View of Relationship of Third Trimester Primigravida Mothers’ Anxiety With Psychosocial Preparedness In Facing Delivery At Kombos Public Health Center at Manado City, North Sulawesi Province

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Journal of Nursing Science Update

Vol. 11, No. 2, November 2023 e-ISSN: 2829-0003 DOI : http://dx.doi.org/10.21776/ub.jik.2023.011.02.08 p-ISSN: 2829-7075 Website : http://www.jik.ub.ac.id

@JNSU. This is an open access article under the CC BY-NC 4.0 license

169 Original Research

Relationship of Third Trimester Primigravida Mothers’ Anxiety With

Psychosocial Preparedness In Facing Delivery At Kombos Public Health Center at Manado City, North Sulawesi Province

Juolanda Kristin Surati¹, Julianus Ake², Filia Veronica Tiwatu^3*

1,2,3Nursing Faculty of De La Salle Catholic University Manado

*Corresponding author:

Filia Veronica Tiwatu

Nursing Faculty of De La Salle Catholic University Manado

Kairagi Satu Manado, Sulawesi Utara 95000, Telp: +62 (0431) 871957/Fax: (0431) 871972 Email: [email protected]

How to cite this article: Surati, J. K., Ake, J., & Tiwatu, V. F. (2023). Relationship of Third Trimester Primigravida Mothers’ Anxiety With Psychosocial Preparedness In Facing Delivery At Kombos Public Health Center at Manado City, North Sulawesi Province. Journal of Nursing Science Update, 11(2), 169–178.

Article Info ABSTRACT

Article History:

Received 8 Februari 2023 Revised 22 Juni 2023 Accepted 28 November 2023

Anxiety is a type of feeling felt by pregnant mothers, especially in the third trimester of primigravida, due to lack of pregnancy and delivery experience. If it was not intervened, that anxiety could affect the psychosocial preparedness of third-trimester primigravida mothers in facing delivery. This research aimed to determine the relationship of third-trimester primigravida mothers' anxiety with psychosocial preparedness in facing delivery at Kombos Public Health Center, Manado City, North Sulawesi Province. This research was quantitative with a correlational descriptive design by cross-sectional approach.

This research was conducted at Kombos Public Health Care Center, Manado City, North Sulawesi Province; the sample was collected using a purposive sampling technique with n = 33 samples based on inclusion and exclusion criteria. This research used a non-parametric statistical test, the Spearman correlation test. There was a significant relationship between third-trimester primigravida mothers’ anxiety with psychosocial preparedness in facing delivery with obtained r- coefficient value of 0.493, which showed a reasonably strong relationship correlation with a p-value of 0.004 that was lesser than alpha significant value < 0.05. There was a significant relationship between third-trimester primigravida mothers’ anxiety and psychosocial preparedness in facing delivery at Kombos Public Health Center, Manado City, North Sulawesi Province.

Keywords:

Anxiety Delivery Primigravida Psychosocial Third Trimester

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Relationship of Third Trimester …

170 Introduction

Primigravida mothers often face anxiety in the third trimester, and can have an impact on psychosocial preparedness in facing delivery. According to (Aswitami, 2017), shock, bleeding, and even death can occur in pregnant women as a result of anxiety in facing delivery. Primigravida mothers who enter the third trimester often experience anxiety (Maki et al., 2018). A primigravida mother must understand very well what preparations are needed in the stages and process of childbirth because one of the criteria for successful delivery is psychosocial preparedness (Muthoharoh, 2018). Thus, it can be concluded that primigravida mothers, especially in the third trimester, often experience anxiety, which can cause various impacts, especially on readiness for childbirth.

One of the problems that pregnant women in the world often experience is anxiety. Based on the results of research from Kang in Nicaragua, Central America, pregnant women experience psychological symptoms, both anxiety and depression. That is, 41% of pregnant women experienced anxiety, and 57% of pregnant women experienced depression (Windatania et al., 2019).

According to WHO, the prevalence of anxiety during pregnancy also occurs in several Asian countries, including 70% in Pakistan, 29% in Bangladesh, and 54% in Hong Kong (Nelsi et al., 2019). So, it can be seen that anxiety is experienced by pregnant women in various parts of the world.

Anxiety experienced by pregnant women in Indonesia affects their readiness for childbirth. The Indonesian Ministry of Health 2017 (Amriani et al., 2019) noted that in 2016, there were 67,976 pregnant women on the island of Java, of which 35,587 of them felt anxiety during childbirth. This is the same as what happened at the Puskesmas Cipinang Besar Utara, East Jakarta, which said that there were 94% of pregnant women experienced anxiety, namely the most with the moderate category as much as 54%, the heavy as much as 38%, and in the mild category as much as 2% (Septiani et al., 2020). From these data, it can be seen that most pregnant women in Indonesia experience anxiety.

In North Sulawesi, pregnant women also experience anxiety before giving birth.

Based on the results of research at the Sonder Minahasa Health Center in 2017, primigravida mothers experienced anxiety; 76.7% of mothers experienced moderate pressure, 13.3% experienced mild anxiety, and 10%

experienced severe anxiety (Menajang et al., 2017). Another study conducted by (Sangkoy et al., 2020) at GMIM Bethesda Tomohon Hospital noted that 53.7% of primigravida mothers before delivery experienced moderate anxiety, followed by mild anxiety as much as 29.3% and severe anxiety as much as 17%. So, it can be concluded that most pregnant women experience anxiety, which tends to be felt by primigravida mothers, especially in the third trimester.

Several efforts have been made to minimize the anxiety of pregnant women in Indonesia, and based on research from Miarso et al. (2018), the government, especially the Ministry of Health, made a class program for pregnant women as a meeting place for multigravida and primigravida mothers. In this program, the multigravida mothers who already have the experience will share their experiences with the primigravida mothers so that knowledge and skills related to pregnancy and childbirth of the primigravida mothers and their families can be increased. Another policy that has just been implemented is the Sustainable Development Goals (SDGs), a policy with one focus: providing guarantees for a healthy and prosperous life for all people of all ages. If this program is applied to pregnant women, it can help reduce maternal anxiety during pregnancy until delivery (F. et al., 2017). Although there have been efforts from the government, because the implementation has not been effective, there are still many pregnant women who often experience anxiety, especially pregnant women in the third trimester.

Based on the data above, the researcher concluded that anxiety in pregnant women during pregnancy could cause bleeding and shock to death, especially experienced by third-trimester primigravida women because they do not have experience in facing delivery. So, when the anxiety of the third-trimester primigravida mother increases, it will have an impact on psychosocial preparedness in facing delivery.

Therefore, the researcher conducted a study

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171 on whether or not there is a relationship between third-trimester primigravida mothers' anxiety and psychosocial preparedness in facing delivery at Kombos Public Health Center in Manado City, North Sulawesi Province.

Method

In this study, the researcher used a descriptive-analytic/quantitative design with a cross-sectional approach to determine the relationship between third-trimester primigravida mothers' anxiety and psychosocial preparedness in facing delivery at Kombos Public Health Center at Manado City North Sulawesi Province which was measured at the same time.

The population in this study were all third-trimester primigravida mothers at the Kombos Public Health Center, Manado City, North Sulawesi Province. The sample size was taken using the purposive sampling method, which is a type of non-probability sampling carried out by including all subjects who met the sample selection criteria and determined by the Lemeshow formula, namely the infinite population or unknown population to obtain the results of the study sample totalling 33 samples.

This study uses a questionnaire as a research instrument; two types of questionnaires are used: A and B. The researcher made these two types of questionnaires by adjusting the concepts and theories in Chapter 2. Questionnaire A to measure the anxiety of third-trimester primigravida mothers contains 20 statements using a Likert scale; scores range from 20-80 with measurement results if <20 are not anxious, 20-34 are mildly anxious, 35-50 are moderately anxious, 51-64 are severely anxious, and 65-80 are very severe or panicked. Questionnaire B to measure psychosocial preparedness in facing delivery consists of 23 statements using the Guttman scale with category determination if the score of 34.5 means the respondent is quite ready and a score less than 34.5 means the respondent is not psychosocially ready to face delivery.

Results and Discussion

The study was conducted at the Kombos Public Health Center, Manado City,

North Sulawesi Province, from May 25 to June 28, 2021. The number of respondents was 33 third-trimester primigravida mothers. The following are the results of the univariate and bivariate analysis, which are distributed through the table:

Table 1. Characteristics of Respondents at Kombos Public Health Center Manado City,

North Sulawesi Province in 2021 (n=33) Characteristics Frequency Percentage Maternal Age

<20 years old

20-35 years old 6

27 18.2 %

81.8 % Mother's

Gestational Age Seven months Eight months Nine months

10 15 8

30.3%

45.5%

24.2%

Recent Education History

Elementary school Junior high school Senior high school University

15 4 9 5

12.1%

45.5%

27.3%

15.2%

Mother's Job IRT

Entrepreneurs Private sector Honorary

22 4 5 2

66.7%

12.1%

15.2%

6.1%

Source: Primary Data 2021

Table 1 above shows that most respondents are between 20 and 35 years old.

It showed from the data above that there are 27 respondents (81.8%) who are 20-35 years old, and respondents who are less than 20 years old are six respondents (18.2%). Based on maternal gestational age, there were 15 respondents (45.5%) whose gestational age was eight months, then there were 10 respondents (30.3%) whose gestational age was seven months, and at least eight respondents (24.2%) aged nine months pregnant. For the latest education, it can be seen that as many as 15 respondents (45.5%) with the last education history are in junior high school, for the last education history is in senior high school, there were nine respondents (27.3%), and only five respondents (15.2%) whose last education was university, and at least four respondents (12.1%) whose last education history was in the elementary school. Furthermore, for the mother's occupation, as many as 22 respondents (66.7%) work as IRT, followed by

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172 five respondents (15.2%) who work in the private sector, four respondents (12.1%) who work as entrepreneurs, and those who work as honorarium only two respondents (6.1%).

Table 2. Anxiety description of the third trimester Primigravida Mother at the Kombos Public Health Center, Manado

City, North Sulawesi Province in 2021 (n = 33)

Third Trimester Primigravida Mother Anxiety

Frequency (f) Percentage (%)

Mild Anxiety 2 6.1 %

Moderate Anxiety 8 24.2 %

Severe Anxiety 23 69.7 %

Based on Table 2 regarding the Anxiety Description of the Third Trimester Primigravida Mother at the Kombos Public Health Center, Manado City, North Sulawesi Province, it was found that more dominant data was the third-trimester primigravida mother who experienced severe anxiety in as many as 23 respondents (69.7%). There were eight respondents with moderate anxiety (24,2%), and mild anxiety there were only two respondents (6.1%). Thus, it can be concluded that the most anxiety in the third trimester of Primigravida Mother is severe anxiety.

Table 3. Description of Psychosocial Preparedness in Facing Delivery at Kombos Public Health Center Manado City,

North Sulawesi Province in 2021 (n = 33) Psychosocial

Preparedness in Facing Delivery

Frequency (f) Percentage (%)

Not Ready 18 54.5 %

Quite Ready 15 45.5 %

Based on Table 3 on the description of Psychosocial Preparedness in Facing Delivery at the Kombos Public Health Center, Manado City, North Sulawesi Province, it was found that data that was more dominant for third- trimester primigravida mothers who were not ready were 18 respondents (54.5%), and 15 respondents who were quite ready (45.5%).

Thus, the Psychosocial Preparedness of the

Third Trimester Primigravida Mothers Facing Delivery is more or less prepared.

Table 4. Description of the Relationship of Third Trimester Primigravida Mothers Anxiety with Psychosocial Preparedness

in Facing Delivery at the Kombos Public Health Center, Manado City, North Sulawesi Province in 2021 (n = 33) Third Trimester

Primigravida Mother Anxiety

Psychosocial Preparedness in Facing Delivery Not Ready Quite Ready

f % f %

Mild Anxiety 0 0.0 2 6.1 Moderate Anxiety 3 9.1 5 15.2

Severe Anxiety 15 45.5 8 24.2 Spearman p = 0.004

Correlation value = -0.493 Source: Primary Data 2021

Based on table 4 on the description of the relationship between the third-trimester primigravida mother's anxiety with psychosocial preparedness in facing delivery at the Kombos Public Health Center, Manado City, North Sulawesi Province, shows that the highest frequency and presentation are primigravida mothers who are severely anxious as many as 23 respondents (69.7%) with psychosocial preparedness in 18 respondents (54.5%).

From the results of data analysis using a non-parametric statistical test, namely the Spearman's test, the test results obtained with a calculated r-value of 0.493 > r-table 0.344 and for a p-value of 0.004 < alpha (α) 0.05 so that based on the test results stated that H0 was rejected and H1 is accepted. Then, based on the results of the calculated r-value, which is 0.493 when viewed from the table of correlation and relationship levels, there is a relatively strong relationship between third- trimester primigravida mothers' anxiety and psychosocial preparedness in facing delivery.

Therefore, it can be concluded that based on the results of the analysis between the independent and dependent variables, there is a significant relationship of the third trimester Primigravida Mother and Psychosocial Preparedness in Facing Delivery at the Kombos Public Health Center, Manado City, North Sulawesi Province.

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173 Description of Respondents' Characteristics

Based on the study's results, most pregnant women were aged 20-35 compared to those aged <20. The results of the study (Shodiqoh & Fahriani, 2014) explained that the age range <20 years pregnant women tend to experience moderate anxiety, and those aged >35 years experience mild anxiety, while at the productive age of 20-35 years pregnant women tend to experience severe anxiety.

Primigravida mothers with the age range mentioned above are often found experiencing anxiety because they do not have an idea regarding what things are related to childbirth; the anxiety in primigravida mothers is also due to various stories in their environment related to the scary childbirth processes (Mezy, 2016). Therefore, from the study's results, it can be concluded that age affects the mother's readiness for childbirth.

From the data on the category of maternal gestational age, the majority were respondents with an age of 8 months, then seven months, followed by respondents with a gestational age of 9 months. Increasing gestational age affects thinking processes and increases feelings of fear and anxiety because the time for delivery is getting closer (H. Sari, 2016). Therefore, it can be seen that mothers in the third trimester of pregnancy who are approaching delivery tend to experience anxiety.

Based on the data on the latest educational history characteristics, it can be seen that most respondents have the latest education history in junior high school, followed by the last education history in senior high school, then the last education history in university, and the least with the last education history in elementary school. The results of this study are supported by research from Suyani (2020), namely, pregnant women with primary and secondary education feel severe and moderate anxiety as much as 66.7% and only a small part, namely 33.3%

with a high level of education and experiencing mild anxiety or not experiencing anxiety. So, the level of education affects the level of anxiety and readiness of pregnant women.

In addition, based on the occupation category, most mothers are domestic workers, followed by the private sector, then entrepreneurs, and the least are temporary workers. Pregnant women whose anxiety is lighter and do not experience anxiety are pregnant women who have jobs. The activities they do can divert feelings of anxiety, in contrast to pregnant women whose work is only a Housewife (IRT) or who do not work because they tend to experience moderate to high anxiety (Ratnawati, 2016). So, pregnant women need to have jobs to reduce anxiety related to their pregnancy.

Anxiety Overview of Third Trimester Primigravida Mothers

Based on the results of research on 33 respondents of third-trimester primigravida mothers at the Kombos Public Health Center, Manado, North Sulawesi, it showed that all respondents at the Kombos Public Health Center experienced anxiety, where most of the respondents experienced severe anxiety, followed by moderate anxiety and only a tiny portion experienced mild anxiety.

The absence of experience related to childbirth makes a primigravida mother feel more anxious compared to multigravida and more experienced mothers (Nugraheni &

Romdiyah, 2018). The confidence of a pregnant woman can increase with the experience of childbirth, where when the mother is more confident, her anxiety will decrease (Palupi, 2014). Anxiety in pregnant women can increase, as explained by (Arifin et al., 2015); as gestational age increases, the centre of attention of mothers is increasingly focused on the day before delivery, so fear and anxiety are always a sign of increased anxiety.

This is in line with research conducted by (Wanda, 2014), which showed that as many as 40 third-trimester pregnant women experienced anxiety with a percentage of severe anxiety and panic as many as 62.5%, moderate anxiety as many as 30%, and mild anxiety are many as 7.5%. On average, pregnant women must feel anxiety, as evidenced by research from (Yunita & Angin, 2020), which showed that of the 40

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174 respondents who studied primigravida mothers, all experienced anxiety, with a percentage of 50% experiencing severe anxiety, followed by moderate anxiety 47.5%, and 2.5% were very anxious or panicked. This is also in line with the results of research (Wiulin Setiowati, 2020), which shows that pregnant women in the third trimester tend to experience anxiety with the result that the percentage of respondents who experience severe anxiety is 70%, while the rest experience moderate anxiety as much as 30%.

However, some studies are not in line with some of the studies above, namely the results of research from Sari (2019), which shows that the 35 respondents studied did not experience moderate or severe anxiety; they only experienced mild anxiety, as many as 34.28% of respondents and most of them were 65, 71% and they are pregnant women who do not experience anxiety.

The researcher has assumptions based on the results of the study and also a description of the theory, namely, the anxiety experienced by third-trimester primigravida mothers is due to the lack of experience they have about pregnancy and childbirth as well as because of the time of delivery is getting closer so that all respondents feel anxiety, whether severe, moderate or mild. It is essential to have experience related to pregnancy and childbirth in the third trimester primigravida because, through experience, they can be more confident in the process of pregnancy and childbirth. Difficulty adjusting to new conditions and changes in herself occurs in a mother who is pregnant for the first time; plus, when the day before delivery draws near, anxiety will increase due to various thoughts, making pregnant women try to reduce the anxiety experienced due to excessive anxiety, must be an alarming activity. Several research results provide evidence that in the first pregnancy experienced by the mother, there must be anxiety because of the lack of experience, especially when entering the third trimester of pregnancy.

Therefore, the researcher concluded that research to find out the anxiety of third- trimester primigravida mothers is significant

because excessive anxiety can cause various conditions that endanger both mother and baby and because the first experience for a pregnant mother will always be the first time to face any process starting from pregnancy to delivery, the anxiety that occurs can affect every existing process. Moreover, it also affects the readiness of the mother before delivery.

Overview of Psychosocial Preparedness in Facing Delivery

The study's results on 33 respondents of third-trimester primigravida mothers at the Kombos Public Health Center, Manado, North Sulawesi, showed that more respondents had less readiness and only a few had sufficient psychosocial preparedness in facing delivery.

The thing that’s very important in the process of pregnancy until facing delivery is related to how the preparedness and the maternal and infant mortality rates can decrease when a mother is more prepared to undergo the delivery process (Rosyidah, 2017). According to Fauziah & Rahmawati (2021), the lack of maternal readiness can occur because it is influenced by parity or a large number of deliveries experienced so that mothers who have had experience giving birth will know and understand more about preparation for childbirth, which is different from primigravida mothers for the first time pregnant.

This is in line with research (Muthoharoh, 2018), which explains that of the 28 primigravida mothers studied, 85.7%

were not ready to face delivery, and only a tiny percentage, namely 14.3%, were prepared to face delivery. This is also in line with research (Gitanurani, 2017), which showed that from 46 respondents of pregnant women in the third trimester, the study results were that 56.5% of mothers were not prepared to face delivery. Only 43.5% were ready to face delivery. The results of both studies above are not in line with Rante's research (2018), which shows that the preparedness facing delivery from 30 pregnant women respondents was 43.33% who were very ready and 36.67%

were ready, while only 20% were not ready.

These results were obtained because each

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175 respondent attended a class program for pregnant women so that mothers could be more prepared and increase their knowledge about pregnancy and childbirth.

Seeing the theoretical basis and the results of the research above, the researcher assumes that psychosocially unprepared attitudes in third-trimester primigravida mothers facing delivery often occur. This needs to be addressed to minimize the risks due to a lack of preparedness. In the third trimester, a primigravida mother has to think about her condition both physically, mentally, and socially so that she is ready psychosocially to face delivery.

Therefore, the researcher concludes that psychosocial preparedness is essential in facing delivery because when ready, third- trimester primigravida mothers can minimize the dire possibilities in the labour process.

Third-trimester primigravida mothers who can have sufficient self-preparation in the process of pregnancy until delivery have the potential not to experience various difficulties in their delivery later.

Relationship of Third Trimester Primigravida Mother's Anxiety with Psychosocial Preparedness in Facing Delivery

Based on the results of research conducted on 33 respondents of third- trimester primigravida mothers at the Kombos Public Health Center, Manado City, North Sulawesi Province, using the Spearman's Rho correlation analysis test, the Correlation Coefficient value was obtained was 0.493, which stated that there was a reasonably strong relationship between the two variables and the relationship was shown in the p-value 0.004 which is less than alpha 0.05 thus H0 is rejected, and H1 is accepted so it can be concluded that there is a significant relationship of third-trimester primigravida mothers' anxiety and psychosocial preparedness in facing delivery.

At the beginning of pregnancy, a mother has started to feel restless. According to Wati (2018), mothers who are pregnant for the first time often have various kinds of disturbing thoughts, so they have the potential to develop an anxiety reaction that can affect

the mother's readiness both physically and psychologically in facing delivery. In third- trimester pregnant women, more complex psychological changes occur so that anxiety is always felt before delivery is getting closer;

that is why some pregnant women are less ready to face delivery (Naha & Handayani, 2018).

In a study (Naharani et al., 2018) regarding the relationship between participation behaviour in pregnant women with anxiety in third-trimester primigravida mothers facing delivery, the results of 30 respondents showed that all respondents experienced mild, moderate and even severe anxiety with the results of the Spearman bivariate statistical test. Rho stated that there is a significant relationship between primigravida mothers' anxiety and their participation in classes for pregnant women, which can help reduce anxiety and even reduce unprepared behaviour in facing delivery when pregnant women are more diligent in attending classes. Another study was also conducted by Arisandi (2012) on the relationship between anxiety levels and the smooth delivery of primigravida mothers at the Banda Aceh Mother and Child Hospital, which explained that smooth delivery was something that could be achieved when primigravida mothers had sufficient readiness to undergo the labour process. Through the results of his research, Arisandi showed that of the 36 respondents studied, 63.9% of respondents experienced severe or moderate anxiety and were not fluent in the delivery process, for the results of the bivariate test found a significant relationship between the level of anxiety and the smooth delivery of primigravida mothers.

Seeing the results of the research that has been done and even the theory described, the researcher assumes that there is a relationship between third-trimester primigravida mothers' anxiety and their psychosocial preparedness in facing delivery.

According to the researcher, a good adjustment in the process, that is, the first time a primigravida mother goes through the third trimester, is necessary so that anxiety can be

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176 reduced and readiness for childbirth can be increased.

This research is related to Callista Roy's nursing theory, namely the Holistic Adaptive System; it is very clear that the relationship is where the individual, namely the third-trimester primigravida mother, must be able to adapt to new conditions starting from her anxiety during pregnancy to the end being more prepared to face delivery. Third- trimester primigravida mothers must focus on themselves thoroughly, not only paying attention to physical but also psychological aspects related to anxiety. When a third- trimester primigravida mother has just adapted to her pregnancy and experiences anxiety, it is necessary to be able to use coping mechanisms to reduce and even overcome the anxiety that occurs so that she can be more psychosocially prepared to deal with childbirth. However, if the individual is unable to cope with her anxiety, the result is a lack of psychosocial preparedness in facing delivery.

Thus, it is obvious how the relationship between the two variables studied, so it can be said that the higher the anxiety experienced by primigravida mothers in the third trimester, the less psychosocial preparedness in facing delivery and vice versa, the lower the anxiety experienced by primigravida mothers in the third trimester, the better the psychosocial preparedness in facing delivery.

Conclusion

The results showed that most of the third-trimester primigravida mothers at the Kombos Public Health Center, Manado City, North Sulawesi Province, experienced severe anxiety and were included in the category of less prepared psychosocially in facing childbirth.

There is a significant relationship between the anxiety of third-trimester primigravida mothers and psychosocial readiness in facing childbirth at the Kombos Health Center, Manado City, North Sulawesi Province. Thus, it can be said that the higher the level of anxiety experienced by the third- trimester primigravida mother, the less psychosocial readiness in facing the labour process.

Limitations of the study

There were research limitations during the data collection processes. The study began by collecting initial data at the Kombos Health Center in Manado, North Sulawesi, where researchers also surveyed to see the conditions and the target place of research. When the study participants first came to the research site, the researcher conducted brief interviews with several pregnant women who were present regarding the need for data collection through a questionnaire initially given via Google Forms.

Based on the interviews conducted, the researchers got information that most pregnant women who attended tended to prefer not to bring cell phones, so the researchers consulted with the supervisor again, and an agreement was obtained for researchers to replace the Google form method with a questionnaire sheet distributed to respondents. There are positive things from the direct distribution of questionnaire sheets.

Namely, researchers can directly interact and see the condition of existing respondents.

Acknowledgement

Thank you to the Dean, Vice Dean, and Head of the Science Study Programme of Nursing, All the staff and lecturers of the Faculty Of Nursing at the Catholic University of De La Salle, Manado. Thank you to my Thesis adviser, Sir Dr Julianus Ake, S.Kp., M.Kes and Ma'am Filia V. Tiwatu, S.Kep., Ns., M.Kep., Sp.Kep.Mat. Thank you to my parents and everyone who always supports me; God Bless.

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