Original research

THE EFFECTIVENESS OF INTEGRATED EDUCATION IN IMPROVING

THE SELF-EFFI CACY OF THE PATIENTS AFTER THE OPERATION OF
THE TOTAL HIP AND KNEE REPLACEMENT SURGERY IN HOSPITALS

Muhajirun Maliga1.2, Elly Lilianty Sjattar3, Syahrul Syahrul4

1. Master Course Student Of Nursing, Hasanuddin University, Makassar

2. Surgical Nurse Rs TK. II Pelamonia
e-mail: muhajirinmaliga34@gmail .com
3. Medical Surgical Nursing Section, Nursing Science Course of Hasanuddin University, Makassar
4. Part of community and family Nursing, Nursing Course of Hasanuddin University, Makassar

Abstract

Background: Integrated Education is very effective in improving self-efficacy in post-operative patients of Total
Hip and Knee Replacement
Objective knowing the effectiveness of integrated education in the intervention group and the control group on the
standard of education in improving the efficacy of self with a reduction of pain, improved muscle strength, udema
and the scope of the motion of joints in patients post operation total Hip and knee replacement surgery.
Method s : design research quasi experimental pre test and post test control group with a sample of 31 patients of
total hip and knee replacement surgery in the hospital Nursery II Pelamonia Makassar. Measuring self-efficacy
was conducted one day before the respondents underwent surgery and post-operative day. HHS and KSS
measurement with level udema done 1 day post surgery and post-operative day.
Results: The average increased self-efficacy on respondents a Total Hip Replacement after the awarding of the
integrated education in the intervention group than (65.67 ± 4.94) becomes (106.25 ± 3.36) p= 0.000. This was
followed by pain intensity decreased from average (20.00 ± 0.00) becomes (40.00 ± 0. 00) p= 0.001, udema
declined from an average (1.50 ± 0.52) becomes (0.92 ± 0.28) p= 0.020, muscle strength increased from the
average (15.00 ± 0.00) (36.92 ± 0.00) p= 0.000 and the motion of joints under increased from the average (3.10 ±
0.18 ) into (4.66 ± 0.05) p= 0.002. To the respondent a Total Knee Replacement on average increased self-efficacy
after the awarding of the integrated education in the intervention group than ( 61.50 ± 2.38) to (105.25 ± 3.86) p =
0.000, followed by a decrease in the intensity of pain from the average (20.00 ± 0. 00) becomes (40.00 ± 0.00) p=
0.046, udema decreased from average (1.75 ± 0.50) (0.50 ± 0.57) p= 0.015. Muscle strength increased from the
average (-2.50 ± 0.57) becomes (28.50 ± 1.91) p= 0. 000, the motion of joints under increased from (25.00 ± 0.00)
becomes (70.00 ± 0.00) p= 0. 046.
Conclusion: integrated education is very effective in improving self-efficacy after intervention was followed by a
decrease in the intensity of pain, muscle strength, increased udema and joint motion compared to the scope of
educational standards.

Keywords: Integrated Education, Educational Standards, Self-Efficacy, Total Hip and Knee Replacement

INTRODUCTION

Independence the patient is a paradigm in clinical practice (Bravo et al., 2015).

Independence aims to develop or strengthen the ability of physical, mental, social or patients in
Managing the disease and the treatment ofhim and can determine the degree of the health ofhis
own. In Taiwan, the independence of the patient is very important in the system of the Ministry of
health (Huang, Che, & Yeh, 2010).
The purpose of the independence This is to improve the health and well-being of patients
focusing on an increase in the self-efficacy of patients, harness information about treatment and
care, builds good relationships with health workers, are committed to complying with treatment
 program and care, with the aim of reach degrees the health. (Deccache & van Ballekom, 2010;
European Patients' Forum, 2015; Pulvirenti, 2011).
Patient Education is a process of independence patients that are designed in order for the
patients are responsible for their own health (Falvo, 2004; Malternd, 2010; Piper, 2010). One of
the educational goals of the patient is memandirikan patients and enhance their participation on the
service of treatment (Deccache & van Ballekom, 2010) in improving change in behavior/self-
efficacy (Stoilkova, Janssen, & Wouters, 2013). The primary Key on the efficacy of self is the
most powerful determining factor in behavior change because with self-efficacy can determine the
initial decision in behavior change, time, efficiency and capabilities in dealing with various
difficulties (Hartley, Vance, Elliott, Cuckler, & Berry, 2008).
TKR Surgery is considered solutions penanganan the most effective in treatment OA end
stage knee (Skou et al., 2015) . National Joint Registry (NJR) in United Kingdom and Wales report
the number of procedures and procedural 81,979 TKR THR 76,759 in 2010 showed a rise of 5.7%
on the TKR and 6% on THR, an increase in compared with the same reporting period in the
previous year (Lim, Yobas, & Chen, 2014).
Of post-operative, handling during the primary recovery is the restoration of the strength of
the muscle and f ungsional knee joint with the aim of improve the ability of functional mobilisusi
self, besides handling the psychological is also very necessary (Lim, Yobas, & Chen, 2014).
To reduce pain and improve physical function in patients of hip and knee OA, 28 of 34
clinical guidelines recommend patient education (PE) and 27 of the 34 recommends program
strengthening exercises on extremities (Fernandes, Storheim, Sandvik, Nordsletten, & Risberg,
2010).
Based on the data in the hospital Pelamonia Makassar, d ari post-operative care , a total of
10 patients who did not do the movement as recommended by the health team. If it is not
monitored continuously and without educational adekuat then the risks will be experienced by the
patient is the occurrence of kontraktur, which in the end the occurrence of dislocations and post-
operative failure.
The purpose of this research is to knowing the effectiveness of integrated education in
improving self-efficacy of post-operative patients of Total Hip and Knee Replacement Surgery in
the hospital Nursery II Pelamonia Makassar Year 2018.

METHODS
Type of this research is quantitative using quasi experimental design approach to pre-and post test-
test with control group design done by researchers to patients who undergo surgery Total Hip and
Knee Replacement, to know the influence of a treatment of the effects of treatment.
Research Places is RS Pelamonia. Research time is between April and August with 2018 until
samples are met.
The number of sample 16 for THR and TKR to 15. As for adding the total sample are met if one
dropped out, then the researchers took samples from patients undergoing Partial Hip and Knee
Replacement.
Data on Self-efficacy were taken one day before the operation, by means of the respondents fill in a
detailed questionnaire from the SERS. The data is then taken after given integrated educational or
educational treatment standards. The result of the scale of the original version of SER and in the
Netherlands, have proven to be reliable with internal consistency reliability 0.94, in patients
undergoing orthopedic surgery knee and hip. It has also been shown to predict the degree of
independence when out of the hospital. Self-efficacy is assessed in conjunction with muscle strength,
joint motion, and pain intensity degree udema on sixth day post surgery.
Instrument used is 12 items of the statement of SER (Self-Efficacy for Rehabilitation Outcomes Scale)
by assessing the patient's beliefs about their ability to do activities that are specific to physical
rehabilitation. Item Likert scale rated at 11 points starting from 0 (I certainly couldn't) to 10 (I could
definitely do it) with assessment criteria: 0 – 120 criteria score lowest highest score of 0 and 100 that
represents the higher self-efficacy. To measure the intensity of pain, muscle strength and joint motion
of researchers using the Harris Hip Score for THR and TKR Knee Society to Score.
Before the research is conducted, researchers apply a test of Ethics Committee of ethics from
researchers of the Faculty of nursing at the Hasanuddin University and Instaldik part of RS Tk II
Pelamonia. In an effort to protect the rights and welfare of the respondents then researchers complete
with evidence in the form of affidavits escaped kaji of ethics and research licences. At RS TK. II
Pelamonia is done by the Instaldik of ethics trials, so the researchers used the description passes from
ethics review of RS Tk II Pelamonia. The confidentiality of the information maintained by replacing
names with initials and used only for the purposes of research. The finished Data examined and no
longer needed in the process of research, then the data will be destroyed.
The test was conducted by the independent t-test if the Gaussian and Gaussian otherwise then the test
used is the mann-whitney U. As for knowing the influence of self-efficacy to increased education pre
test and post test in each group conducted a test of paired t-test if a Gaussian, and wilcoxon test if not
Gaussian .

RESULTS

A. Characteristics Of Respondents
The average age of respondents on integrated education intervention group dominated by
66-80 (67.69±6.76 years). In contrast, the control group respondents educational standard is
dominated 50-65 years (65. 40 ± 8.81 years) p= 0.106. Gender in integrated education intervention
group dominated by women (12 persons, 75.0%) and so did in the standard educational control
group respondents are predominantly female (14 people, 93.3%) p= 0.186. The level of education
on integrated education intervention group dominated by low education (13 people, 81.3%), as
 well as with a standard educational control group respondents are predominantly educational low
(12 persons, 80.0%) p= 0.641. The respondent's work on integrated education intervention group
dominated by IRT (10 people, 62.5%), and so also in the control group the standard education
IRT-dominated (11 people , 73.3% ) p= 0.285. On the types of operations the respondents on
integrated education intervention group most is Total Hip Replacement Surgery (12 persons,
75.0%) and so also in the control group education standards dominated Total Hip Replacement (12
persons, 80.0%) p= 0.539 (table 5.1).
Table 5.1
Equity Characteristics Of Respondents Based On Age, Gender, Level Of Education, employment and the
type of operation In the intervention group and the control group in the Hospital Tk.II Pelamonia, 2018

Intervention group (n = 16) Control group (n = 15) p

n % Mean SD n % Mean SD Value c
Age (Years)
50 – 65 4 25.0 67.69 6.76 8 53.3 65.40 8.81 0.106
66 – 80 12 75.0 7 46.7
Gender
Men 4 25.0 1 6.7 0.186
Women 12 75.0 14 93.3
Education
High 3 18.8 3 20.0 0.641
Low 13 81.3 12 80.0
Jobs
Private 1 6.3 1 6.7
Self employed 2 12.5 0 0
Ret. PNS 3 18.8 1 6.7 0.283
PNS 0 0 2 13.3
IRT 10 62.5 11 73.3
Type Of Operation
THRa 12 75.0 12 80.0 0.539
TKRb 4 25.0 3 20.0
a. Total Hip Replacement
b. Total Knee Replacement Surgery
c. Parametric Tests: Chi-Square

B. The Difference In Efficacy On Integrated Education Intervention Group And A Control Group Of
Education Standards
 Tabel 5.2
The difference in Efficacy On Integrated Education intervention group and a control group of
Education Standards in patients Post Total Hip and Knee Replacement Hospital TK. II
Pelamonia, 2018

n Before p-value After Education p-

Education value
Mean SD Mean SD
Total Hip Replacement
Self-efficacy
Interventiona 12 65.67 4.94 0.000c 106.25 3.36 0.000c
Controlb 12 49.25 4.57 83.67 1.92
Harris Hip Score
Intensity Of The Pain
Interventiona 12 20.00 0.00 1.000d 40.00 0.00 0.000d
Controlb 12 20.00 0.00 31.67 3.89
Muscle Strength
Interventiona 12 15.00 0.00 1.000d 36.92 2.61 0.000d
Controlb 12 15.00 0.00 25.67 1.67
Joint Motion
Interventiona 12 3.10 0.18 0.799 d 4.6625 0.05 0.000d
Controlb 12 3.07 0.20 3.9333 0.24
Udema
Interventiona 12 1.50 0.52 0.216 d 0.92 0.28 0.317d
Controlb 12 1.75 0.45 1.00 0.00

Total Knee Replacement

Self-efficacy
Interventiona 4 61.50 2.38 0.029c 105.25 3.86 0.000c
Controlb 3 49.33 4.61 82.33 2.08
Knee Society Score
Intensity Of The Pain
Interventiona 4 20.00 0.00 1.000d 40.00 0.00 0.014d
Controlb 3 20.00 0.00 30.00 0.00
Joint Motion
Interventiona 4 -2.50 0.57 0.436c 28.50 1.91 0.006c
Controlb 3 -1.33 2.08 18.00 2.64
Muscle Strength
Interventiona 4 25.00 0.00 1.000d 70.00 0.00 0.018d
Controlb 3 25.00 0.00 56.67 2.88
Udema
Interventiona 4 1.75 0.50 0.391c 0.50 0.57 0.182c
Controlb 3 2.00 0.00 1.00 0.00
a: Integrated Education
b: Standards Education
c: test t-independent
d: test the Mann-Whitney U

Self-efficacy measurements on respondents a Total Hip Replacement intervention group

prior to the awarding of the integrated education is the average (65.67 ± 4.94) different from the
control group prior to the granting of educational standards (49.25 ± 4.57) p = 0.000. Occur after
the awarding of the integrated education (106.25 ± 3.36) higher average difference after granting
educational standards (83.67 ± 1.92) p= 0.000 (table 5.2).
Self-efficacy measurement on respondents a Total Knee Replacement intervention group
before the awarding of the integrated education is the average (61.50 ± 2.38) different from the
control group prior to the granting of an average standard of education (49.33 ± 4.61) p= 0.029.
Occur after the awarding of the integrated education intervention group (105.25 ± 3.86), higher
educational standards i.e. the grant after (82.33 ± 2.08) p= 0.000 (table 5.2).
Measurement of the level of pain assessment methods with HHS on the intervention group
prior to the awarding of the integrated education is the average (20.00 ± 0.00) and occurs in
common with control group prior to the granting of educational standards (20.00 ± 0.00) p= 1.000.
There is a difference higher decline rate of pain after the awarding of the integrated education
(40.00 ± 0.00) and higher than the control group education standards (31.67 ± 3.89) p= 0.000.
Measurement with the method of assessment of KSS in the intervention group before the
integrated education is (20.00 ± 0.00), happened the same thing prior to the granting of educational
standards (20.00 ± 0.00) p = 1.000. Pain levels decline after concerted education i.e. (40.00 ±
0.00), unlike the control group, there was a decline in the standard of education level of pain just
on (30.00 ± 0.00) p= 0.014 (table 5.2).
Measurement level udema on respondents a Total Hip Replacement intervention group
prior to the awarding of the integrated education is the average (1.52 ± 0.52) occur differences
with the control group prior to the granting of educational standards (1.75 ± 0.45) p= 0.216. Occur
after the awarding of the integrated education (0.92 ± 0.28) higher educational standards granting
after differences are (1.00 ± 0.00) p= 0.317 (table 5.2).
Measurement level udema on respondents a Total Knee Replacement intervention group
before the awarding of the integrated education is the average (1.75 ± 0.50) different from the
control group prior to the granting of educational standards of the average (2.00 ± 0.57) p= 0391.
Occur after the awarding of the integrated education intervention group (0.50 ± 0.57), higher
educational standards i.e. the grant after (1.00 ± 0.00) p= 0.182 (table 5.2).
Measurement of muscle strength with HHS on the assessment methods of intervention
group prior to the awarding of the integrated education is the average (15.00 ± 0.00) and occurs in
common with control group prior to the granting of educational standards (15.00 ± 0.00) p= 1.000.
There is a difference higher increase in muscle strength after the awarding of the integrated
education (36.92 ± 2.61) and higher than the control group education standards (25.67 ± 1.67) p=
0.000.
Measurement with the method of assessment of KSS in the intervention group before the
integrated education is (25.00 ± 0.00), not different from the control group prior to the granting of
educational standards (25.00 ± 0.00) p= 1.000. An increase in muscle strength after integrated
education (70.00 ± 0.00), different from the control group educational standards, an increase in
muscle strength are just on (56.67 ± 2.88) p= 0.018 (table 5.2).
Measurement of joint motion down with HHS on the assessment methods of intervention
group prior to the awarding of the integrated education is the average (0.180 ± 3.10) and going on
the differences with the control group prior to the granting of educational standards (3.07 ± 0.20) p
= 0.799. There is a difference even higher increase in the lower joint motion after the awarding of
 the integrated education (0.056 ± 4.66) and higher than the control group educational standard that
is average (3.93 ± 0.24) p= 0.000.
Measurement with the method of assessment of KSS in the intervention group before the
integrated education is (-2.50 ± 0.57), different from the control group prior to the granting of
educational standards are (-1.33 ± 2.08) p= 0.436. An increase in the lower joint motion after
integrated education (28.50 ± 1.91), different from the control group educational standards,
improved joint motion down just on (18.00 ± 2.64) p= 0.006 ( Table 5.2).

C. The influence of integrated educational effectiveness in improving the efficacy of the self with a
decrease in pain and increased muscle strength, udema and motion of joints in post-operative
patients of total hip and knee replacement
The average increased self-efficacy on respondents Total Hip Replacement after the
awarding of the integrated education in the intervention group than (65.67 ± 4.94) becomes
(106.25 ± 3.36) p= 0.000. This was followed by pain intensity decreased from average (20.00 ±
0.00) to (± 0.00 40.00) p= 0.001, udema declined from an average (1.50 ± 0.52) (0.92 ± 0.28) p=
0.020, muscle strength increased from the average (15.00 ± 0.00) to (36.92 ± 0.00) p= 0.000 and
motion of joints under increased from an average of 3.10 ± (0. 180 ) to (0.056 ± 4.66) p= 0.002. To
the respondent a Total Knee Replacement on average increased self-efficacy after the awarding of
the integrated education in the intervention group than (61.50 ± 2.38) to (105.25 ± 3.86) p= 0.000
followed by a decrease in the intensity of pain from the average (20.00± 0.00) to (± 0.00 40.00) p=
0.046, decreased udema from average (1.75 ± 0.50) to (0.50 ± 0.57) p= 0.015. Joint motion bottom
increased from the average (-2.50 ± 0.57) to (28.50 ± 1.91) p= 0.000, muscle strength increased
from (25.00 ± 0.00) to (± 0.00 70.00) p= 0.046.
Similarly, there are differences with the control group increased self-efficacy on
respondents Total Hip Replacement of (49.25 ± 4.57) to (83.67 ± 1.92) p= 0.000 and followed a
decrease in the intensity of pain (20.00 ± 0.00) to (31.67 ± 3.89) p= 0.001, udema declined from an
average (2.00 ± 0.00) to (1.00 ± 0.00) p= 0.083, muscle strength increased from the average (15.00
± 0.00) to (25.67 ± 1.67) p= 0.000 and motion of joints is increased from the average (3.07 ±
0.200) to (3.93 ± 0.242) p= 0.002. To the respondent a Total Knee Replacement on average
increased from self-efficacy (49.33 ± 4.61) to (82.33 ± 2.08) p= 0.009, this was followed by a
decrease in the intensity of pain from an average (20.00 ± 0.00) to (30.00 ± 0.00) p = 0.083,
decreased udema from average (2.00 ± 0.00) to (1.00 ± 0.00) p = 0.083. Joint motion bottom
increased from the average (-1.33 ± 2.08) to (18.00 ± 2.64) p= 0.009, muscle strength increased
from (25.00 ± 0.00) to (56.67 ± 2.88) p= 0102 (table 5.3).
 Tabel 5.3
The influence of self-Efficacy On Integrated Education intervention group and a control
group of Education Standards in patients Post Total Hip and Knee Replacement Hospital
TK. II Pelamonia, 2018

Prior To Education After Education p-value

n Mean SD Mean SD
Total Hip Replacement
Self-efficacy
Interventiona 12 65.67 4.94 106.25 3.36 0000c
Controlb 12 49.25 4.57 83.67 1.92 0000c
Harris Hip Score
Intensity Of The Pain
Interventiona 12 20.00 0.00 40.00 0.00 0.001d
Controlb 12 20.00 0.00 31.67 3.89 0.001d
Muscle Strength
Interventiona 12 15.00 0.00 36.92 2.61 0000c
Controlb 12 15.00 0.00 25.67 1.67 0000c
Joint Motion
Interventiona 12 3.10 0.180 4.66 0.056 0.002d
Controlb 12 3.07 0.200 3.93 0.242 0.002d
Udema
Interventiona 12 1.50 0.52 0.92 0.28 0.020d
Controlb 12 1.75 0.45 1.00 0.00 0.003d
Total Knee Replacement
Self-efficacy
Interventiona 4 61.50 2.38 105.25 3.86 0000c
Controlb 3 49.33 4.61 82.33 2.08 0.009c
Knee Society Score
Intensity Of The Pain
Interventiona 4 20.00 0.00 40.00 0.00 0.046d
Controlb 3 20.00 0.00 30.00 0.00 0.083d
Joint Motion
Interventiona 4 -2.50 0.57 28.50 1.91 0000c
Controlb 3 -1.33 2.08 18.00 2.64 0.009c
Muscle Strength
Interventiona 4 25.00 0.00 70.00 0.00 0.046d
Controlb 3 25.00 0.00 56.67 2.88 0.102d
Udema
Interventiona 4 1.75 0.50 0.50 0.57 0.015c
Controlb 3 2.00 0.00 1.00 0.00 0.083d

a: Integrated Education
b: Education Standards
c: test t-paired
d: test Wilcoxxon

DISCUSSION

1. Self-efficacy Changes before and after the educational intervention is integrated in the
intervention group and the control group on standards education
From the results of the study indicate that there is a significant difference between an
intervention group or a control group. Where patients in the intervention group efficacy himself
better.
This happens because the patient had the support of families who often provide support
followed by monitoring of health workers are mainly engaged in Ministry in a maintenance
room. Thus the confidence patients will do him in ability of post-operative activity increased.
 The results of the the research is in line with The race, Kapstad, Van Dulmen, & Eide,
(2017) that the patient's self-efficacy OA and social support from others can improve recovery
after THR. Other studies conducted by Tristaino et al., (2016) that there is a decrease in the level
of anxiety and depression as well as a better mental health in a group of patients who receive
psychological support (intervention group). Hip Arthroplasty patients, who receive psychological
support achieving the goals of physiotherapy 1.2 days earlier compared with patients in the
control group.
2. Changes the intensity of the pain before and after the educational intervention is integrated in the
intervention group and the control group on standards education
Based on the research results obtained good pain intensity changes in the intervention
group or a control group. Interesting things found was at the time one day post-operative
treatment rooms, the initial assessment of pain based methods of HHS and KSS and obtained the
same results/is no different. Occurs after a decline in integrated education for the intervention
group and of his descent is much different compared to the control group given educational
standard although the value is significant (table 5.2).
This is in accordance with the research Chen, Chen, & Lin, (2014) that the granting of
health education before operation can reduce the level of pain the patient's post-operative knee
total replacements, compliance increased respondents do exercise rehabilitation and speed up the
recovery of their physical function. In line with research Kearney, Jennrich, Lyons, Robinson, &
Berger (2011) that patients who follow education before operation to feel better prepared for
surgery and they are better able to control the pain after operation.
In this study that the level of pain occurs due to a decline in the role of the family
involved in the exercise and get monitoring of researchers and health workers on duty at the
hospital in the treatment rooms.
With the awarding of the integrated education before surgery can provide information
regarding the management of post-operative pain, so that patients can develop accurate pain
control. Patients can have a proper understanding about pain control so as to allow the patient can
manage it effectively, especially being able to adapt to the perceived pain. Thus, the expectations
of the results regarding pain management can be achieved.
3. Udema rate change before and after the educational intervention is integrated in the intervention
group and the standards education for control group
The results showed that decline udema on intervention group started from the first day to
the fifth day post-operative THR good nor the TKR. Unlike the control group to outpatients on
the sixth day, there is still an average udema degree 1-2. The results obtained are not significant
difference in value both before and after integrated education and educational standards. This
happens because the variance value of the level there are groups on both udema value of 0 (no
udema).
 Based on research Villalta & Peiris (2013) that therapy of post-operative orthopedic
physical training is very effective at increasing function and lower risk of side effects related to
the State of the wound and highly effective in overcoming pain, muscle strength, improve udema,
and range of motion in the early post-operative period.
When research lasts, all post-operative patients plugged drainage which aims to drain the
remaining liquid/blood, and reducing the risk of udema. There is a difference in patients in the
intervention group udema decline faster compared to the control group. As for drainage, 2 days
faster moving parts compared to the control group.
For that very exercise needs to be given before the implementation of the operations so
that patients and families have experience in performing post-operative exercises. Thus the
patient can understand and follow the procedure given by health workers.
4. Changes in muscle strength before and after the educational intervention is integrated in the
intervention group and educational standards in the control group.
The results showed that there is a difference of muscle strength at higher intervention
group compared with the control group. There are significant differences before and after
integrated education. Interesting things found was obtained the same mean values and their
significance is not unlike prior education in both groups (table 5.2). One of the reasons is that
they are still in effect in post anaesthetic drug. As for the second group of passive exercises are
still doing the bare minimum.
This is in accordance with the research Holm, Thorborg, Husted, Kehlet, & Bandholm
(2013) that changes muscle strength significantly from time to time after doing the exercises
early (Fleksi Hip, abduction, adduction and leg-press power) in patients post total knee
replacement surgery.
Although the patient's limb activity improved, increasing compliance regarding exercise
routines are indispensable in lowering the pain and improve muscle strength. In clinical practice,
patients of Total Knee Replacement rehabilitation exercises should start on the first day after the
operation and the patient a Total Hip Replacement 3 days post surgery. When the exercise began,
patients will feel great pain and would subside as they gradually adapt to the movement. If this
happens, it will be risky mal function and the healing process be hampered.
5. The change of motion of the joints down before and after the educational intervention is
integrated in the intervention group and the control group on standards education
The results show that there is a difference under the joint motion before and after
intervention either intervention group or a control group, in which the intervention group was
higher under the joint motion enhancement compared with the control group. In this study we
found that the motion of joints in patients of Total Knee Replacement before the awarding of the
integrated education and standards obtained the same mean, however significant differences
 occurring after the grant of the action each group (table 5.2). This happens because the patient
initially passive exercise just do the bare minimum.
Based on research Gill & McBurney (2013) that with the granting of exercise
interventions can reduce pain and improve joint physical motion in patients undergoing hip
replacement surgery. In line with research Matassi, Duerinckx, Vandenneucker, & Bellemans
(2014) granting program that exercises can improve movement of the knee in patients
gonarthrosis. After surgery Total Knee Replacement Surgery, the patients in the intervention
group, fleksi knee faster reach 90 ° and the treatment at the hospital. Praoperasi the knee arthritis
exercises can improve post-operative recovery immediately after Total Knee Replacement
primer.
Thus education practice taught before surgery Total Hip Replacement and Total Knee
Replacement Surgery is very necessary so that it can improve the patient's participation in terms
of faster healing process.
6. Effectiveness of integrated education in improving self-efficacy with a decrease in pain and
increased muscle strength, udema and motion of joints in post-operative patients of Total Hip and
Knee Replacement
Based on the results of the study showed that by administering the integrated education
may increase the patient's self-efficacy, accompanied by a decrease in the intensity of pain,
muscle and increase strength udema and joint motion down. This is in line with the research
Holm et al. (2013) that rehabilitation intervention in General is highly recommended for both
procedures Total Hip and Knee Replacement Surgery including supervision of treatment
performed by a trained health professional in order to optimize the expected treatment outcomes.
One of the interesting findings that the prior Act of surgery, researchers doing early
education by providing postoperative exercise booklets on the respondent in accordance with
intervention group exercises will be done postoperatively total Hip and knee replacement
surgery. The result was the intervention group feel more ready for operations and better able to
control the pain after surgery than patients in the control group.
In this study, we found that integrated education is very influential towards the
improvement of self-efficacy respondents particularly intervention group/treatment. This can be
seen in table 5.3. As for the assessment method based on HHS and KSS took place increase in
the intervention group compared to the control group.
Education pre operation is useful, can reduce the risk of unwanted effects, especially in
certain patients, such as the presence of depression, anxiety or expectations, can respond well
after education pre-existent operation designed specifically to suit the needs of physical, social
and psychological patient (Mcdonald, Mj, Beringer, Wasiak, & Sprowson, 2014). In line with
research Svege, Nordsletten, Fernandes, & Risberg (2015) that exercise therapy in addition to
 patient education can reduce the reliance of post Total Hip Replacement amounted to 44% in
patients with hip osteoarthritis.
In line with research conducted by Hartley et al., (2008) which aims to examine the
relationship between hope and self-efficacy of rehabilitation in order to overcome depression and
functional ability in patients undergoing joint replacement surgery find that self-efficacy
increased by showing a decrease post-operative depression score. So it can be concluded that
increased self-efficacy expectations and post-operative rehabilitation after being given as well as
lowering the patient's depression.
In line with the findings of the Hartley et al., (2008) conducted by Huang, Sung, Wang &
Wang, (2017) in order to measure the effectiveness of educational empowerment program at
primary stages (self-efficacy and competence of self care) and secondary phase (activities of daily
life, mobility, State of depression and quality of life) at the ripe old age with total hip
replacement surgery, found that respondents to the intervention group showed significantly
educational competence of self care and self-efficacy is higher and more depressive tendencies
low compared to the control group respondents. So that it can be summed up this very
educational empowerment interventions are effective in increasing the better results for patients.
In addition, involving patients and families for participation in this program is highly
recommended to achieve better results.
This is contrary to the findings of the Research McKay, Prapavessis, & Doherty (2012)
who finds no benefit to patients in the length of 12 weeks after surgery TKA. The results of the
analysis showed that muscle strength quadricep showed no functional improvement after
surgery.
Thus, the integrated education pre surgery can be done on the recommendations we
recommend that the entire patient who will undergo surgery especially orthopedic field.

CONCLUSION

Integrated Education very effective in improving self-efficacy proven with a decrease in pain
and increased muscle strength, udema and motion of joints in post-operative patients of Total Hip and
Knee Replacement Surgery Nursery in the hospital II Pelamonia 2018 .

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