the total number of hypertension cases). Primary hypertension is a type of hypertension where the cause is unknown or idiopathic (Ministry of Health of the Republic of Indonesia, 2014).

The World Health Organization (2013) noted that, in the world, there were 17,000 people per year who died from

cardiovascular diseases and 9,400 of them were caused by complications resulting from hypertension. The prevalence of world hypertension reached to 29.2% in men and 24.8%

in women (WHO, 2013). In America, there were 74.5 million people who experienced hypertension (American Heart Association, 2013). While in Indonesia, it was estimated that 25.8% of people experienced hypertension (Ministry of Health of the Republic of Indonesia, 2013). Particularly in North Sumatra, Indonesia, it was recorded that 151,939 people suffered from hypertension (Health Office, 2015).

One of the non-pharmacological primary hypertension treatments is hatha yoga, which is a program of unification of the body, mind and spirit. Hatha yoga is a combination of breathing techniques (pranayama), relaxation and stretching or posture exercises (asanas) (Sindhu, 2015). Asana aims to stimulate the release of endorphin hormones, which function as a natural sedative produced by the brain to create a sense of comfort. Increased endorphin hormones

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Tamba, D., Dharmajaya, R., & Sitohang, N. A. (2021)

have the effect of reducing high blood pressure. Pranayama in yoga is a systematic and voluntary controlled breathing exercise, which results in an increase in the activity of the parasympathetic nervous system to stimulate the release of dopamine levels, reduce emotional stress and relax blood vessels so that blood pressure can decrease. It is therefore that hatha yoga is recommended as a complementary therapy for hypertensive sufferers (Sindhu, 2015).

METHOD

Study design

The research design used a quasi-experimental, pre- posttest with control group design (Polit & Beck, 2012).

Instrument

The instrument used in this study was a tensimeter to measure the respondent's blood pressure before and after being given treatment in both the control group and the intervention group.

Intervention

The intervention group received the hatha yoga therapy including pranayama and asana for 30 minutes per session and this was followed by relaxation for 5 minutes – 35 minutes for the total duration of the intervention. The intervention group received the hatha yoga that was carried out for a month, twice a week, and they were also prescribed pharmacological treatment from doctors i.e.

amlodipine 1x5mg/day for 4 weeks. Meanwhile, the control group only received the same pharmacological treatment.

The examination and measurement of blood pressure (systolic and diastolic) was measured twice: the first time was before treatment and the last was after receiving hatha yoga and amlodipine therapy for the intervention group and after only receiving amlodipine for the control group.

Data Analysis

The data was analyzed using univariate and bivariate analysis. Univariate was used to see the percentage of age, gender, education, smoking history, and the duration of taking drugs. Bivariate analysis using the paired t-test was used to examine the differences in blood pressure before and after the intervention in primary hypertension patients at Mitra Medika Hospital, Medan.

Sample/ Participants

The respondents were collected using a consecutive sampling method, which is the method of selecting samples by selecting all individuals who meet the selection criteria (inclusion criteria), until the desired sample size is met (Polit Beck, 2012). The total samples in this study were 64 respondents that was determined based on the power analysis table with the equal power set (1-β) = 0.80 and the estimated effect size of 0.7 with a significant level (alpha [α])

= 0.05; therefore the number of samples were 32 respondents for the intervention group and 32 respondents for the control group.

The inclusion criteria included (a) patients who were medically diagnosed with hypertension and received medication or consumed 5mg/day of amlodipine therapy; (b) patients aged 25-55 years; (c) patients with a history of blood pressure ≥140 / 90 mmHg; and (d) patients who were willing to be a respondent. Meanwhile, the exclusion criteria consisted of (a) patients suffering from heart disease; (b) the presence of sensory neuropathy; (c) patients with a right / left lower limb strength <5; (d) patients who were uncooperative; and (e) patients who were unwilling to be a respondent. The number of outpatients who were primary hypertension sufferers at Mitra Medika Hospital Medan was recorded and then collected.

Ethical consideration

The respondents were asked to fill in an informed consent form stating their willingness to be involved in this research.

Previously, the researcher had approval of the health research ethics commission from the Faculty of Nursing, Universitas Sumatera Utara, Indonesia with number 1682/III/SP/2019.

RESULT

This research was conducted in Mitra Medika Hospital, Medan from April to May 2019. The total sample was 64 respondents according to the inclusion and exclusion criteria.

Respondent Characteristics

Variables involved in univariate analysis included age, gender, education, smoking history, and the duration of drug consumption as can be seen in Table 1.

Table 1. Respondent characteristics (n = 64)

Variable Intervention Group Control Group

Frequency (f) Percentage (%) Frequency (f) Percentage (%) Age

25-35 years old 7 21.9 3 9.4

36-45 years old 15 46.9 18 56.2

46-55 years old 10 31.2 11 34.4

Gender

Male 15 46.9 14 43.75

Female 17 53.1 18 56.25

Education

Junior high school 9 28.1 11 34.4

Senior high school 23 71.9 21 65.6

Smoking history

Yes, smoked 13 40.6 13 40.6

Not smoked 19 59.4 19 59.4

Duration of taking drugs

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Variable Intervention Group Control Group

Frequency (f) Percentage (%) Frequency (f) Percentage (%)

<7 days 17 53.1 16 50.0

7-21 days 10 31.3 11 34.4

> 21-30 days 5 15.6 5 15.6

Table 1 explained that the majority of respondents in the intervention group were aged 36-45 years old, which was as many as 15 people (46.9%), while the majority of respondents in the control group were 36-45 years old (18 people or 56.3%). Most respondents were women, which was as many as 17 people (53.1%) and 18 people (56.3%) in the intervention and control group respectively. Generally, the respondents were high school graduates: 23 people (71.9%) in the intervention group and 21 people (65.6%) in the control group. The majority of the smoking history in the

intervention group was 13 people who smoked (40.6%) and 19 people (59.4%) who had not smoked. As many as 17 people (53.1%) had taken medication <7 days in the intervention group whilst in the control group it was 16 people (50.0%).

Systolic and Diastolic Blood Pressure of Primary Hypertensive Patients in the Intervention Group

The systolic blood pressure of primary hypertensive patients in the intervention group can be seen in Table 2.

Table 2. Systolic and diastolic blood pressure of primary hypertensive patients in the intervention group (n = 64)

Week Variable Average Maximum Minimum

Week 1

Pretreatment 1 Systolic 161.84 179 151

Diastolic 93.25 100 90

Post treatment 1 Systolic 158.81 165 150

Week 2

Week 3

Week 4

Table 2 reports that the systolic blood pressure among primary hypertensive patients after hatha yoga decreased from 151 mmHg after the first treatment to 110 mmHg after the eighth treatment. The maximum the systolic blood pressure, after the hatha yoga, decreased by was from 179 mmHg for the first treatment to 136 mmHg after the eighth treatment and the mean blood pressure for each treatment decreased from 161.84 mmHg in the first treatment to 122.87 mmHg after the eighth treatment. The minimum

diastolic blood pressure, after the hatha yoga, decreased by was from 90 mmHg in the first treatment to 69 mmHg after the eighth treatment. The maximum the diastolic blood pressure, after the hatha yoga, decreased by was from 100 mmHg for the first treatment to 76 mmHg after the eighth treatment and the mean blood pressure for each treatment decreased from 93.25 mmHg for the first treatment to 71.69 mmHg.

Systolic and Diastolic Blood Pressure of Primary Hypertensive Patients in the Control Group.

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The systolic and diastolic blood pressures of primary hypertensive patients in the control group can be seen in Table 3.

Table 3. Systolic and diastolic blood pressure of primary hypertensive patients in the control group (n = 64)

Week Variable Average Maximum Minimum

Week 1

Week 2

Week 3

Week 4

Table 3 shows the systolic blood pressure in patients with primary hypertension. In the control group, it decreased from 154 mmHg at the first treatment to 112 mmHg after the eighth treatment. The maximum systolic blood pressure, after receiving the treatment, decreased by was from 170 mmHg to 142 mmHg after the treatment and the mean blood pressure for each treatment decreased from 161.66 mmHg to 127.66 mmHg.

The minimum diastolic blood pressure after treatment decreased from 90 mmHg to 70 mmHg; the maximum

systolic blood pressure decreased from 100 mmHg to 80 mmHg after treatment and the mean blood pressure after treatment decreased from 93.37 mmHg to 73.13 mmHg.

Bivariate Analysis

Bivariate analysis was used to examine differences in blood pressure before and after intervention among primary hypertensive patients.

The Effect of Hatha Yoga Therapy on Systolic and Diastolic Blood Pressure for Each Treatment in Primary Hypertension Patients

Table 4. The effect of hatha yoga therapy on systolic and diastolic blood pressure for each treatment in primary hypertensive patients in the intervention group

Variable

Systolic Diastolic

Pre-test Post-test Pre-test Post-test

Treatment 1

Mean ± SD 161.75 ± 4.277 158.89 ± 4.704 93.31 ± 3,270 92.89 ± 3.056

Mean difference ± SB 2.86 ± 0.427 0.42 ± 0.214

95% CI 1,609 - 4,571 0.069 - 0.775

p 0.000 0.020

t .171 -.132 -.152 -.745

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Variable

Treatment 2

Mean ± SD 155.52 ± 4.163 153.36 ± 5.015 88.94 ± 4,000 86.36 ± 4,064

95% CI 1,012 - 3,301 1,503 - 3,653

p 0.000 0.000

t -1.113 -2.071 4.222 -.397

Treatment 3

Mean ± SD 150.02 ± 7,117 147.75 ± 5.809 83.73 ± 4.141 82.94 ± 3,800

95% CI 0.994 - 3,537 0.253 - 1.340

p 0.001 0.005

t -2.385 -.772 .270 -.721

Treatment 4

Mean ± SD 145.20 ± 7,069 144.03 ± 6,794 80.94 ± 3,813 80.31 ± 3,536

95% CI 0.033 - 2.311 0.134 - 1.116

p 0.044 0.013

t -2.243 -3.145 .065 -1.062

Treatment 5

Mean ± SD 141.42 ± 8,271 139.42 ± 7,184 78.75 ± 4.239 77.94 ± 4.397

Mean difference ± SB 2.00 ± 1,087 0.81 ± 0.158

95% CI 0.709 - 3,291 0.350 - 1.275

p 0.003 0.001

t -2.398 -2.166 -.410 -1.733

Treatment 6

Mean ± SD 137.28 ± 7,531 134.81 ± 6,671 77.22 ± 3,811 76.53 ± 4,024

95% CI 1,114 - 3,823 0.025 - 1.350

p 0.001 0.042

t -1.336 -.597 -1.185 -1.769

Treatment 7

Mean ± SD 133.03 ± 8.365 131.95 ± 6,627 74.92 ± 3,031 73.97 ± 3.065

95% CI 0.003 - 2.153 0.415 - 1.492

p 0.049 0.001

t -.835 -.619 -.533 -2.365

Treatment 8

Mean ± SD 128.25 ± 7.950 125.27 ± 7,394 72.94 ± 2,630 72.41 ± 2.505

95% CI 2,130 - 3,839 0.207 - 0.855

p 0.000 0.002

t -1.691 -2.714 -.758 -2.378

Based on the Table 4, the results of the t test statistical test on systolic blood pressure obtained the p-value <α = 0.05 for each treatment, meaning that Null Hypothesis (H0) is rejected. There were differences in systolic blood pressure before and after the treatment of hatha yoga therapy. The

results of the t test statistical test on diastolic blood pressure obtained the p-value <α = 0.05 of each treatment, meaning that H0 was rejected. It means that there was an effect of hatha yoga therapy on reducing blood pressure in primary hypertensive patients.

The Effect of Hatha Yoga Therapy on Decreasing Systolic and Diastolic Blood Pressure in Primary Hypertensive Patients

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The effect of hatha yoga therapy on reducing systolic and diastolic blood pressure in primary hypertensive patients can be seen in Table 5.

Table 5. The effect of hatha yoga therapy on systolic and diastolic blood pressure among primary hypertensive patients in the control group

Variable

Mean ± SD 161.75 ± 4.353 125.27 ± 7,394 93.31 ± 3,270 72.41 ± 2.505

95% CI 34,659 - 38,310 19,821 - 21,492

p 0.000 0.020

Table 5 shows the results of the t test statistical test obtained the p-value <α = 0.05 that means that H0 is accepted or in other words, there are differences in the systolic and diastolic blood pressure of primary hypertensive patients before and after practicing hatha yoga therapy in the intervention and control groups.

DISCUSSION

Blood Pressure of Hypertensive Patients in the Intervention Group

Statistical tests showed that the systolic and diastolic blood pressure in primary hypertensive respondents was significantly reduced by 38.97 mmHg. It could be because the respondent received therapeutic treatment from a doctor as well as non-pharmacological therapy using hatha yoga regularly over 4 weeks with 8 meetings. According to Palmer & Williams (2009), the treatment for primary hypertension can be done pharmacologically and non- pharmacologically. Non-pharmacological medications can be used as a complement to get a medicinal effect when anti-hypertensive drugs are given.

Blood Pressure of Hypertensive Patients in the Control Group

In this study, primary hypertension patients who received pharmacological treatment experienced a significant reduction in systolic and diastolic blood pressure, but interestingly it sometimes increased or decreased. This may be because the patients regularly follow the medication given by the doctor. This is in accordance with JNC (2013) who stated that the goal of hypertensive treatment is not only to reduce blood pressure but also to reduce and prevent complications due to hypertension so that sufferers can increase their strength.

According to Gunawan (2015), preventive efforts, besides drugs prescribed by doctors, are also beneficial for people with hypertension to prevent the disease from getting any worse. Hypertensive patients need to check their blood pressure regularly in order to know the development and state of their blood pressure so that they can maintain a healthy lifestyle to keep their blood pressure in a normal range.

Differences in Blood Pressure of Hypertensive Patients between the Intervention Group and the Control Group Table 2 shows that the decrease in systolic blood pressure before and after the implementation of yoga hatha therapy in the intervention group of primary hypertensive patients was 38.97 mmHg (before 161.84 mmHg and after 122.87 mmHg) and a decrease in diastolic blood pressure by 21.56 mmHg (before 93.25 mmHg and after 71.69 mmHg).

Meanwhile, Table 3 shows that the decrease in systolic and

diastolic blood pressure in the control group was 34.0 mmHg (before 161.66 mmHg and after 127.66 mmHg) and the decrease in diastolic blood pressure was 20.24 mmHg (before 93.37 mmHg and after 73.13 mmHg) so that the mean difference in the decrease of systolic blood pressure was 4.97 mmHg (from 38.97 mmHg to 34.0 mmHg) and the mean difference in diastolic blood pressure reduction was 1.32 mmHg (from 21.56 mmHg to 20.24 mmHg). According to Cohen et al. (2011) in Ridwan (2009), yoga therapy is very helpful for those suffering from hypertension.

The Effect of Hatha Yoga Therapy on the Blood Pressure of Primary Hypertensive Patients

The basic mechanism of increasing systolic and diastolic blood pressure corresponds to a decrease in the elasticity of the blood vessels and the ability to stretch the large arteries.

Changes in sympathetic nervous system activity with increased norepinephrine cause a decrease in the sensitivity of the beta-adrenergic receptor system, resulting in decreased muscle relaxation function of blood vessels (Palmer & Williams, 2009).

Vasoconstriction causes decreased blood flow to the kidneys, resulting in the release of renin. Renin stimulates the formation of angiotensin I which is then converted by the ACE (Angiotensin Converting Enzyme) to angiotensin II, a potent vasoconstrictor, which in turn stimulates aldosterone secretion by the adrenal cortex. This hormone causes retention of sodium and water by the renal tubules, causing an increase in intravascular volume. All of these factors tend to trigger hypertension (Palmer & Williams, 2009).

Asana in yoga can stimulate the release of endorphin hormones which function as natural sedatives produced by the brain that creates a sense of comfort. Increasing levels of endorphins in the body can reduce high blood pressure.

Pranayama in yoga is a form of voluntary controlled breathing that affects the increase in activity of the parasympathetic nervous system and increases the level of dopamine, which function is to reduce emotional stress as well as relaxing blood vessels. It is therefore that yoga is recommended as a complementary therapy for hypertension sufferers (Sindhu, 2015).

Hatha yoga therapy affects systolic and diastolic blood pressure in patients with primary hypertension. This is in line with Cramer et al. (2014) who reported that the provision of yoga that is done regularly for 8 weeks can significantly influence changes in blood pressure in hypertensive patients.

CONCLUSION AND RECOMMENDATION

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There is an effect of hatha yoga and amlodipine therapy in reducing blood pressure. It is recommended that hypertensive patients practice hatha yoga therapy as a non- pharmacological therapy in managing hypertension.

REFERENCES

Ajjimaporn, PT., A, Rachiwong, S., Siripornpanich, V., (2018). Effects of 8 Weeks of Modified Hatha Yoga Training on Resting-State Brain Activity and The P300 ERP in Patients With Physical Disability- Related Stress. J. Phys. Ther. Sci. 30: 1187–1192:

Mahidol University, Thailand.

Bhavanani, AB, Ramanathan, M., Balaji, R., & Pushpa, D.

(2014). Comparative immediate effect of different yoga asanas on heart rate and blood pressure in healthy young volunteers. International Journal of Yoga. 2014: 7, 89–95.

Black, JM, Hawks, JH (2014). Medical Surgical Nursing Clinical Management for the expected results, Edisi 8. Singapore: Elsevier.

Chimkode, S. M., Kumaran, S. D., Kanhere, V. V., &

Shivanna, R. (2015). Effect of yoga on blood glucose levels in patients with type 2 diabetes mellitus.

Journal of clinical and diagnostic research: JCDR, 9(4), CC01.

Cohen, D. L., Bloedon, L. T., Rothman, R. L., Farrar, J. T., Galantino, M. L., Volger, S., ... & Townsend, R. R.

(2011). Iyengar yoga versus enhanced usual care on blood pressure in patients with prehypertension to stage I hypertension: a randomized controlled trial.

Evidence-Based Complementary and Alternative Medicine, 2011.

Ministry of Health, Republic of Indonesia. (2014).

Measurement and Inspection Guidelines. Jakarta MOH: RI.

Diguilo, M. & Donna, J. (2014). Medical Surgical Nursing, Yogyakarta: Rapha Publishing.

Fawcett, J. (2010). Contemporary Nursing Knowledge:

Analysis and Evaluation of Nursing Models and Theories, Second Edition. Philadelphia: FA Davis Company.

Gunawan-Lany, (2008). Hipertention. Penerbit Kanisius.

Yogyakarta.

Hagins, M., Rebecca, S., Terry, S., & Kim, I., (2015).

Effectiveness of Yoga Hypertension: Systematic Review and Meta-Analysis. Hindiawi Publishing Corporation. Volume 2013 Article ID 649836, 13 pages http://dx.doi.org/10.1155/2013/649836.

Hajir., R. (2010). Easy Yoga - Healthy and Fit with Practical Yoga. Jakarta: Penerbit Bukune.

Health Office (2015). physical activity consumption of salty foods and incidence of hypertension in coastal

communities. Retrieved from

https://www.neliti.com/publications/325955/aktivitas- fisik-konsumsi-makanan-asin-dan-kejadian-

hipertensi-masyarakat-pesisir.

Hendarti E., S., Hidayah, A., (2018) Giving Yoga Gymnastics Therapy Against Changes in Blood Pressure in the Elderly with Hypertension in Sidoarjo Regency. Prosiding Seminar Nasional Unimus Volume 1, 2018. e-ISSN: 2654-3257., p-ISSN: 2654- 3168.

Ramos-Jiménez, A., Hernández-Torres, R. P., & Wall- Medrano, A. (2011). Hatha yoga program determinants on cardiovascular health in physically active adult women. J Yoga Phys Ther, 1(103). DOI:

10.4172 / 2157-7595.1000103.

Kaplan, N.M, (2009). Kaplan's Clinical Hypertension.

Philadelphia: Lipincott Williams & Wilkins.

Ministry Health Republic of Indonesia. (2013). Basic Health Research Report. Jakarta: Pusat Data dan Informasi.

McCaffrey, R., Ruknui, P., Hatthakit, U. & Kasetsomboon, P.

(2005). The Effects of Yoga On Hypertensive Persons In Thailand. Holistic Nursing Practice, vol.19, no. 4, pp. 173-180.

Nopitasari, D., Sri Ratna Rahayu, (2017). Analysis of The Effect of Hatha Yoga on The Quality of Sleep and Immune System Among The Students in Public Health Postgraduate Program At UNNES. Public Health Perspective Journal 3 (1) (2018) 1 - 6.

Semarang State University, Indonesia.

Okonta, NR, (2012). Does Yoga Therapy Reduce Blood Pressure in Patients With Hypertension?: An integrative review. Holist Nurs Pract; 26: 137–141.

DOI: 10.1097 / HNP.0b013e31824ef647. PubMed:

22517349.

Palmer, A., & Williams, B. (2009). Simple Guides for High Blood Pressure. Jakarta: Erlangga.

Polit, DF, & Beck, CT (2012). Nursing Research: Generating and Assessing Evidence of Nursing Practice. 9th Edition. Philadelphia: Lippincot Williams & Wilkins.

Riskesdas. (2013). Badan Penelitian dan Pengembangan Kesehatan Kementrian Kesehatan RI. Diperoleh tanggal 10 Januari 2018 dari http: www. riskesdas.

Litbang depkes.go.id/download/laporan riskesdas.

Roche, L. T., & Hesse, B. M. (2014). Application of an integrative yoga therapy programme in cases of essential arterial hypertension in public healthcare.

Complementary Therapies in Clinical Practice, 20(4), 285-290. DOI: 10.1016 / j.cctp. 2014. 1744- 3881.Madrid.

Satyanand, V., Bhakthavasala, R., Lilly, N., Shaik, M., Shaik, A. B., & Aditya, M. (2014). Studying the role of yogic Pranayama in the management of Blood pressure. Int J of Biomedical And Advance Research, 5(12), 609-11.

Smeltzer, SC, Bare, BG, Hinkle, JL, & Cheever, KH (2013).

Brunner & Suddarth's Textbook of Medical-Surgical Nursing (12th ed.). Philadelphia: Lippincott Williams

& Wilkins.

Snyder, M. & Lindquist, R. (2009). Complementary / Alternative Therapies In Nursing. 4th ed. New York:

Spirnge.

Therese, AM, & Murail, R. (2016). Yoga: Effective Therapy To reduce Blood Pressure Among Hypertension Clients. International Journal of Development Research, vol 6 (05), 7761-7765. ISSN: 2230-9926.

Widyatuti, (2008). Complementary Therapies in Nursing.

Indonesian Nursing Journal, 12 (1), 53-57.

World Health Organization. (2013). A Global Brief Of Hypertension: Silent Kliller, Global Public Health

Crisis. Accessed March 2018.

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http://www.int/cardiovasculardiseases/publications/gl obalbriefhypertension/es/index.html,WHO

Yoga, R., P. (2013). Yoga Pocket Book. Jakarta: An Nuha Publishing

Yoga, T. (2009). Avoid hypertension, consume 1 teaspoon salt per day. Retrieved from http//:

www.depkes.go.id.

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Pattinasarany, I. L. J., Ranimpi, Y. Y., & Pilakoannu, R. T. (2021) Jurnal Keperawatan Soedirman – Vol 16, No 1 page 14-19 http://jks.fikes.unsoed.ac.id/index.php/jks/index

ORIGINAL ARTICLE

THE DESCRIPTION OF NURSES’ SPIRITUAL SUPPORT FOR PATIENTS OF DIFFERENT RELIGIONS IN HOSPITALS

Injilina Luzia Janetha Pattinasarany*

¹

, Yulius Yusak Ranimpi

²

, Rama Tulus Pilakoannu

²

1.

Nursing Program, Faculty of Medicine and Health Science, Universitas Kristen Satya Wacana, Indonesia

2.

Faculty of Theology, Universitas Kristen Satya Wacana, Indonesia

Article Information ABSTRACT

The term spiritual is an inseparable part of the meaning of religion. In the health service, providing spiritual support is a duty of health workers, especially nurses.

Social conflicts that lead to religious conflict, may affect to nurses' performance, especially to fulfill patients' spiritual needs with different religions or beliefs. This is makes studies related to nursing and religion are impressive. This study aimed to describe nurses' spiritual support for patients of other religions in hospitals. The research used qualitative method with phenomenology study approach. The data collection was performed using interviews. The informant selection technique used the purposive sampling technique and resulted in 5 informants. According to Creswell, the trustworthiness used triangulation, while the data analysis method used a method. Six themes emerged from this study, including the meaning of God, the meaning and the purpose of life, source of happiness, the meaning of the tragic event, assessment of good and bad things, and the interaction between nurses and patient with same or different religions. The conclusion of this study is the spiritual support provided by nurses as an informant is focus on two things, namely the meaning of God's existence and relationships with others.

Received: 19 August 2019 Revised: 4 September 2019 Accepted: 24 february 2021

*Corresponding Author

Injilina Luzia Janetha Pattinasarany 462014016@student.uksw.edu

DOI

10.20884/1.jks.2021.16.1.1174

Keywords: Meaning of God; nurses; patients with different religions; spiritual support

ISSN : 1907-6637 e-ISSN : 2579-9320

INTRODUCTION

In some areas in Indonesia, issues concerning religion are sensitive. This is proven by the conflict that occurred in Ambon in 1999, which has a dark history related to the religious issue. Not only were the victims killed in this conflict, but other losses in the form of houses also being burned down, and property that was lost resulted in residents being forced to flee to safer places (Nainggolan, 2012).

The impact arising from this conflict is the occurrence of a rift in relations between community groups and personality changes among individuals (Rudiansyah, 2015). According to (Latipun (2014), the problems that occur in post-conflict and displaced areas are both psychological and social, namely strong suspicion of other groups, hatred, and tendency to blame other groups for the occurring problems.

Besides, physical violence during conflicts, loss of property, and loss of loved ones can be a stressor for psychological

disorders (post-conflict trauma). The trauma experienced by a person after a conflict, known as post-traumatic stress disorder (PTSD), can be in the form of repetitive nightmares and memories of conflicts (Ranimpi, 2003). This disorder is a psychological manifestation of traumatic experiences or life-threatening conditions such as war/conflict, violence and abuse, natural disasters, and serious accidents (Iribarren et al., 2005).

In the context of the Ambonese society, one of the peace solutions adopted is to segregate settlements. Residential segregation is an effort to prevent conflict by placing homogeneous populations together based on religious groups. The act creates separation barriers and creates a negative stigma against people outside the group. Initially, segregation of existing settlements further strengthened the existing trauma. The segregation of religious-based settlements shows that religious solidarity is stronger than cultural solidarity (Latipun, 2014). Pela-gandong culture as a

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Pattinasarany, I. L. J., Ranimpi, Y. Y., & Pilakoannu, R. T. (2021)

form of the covenant of brotherhood (blood relations), that has existed for hundreds of years, has been shaken by religious conflicts (Bakri, 2015). This shows the dominance of religion in influencing people, especially in Ambon today.

This understanding is not much different from Ajawaila's opinion (2000) that said that the development of religion not only affects the pattern of community order that has been fostered long ago but also affects the strengthening of group sentiment and solidarity. Segregation can cause social distance between groups, both because of religious and cultural differences.

The meaning of religion cannot be separated from the term spirituality. According to Yafie, et al. in Hasnani (2012), religion is spiritual nourishment (spiritual nutrition), which can be a preventive part of an illness. Spiritual emptiness or religious sense that occurs can cause problems in the health sector. Meanwhile, according to Triyanta (2002), spirituality is part of religion. Spirituality is an effort to cultivate sensitivity to self, others, creatures other than humans and God. Spirituality is something abstract and intrinsic.

In the context of health, spirituality is one of the human needs that is required to be fulfilled. According to the World Health Organization (WHO) cited by Madadeta and Widyaningsih (2015), there are four elements of health namely physical, psychological, social, and spiritual. Health services are considered holistic if they cover these four elements. Holistic health services must be able to be provided by health workers including nurses.

According to Yanto (2013), nurses are the first person who has the longest contact with patients because of their 24- hour service. In carrying out their duties, nurses are required to be able to care for and help patients by paying attention to their needs holistically including meeting spiritual needs or providing spiritual support (Tricahyono et al., 2015).

According to Kinasih & Wahyuningsih in Madadeta &

Widyaningsih (2015), the spiritual support that the patients get is not only from themselves but also from the participation of the nurses and the patients’ families. This is certainly not an easy task for nurses to perform. Nurses need to be professional and have a strategy in dealing with patients, especially in providing services to patients who are of a different faith from the nurses themselves.

According to Sianturi (2016), one obstacle in the implementation of spiritual care is ambiguity, which arises when nurses have different beliefs to the patients they care for. Ambiguity includes the confusion of nurses, fear of being wrong, and assuming that spirituality is too sensitive and a personal matter of the patients. This may result in insecurity for the nurses.

RSUD Dr. M. Haulussy Ambon is one of the regional public hospitals in Ambon which of course accepts patients from different religious backgrounds. Ideally, in-hospital service must provide holistic health services including in the aspect of spirituality. This is increasingly interesting, seeing a variety of different backgrounds, especially the religious backgrounds of nurses and patients treated at RSUD Dr. M.

Haulussy Ambon. Also, the impact of conflicts in the past has also influenced social life, in this case it has also affected the interaction of nurses and patients in Ambon.

Therefore, the authors are interested to know how nurses spiritually support patients with different religions in RSUD dr. Haulussy Ambon.

METHOD

Study Design

This research used the qualitative method with a descriptive phenomenology approach. In phenomenology studies, researchers focus on describing the general meanings of some individuals regarding their life experiences related to concepts or phenomena (Creswell, 2015). According to Moustakas in Creswell (2015), the type used is transcendental phenomenology that focuses less on interpretations from researchers but rather a description of the experiences of the informants.

Study Informants

The informant selection technique used a purposive sampling technique. The researchers choose the informants and places because it can specifically provide an understanding of the research problem or phenomenon in the study (Creswell, 2015). The criteria for informants were nurses who had work experience of at least 5 years and had a direct role in caring for patients, especially patients of different religions at the hospital. Based on the above criteria and the willingness of informants, the sampling technique obtained 5 nurses.

Data Collection

Data collection techniques used were interviews - both in- depth interviews and semi-structured interviews. This technique was performed because researchers needed to obtain data widely and in-depth but also directed (Sugiyono, 2012).

Data Analysis

The data analysis method used is a method according to Creswell. The data analysis started with organizing data in the form of interviews, observational notes, and converting data in the form of files into appropriate units of text (a word, a sentence, or a complete story). Next, the researcher reads and makes a memo containing the main ideas in the form of short phrases. Then, the data is described, classified, and interpreted into codes and themes. In the coding process, text or visual data is grouped into smaller categories of information. Furthermore, some existing codes are compiled into a general idea called a theme. This is the stage of classification or sorting of texts. The next step is data interpretation. In this stage, the existing code is developed and a theme is formed based on these codes, followed by organizing the theme into a broad picture to interpret the data (Creswell, 2015).

Trustworthiness

Trustworthiness in this study used triangulation.

Triangulation is a data testing technique by checking data from various sources. Data checking is carried out using a variety of ways and times, which is why triangulation is divided into source triangulation, triangulation of data collection techniques, and time (Sugiyono, 2012). In this study, the triangulation data technique used triangulation of data and time, in which researchers interviewed informants from different departments, different religions, and a different time.

Ethical Consideration

The study was approved by the ethics committees of the Faculty of Medicine and Health Science, Universitas Kristen Satya Wacana, and in accordance with the Nuremberg Code and Helsinki Declaration. This study also obtained informants' approval using informed consent.