Volume 7 Issue 3: May - June 2021

BELITUNG NURSING
JOURNAL
E-ISSN: 2477-4073 | P-ISSN: 2528-181X Edited by: Assoc. Prof. Dr. Yupin Aungsuroch & Dr. Joko Gunawan

DOI: https://doi.org/10.33546/bnj.v7i3

Review Article
Implementation of nursing case management to improve community access to care: A scoping review
Alenda Dwiadila Matra Putra, Ayyu Sandhi
Theory and Concept Development
Self-control in old age: A grounded theory study
Laarni A. Caorong

The development of Spiritual Nursing Care Theory using deductive axiomatic approach
Ashley A. Bangcola
Original Research Article
Barriers to exclusive breastfeeding: A cross-sectional study among mothers in Ho Chi Minh City, Vietnam
Nhan Thi Nguyen, Huong Thi Do, Nhu Thi Van Pham

Influence of self-esteem, psychological empowerment, and empowering leader behaviors on assertive behaviors of staff nurses
Ryan Michael F Oducado

Lived experiences of Overseas Filipino Worker (OFW) nurses working in COVID-19 intensive care units
Jane Marnel Pogoy, Jezyl Cempron Cutamora

Symptom experience of adverse drug reaction among male and female patients with newly diagnosed pulmonary tuberculosis in Thailand
Apichaya Thontham, Rapin Polsook

Knowledge, attitude, and practice towards COVID-19 among student nurses in Manila, Philippines: A cross-sectional study
Earl Zedrick S Quisao, Raven Rose R Tayaba, Gil P Soriano

The effect of warm compresses on perineal tear and pain intensity during the second stage of labor: A randomized controlled trial
Soumaya Modoor, Howieda Fouly, Hawazen Rawas

DAHAGA: An Islamic spiritual mindfulness-based application to reduce depression among nursing students during the COVID-19 pandemic
Meidiana Dwidiyanti, Badrul Munif, Agus Santoso, Ashri Maulida Rahmawati, Rikhan Luhur Prasetya

“Accessibility”: A new narrative of healthcare services for people living with HIV in the capital city of Indonesia
Mahathir Mahathir, Wiwin Wiarsih, Henny Permatasari
Original Research: Research Methodology Paper
Psychometric properties of Quality-of-Life Index for Vietnamese women with breast cancer three weeks postmastectomy
Xuan Thi Nhu Ha, Sureeporn Thanasilp
Perspective
Common ethical dilemmas of family caregivers of palliative patients in Indonesia
Martina Sinta Kristanti, Kusmaryanto Kusmaryanto, Christantie Effendy
Case Study
Developmental assessment and early intervention for children with developmental delays: A case study in South Australia
Mardiyanti Mardiyanti, Amanda Case
Letter to Editors
Reflections on International Nurses Day: Current status, issues, and the future of nursing in Indonesia
Feni Betriana, Tetsuya Tanioka, Rozzano Locsin, Nelwati Nelwati

THE OFFICIAL PUBLICATION OF

B E LI T UNG R A Y A F O UND A T I ON
Department of Publication, Indonesia
 BELITUNG NURSING
JOURNAL
Volume 7 Issue 3: May - June 2021

Launched in December 2015, Belitung Nursing Journal (BNJ) is a refereed international publication that provides a venue for the
nursing scholarship with an Asian focus and perspectives from the region. We aim to highlight research on nursing science,
nursing management, policy, education, and practice in the Asia-Pacific region and Asian communities worldwide to a broad
international audience.

BNJ welcomes submissions of original research articles, review articles, concept analysis, perspectives, letter to editors,
research methodology papers, study protocol, case studies, and guest editorials on various clinical and professional topics.

We also welcome "negative" results (i.e., studies which do not support a hypothesized difference or association) provided that
the design was robust. Discussion papers that elaborate issues and challenges facing health care in one country are welcomed,
provided the discussion is grounded in research-based evidence. The authors are addressing a global audience and a local one.

Nurses and midwives write most papers in BNJ, but there are no constraints on authorship as long as articles fit with the
expressed aims and scope. BNJ's intended readership includes practicing nurses and midwives in all spheres and at all levels
who are committed to advancing practice and professional development based on new knowledge and evidence; managers and
senior members of the nursing and midwifery professions; nurse educators and nursing students; and researchers in other
disciplines with interest in common issues and inter-disciplinary collaboration.

BNJ is an official publication of Department of Publication of Belitung Raya Foundation in Belitung Indonesia, jointly with
Indonesian National Nurses Association of Belitung Indonesia (PPNI Belitung) and Prodi D3 Keperawatan Belitung Poltekkes
Kemenkes RI Pangkal Pinang.

Belitung Raya Foundation is a non-profit organization that focuses on education, health, information technology, and the social
and empowerment of the community. Belitung Raya Foundation is established in 2015 with an official license of establishment
from the Ministry of Justice and Human Rights of the Republic of Indonesia (MENKUMHAM RI) with No: AHU-
0009599.AH.01.12.Year 2015 and Notarial Deed No: 12 on 06 July 2015 by SRI ARIYAWATI, SH.,M.KN.

BNJ has been accredited by the Ministry of Science, Research, Technology and Higher Education of Indonesia (RISTEKDIKTI
RI) with No: 10/3/KPT/2019, valid until 2024.

BNJ is indexed in Scopus, Emerging Sources Citation Index (Web of Science), Ovid EMCare (Elsevier), DOAJ, Google Scholar,
SINTA, and Garuda.

© 2021 The Authors.

First published by Department of Publication of Belitung Raya Foundation
Jalan Genayun, Komplek Perumahan Guru RT 06 RW 02, Dusun Urisan Jaya, Desa Padang, Kabupaten Belitung Timur, Manggar,
Bangka Belitung, Indonesia 33512 | Mobile: +6281286251389 | Email: belitungrayafoundation@belitungraya.org and
editorbnj@gmail.com

Volume 7 Issue 3: May - June 2021

Library of Congress Cataloging-in-Publication Data
Belitung Nursing Journal Volume 7 Issue 3
E-ISSN: 2477-4073 | P-ISSN: 2528-181X

This issue is Open Access distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License
which allows others to remix, tweak, and build upon the work non-commercially as long as the original work is properly cited. The new
creations are not necessarily licensed under the identical terms.

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

i
 EDITORIAL TEAM

EDITOR-IN-CHIEF

Assoc. Prof. Yupin Aungsuroch, PhD, RN

Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand

INTERNATIONAL EDITORIAL ADVISORY BOARD

Prof. Mary L Fisher, PhD, RN

The FINE Center, Indiana University School of Nursing, Indianapolis, IN USA
College of Nursing, University of Florida, Gainesville, FL. USA

Prof. Josefina A Tuazon, RN, MN, DrPH

College of Nursing, University of the Philippines Manila, Manila, Philippines

Prof. Rozzano C Locsin, RN, PhD, FAAN

Florida Atlantic University, Boca Raton, FL 33431-0991 USA
Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan 770-8509

Assoc. Prof. Colleen Marzilli, PhD, DNP, MBA, RN-BC, CCM, PHNA-BC, CNE, NEA-BC
The University of Texas at Tyler, School of Nursing, 3900 University Blvd., Tyler, TX 75799, United States

MANAGING EDITOR

Joko Gunawan, S.Kep.Ners, PhD

Belitung Raya Foundation, Belitung, Indonesia

EDITORIAL BOARD MEMBERS

Assist. Prof. Rapin Polsook, PhD, RN

Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand

Assist. Prof. Ying Lie, PhD, RN

School of Nursing, Dalian Medical University, Dalian, China

Barbara Lyn A. Galvez, MAN, RN, PhD

Silliman University Hibbard Avenue, Dumaguete City, Negros Oriental Philippines, Philippines

Bayu Anggileo Pramesona, S.Kep, Ns, MMR, PhD

RSD. Mayjend HM. Ryacudu Kotabumi, Lampung Utara, Indonesia

Dr. Khadizah H. Abdul Mumin, RN, RM, PhD

Pengiran Anak Puteri Rashidah Sa’adatul Bolkiah, Institute of Health Sciences, University Brunei Darussalam, Brunei
Darussalam

Feni Betriana, SKep, Ners, MNS

Belitung Raya Foundation, Belitung, Indonesia

Ha Thi Nu Xuan, RN, MNS, PhD

Nursing Department, The University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam

Jed Ray Montayre, PhD, RN

Western Sydney University, NZW, Australia

Le Thi Thanh Tuyen, RN, MNS, PhD

Faculty of Nursing, Da Nang University of Medical Technology and Pharmacy, Da Nang, Viet Nam

Mohd Khairul Zul Hasymi Bin Firdaus, BHSc, MN

Department of Medical Surgical Nursing, Faculty of Nursing, International Islamic University Malaysia, Malaysia

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

ii
 Souksavanh Phanpaseuth, MNS, RN
University of Health Sciences, Lao PDR

Virya Koy, RN, SNA, MNSc, MHPEd, PhD

Deputy Director of Department Hospital Services, Ministry of Health, Cambodia

COPYEDITOR & LAYOUT EDITOR

Anggie Amanda
Belitung Raya Foundation, Indonesia

JOURNAL MANAGER

Joko Gunawan, S.Kep, Ners, PhD

Belitung Raya Foundation, Belitung, Indonesia

TECHNICAL MANAGERS

Arief Hidayat Sutomo, S. Kom

PT. Bejana Investidata Globalindo, Indonesia

Apriadi
Belitung Raya Foundation, Belitung, Indonesia

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

iii
 T A BL E O F CO NT ENT S

DOI: https://doi.org/10.33546/bnj.v7i3

Review Article
Implementation of nursing case management to improve community access to care: A scoping review PDF
Alenda Dwiadila Matra Putra, Ayyu Sandhi 141-150

Theory and Concept Development

Self-control in old age: A grounded theory study PDF
Laarni A. Caorong 151-162

The development of Spiritual Nursing Care Theory using deductive axiomatic approach PDF
Ashley A. Bangcola 163-170

Original Research Article

Barriers to exclusive breastfeeding: A cross-sectional study among mothers in Ho Chi Minh City, Vietnam PDF
Nhan Thi Nguyen, Huong Thi Do, Nhu Thi Van Pham 171-178

Influence of self-esteem, psychological empowerment, and empowering leader behaviors on assertive PDF
behaviors of staff nurses 179-185
Ryan Michael F Oducado

Lived experiences of Overseas Filipino Worker (OFW) nurses working in COVID-19 intensive care units PDF
Jane Marnel Pogoy, Jezyl Cempron Cutamora 186-194

Symptom experience of adverse drug reaction among male and female patients with newly diagnosed PDF
pulmonary tuberculosis in Thailand 195-202
Apichaya Thontham, Rapin Polsook

Knowledge, attitude, and practice towards COVID-19 among student nurses in Manila, Philippines: A cross- PDF
sectional study 203-209
Earl Zedrick S Quisao, Raven Rose R Tayaba, Gil P Soriano

The effect of warm compresses on perineal tear and pain intensity during the second stage of labor: A PDF
randomized controlled trial 210-218
Soumaya Modoor, Howieda Fouly, Hawazen Rawas

DAHAGA: An Islamic spiritual mindfulness-based application to reduce depression among nursing students PDF
during the COVID-19 pandemic 219-226
Meidiana Dwidiyanti, Badrul Munif, Agus Santoso, Ashri Maulida Rahmawati, Rikhan Luhur Prasetya

“Accessibility”: A new narrative of healthcare services for people living with HIV in the capital city of PDF
Indonesia 227-234
Mahathir Mahathir, Wiwin Wiarsih, Henny Permatasari

Original Research: Research Methodology Paper

Psychometric properties of Quality-of-Life Index for Vietnamese women with breast cancer three weeks PDF
postmastectomy 235-245
Xuan Thi Nhu Ha, Sureeporn Thanasilp

Perspective
Common ethical dilemmas of family caregivers of palliative patients in Indonesia PDF
Martina Sinta Kristanti, Kusmaryanto Kusmaryanto, Christantie Effendy 246-250

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

iv
Case Study
Developmental assessment and early intervention for children with developmental delays: A case study in PDF
South Australia 251-259
Mardiyanti Mardiyanti, Amanda Case

Letter to Editors
Reflections on International Nurses Day: Current status, issues, and the future of nursing in Indonesia PDF
Feni Betriana, Tetsuya Tanioka, Rozzano Locsin, Nelwati Nelwati 260-261

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

v
Original Research
BNJ
Implementation of nursing case Belitung Nursing Journal
Volume 7(3), 141-150

management to improve community © The Author(s) 2021

https://doi.org/10.33546/bnj.1449

access to care: A scoping review

Alenda Dwiadila Matra Putra1 and Ayyu Sandhi2*

Abstract
Background: Case management is an approach used to help patients locate and manage health resources as well
as to enhance effective communication among patients, families, and health systems. Nurses’ role as case
managers has been proven effective in reducing healthcare costs among patients with chronic diseases. However,
little is known about its implementation in improving access to care in community-based settings.
Objectives: This scoping review aimed to examine the components of nursing case management in improving
access to care within community settings and to identify the issues of community-based nursing case management
for future implications.
Design: This study was conducted following the framework of scoping review.
Data Sources: The authors systematically searched five electronic databases (CINAHL, PubMed, Science Direct,
Scopus, and Google Scholar) for relevant studies published from January 2010 to February 2021. Only original
studies involving nurses as one of the professions performing case management roles in the community-based
settings, providing 'access to care' as the findings, were included.
Review Methods: The article screening was guided by a PRISMA flowchart. Extraction was performed on Google
Sheet, and synthesis was conducted from the extraction result.
Results: A total of 19 studies were included. Five components of nursing case management to improve access to
care were identified: 1) Bridging health systems into the community, 2) Providing the process of care, 3) Delivering
individually-tailored health promotion and prevention, 4) Providing assistance in decision making, and 5) Providing
holistic support. In addition, three issues of nursing case management were also identified: 1) Regulation ambiguity,
2) High caseloads, and 3) Lack of continuing case management training.
Conclusion: Care coordination and care planning were the most frequent components of nursing case
management associated with access to care. These findings are substantial to improve nurses' ability in performing
the nursing process as well as to intensify nurses’ advocacy competence for future implications.

Keywords
case management; care manager; nursing process; health service accessibility; health resources; nurses’ role

Access to health care is still a persistent challenge in the organizations have committed to eliminating the barriers to
healthcare system around the world. Since the Alma Ata universal health coverage (UHC), thus providing accessible
Declaration of 1978, 134 countries and 67 international health services for all populations (Pan American Health

1 Department of Nursing, Faculty of Medicine, Public Health and Nursing, Article Info:
Universitas Gadjah Mada, Yogyakarta, Indonesia Received: 25 March 2021
2 Department of Pediatrics and Maternity Nursing, Faculty of Medicine, Revised: 24 April 2021
Accepted: 2 June 2021
Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta,
Indonesia
This is an Open Access article distributed under the terms of the Creative
Corresponding author: Commons Attribution-NonCommercial 4.0 International License, which allows
others to remix, tweak, and build upon the work non-commercially as long as
Ayyu Sandhi, RN, MSc the original work is properly cited. The new creations are not necessarily
Department of Pediatrics and Maternity Nursing, Faculty of Medicine, licensed under the identical terms.
Public Health and Nursing, Universitas Gadjah Mada
Jalan Farmako Sekip Utara, Sleman, Yogyakarta 55281, Indonesia E-ISSN: 2477-4073 | P-ISSN: 2528-181X
Phone: +62-274-545674 | Fax: +62-274-631204
Email: ayyusandhi@ugm.ac.id

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

141
 Putra, A. D. M., & Sandhi, A. (2021)
Organization, 2019). One dimension indicating the UHC is
the proportion of people covered by the health system.
Based on the report from the World Bank and World Health
Organization (WHO), half of the global population could not
obtain basic health services due to poor access (WHO,
2017). Access to health care is defined as reaching a health
care service, provider, or institution to utilize appropriate
services in proportion to their need for care (Levesque et
al., 2013). It comprises three distinct components: 1) being
able to gain entry into the healthcare system; 2) being able
to locate provided health care services; and 3) being able
to communicate with trusted health care providers (Agency
for Healthcare Research and Quality, 2020). The
commitment to accelerate the UHC should be accompanied
by efforts to strengthen community-based health care
services and maintain appropriate healthcare financing
systems.
Case management is used as an approach to promote
better coordination of health care services and enable
broader access to all populations. This intervention helps
optimization of available resources; enhances
communication among health care providers, patients, and
their families; and serves as patient advocates within the
health care system (Fabbri et al., 2017). As the largest
occupational group in the health sector (WHO, 2020), the
nursing profession contributes to important roles in case
management. Within nursing, a case manager is a nurse
responsible for case finding, multidimensional assessment,
care delivery, monitoring, and evaluation of health
outcomes of a patient and their families (Bertuol et al.,
2020). To deliver effective case management intervention,
a nurse case manager should obtain clinical, managerial,
and financial skills. In addition, not only should a nurse case
manager be proficient in the health and well-being of
individuals across the lifespan, but also adept in
communication (with patients, families, and health care
team) and the health care system (Fabbri et al., 2017).
Currently, nurse case managers work in multiple
settings from hospitals, home health services, or patient
homes (Armold, 2019). It has been known as one strategy
to reduce health care costs (van Voorst & Arnold, 2020).
There was strong evidence of using case management to
significantly reduce the patients’ hospital use and improve
their quality of life (Joo & Liu, 2017; van Voorst & Arnold,
2020). For individuals with chronic illnesses transitioning
between hospitals and their communities, case
management is often cited as an effective intervention to
improve access to health care services (Joo & Liu, 2017).
According to the Commission for Case Management
Certification (CCMC) in the United States, on average, two-
thirds of nurse case managers work within community
settings (Armold, 2019). However, the majority of evidence
focused on improving patients' and families' quality of life,
cost-effectiveness, and reduced hospital readmission rates.
Information about community-based case management
implementation in relation to its impact on access to health
care is limited.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
142
This scoping review aimed to examine the components
of nursing case management in improving access to care
within community settings as well as the issues for future
implications. Two research questions were formulated: 1)
“What are the components of nursing case management
interventions to necessarily improve access to health
care?” and 2) “What are the issues faced by nursing
professions in delivering case management interventions?”
This study is expected to provide existing information on
how nursing case management contributes to leaving no
one behind in the health system.
Methods
As the topic of community-based case management’s
impact on access to health care has not been
comprehensively reviewed, this study employed a scoping
approach to evidence synthesis from existing literature
following the guidelines by Arksey and O'Malley (2005): 1)
formulation of the research question(s), 2) identification of
relevant studies, 3) study selection, 4) charting the data,
and 5) collating, summarizing, and reporting the results. A
scoping review does not usually apply critical appraisal for
selected studies as it includes a wide spectrum of studies
and aims to broadly sum up the research findings (Nam et
al., 2015).
Search Methods
Five electronic databases (CINAHL, PubMed, Science
Direct, Scopus, and Google Scholar) had been searched to
retrieve relevant references. Keywords of ((community)
AND ("case manage*")) AND (nurs*) AND (access) AND
(care) were applied to identify original studies published
between January 2010 and February 2021 with free full-text
availability in English or Bahasa Indonesia.
Eligibility Criteria
References were included if those were original studies
employing quantitative, qualitative, or mixed methods;
involving nurses as one of the professions performing case
management roles; providing “access to health care” as the
main finding; and published in peer-reviewed journals.
Conversely, studies were excluded if they did not describe
case management intervention or roles of nurse case
manager; only focused on other types of health workers
(i.e., community health workers, traditional healers); and in
the form of review, editorial, commentary, book, policy
documents, or government document.
Screening
Initially, 505 references were identified, of which 35 were
duplicates. Two authors then independently screened 470
studies by title and abstract. After screening by title and
abstract, the full texts of 34 studies were assessed for
eligibility. After screening the full text, 15 studies were
excluded. Six studies employed study designs that did not
fit into the inclusion criteria, five studies focused on other
 Putra, A. D. M., & Sandhi, A. (2021)

types of health workers, and four studies provided no
explanation about community case managers. Nineteen
studies were found to meet the aim of this scoping review
(Figure 1).
Data Extraction
Narrative tables were used to chart, collate, and summarize
selected studies. The data charting table was created to
identify themes from research findings in accordance with
the research questions and purpose (Tricco et al., 2016).
The data extraction table was formulated to insert the
following information from selected studies: author,
publication date (year), sample, design, research
objectives, and findings.
Data Analysis
Data analysis was conducted by two authors, who
summarized the major findings from selected studies to
draw themes and subthemes independently (Tricco et al.,
2016). Next step, the authors merged the data analysis and
performed joint analysis to determine the sub-themes of
research questions.

Figure 1 Flowchart of searching and screening strategy

Results are qualitative studies, while the remaining articles included

quasi-experimental studies, analytical studies (cross-
Search Results sectional, case study, and cohort study), mixed-method
study, and a study utilizing grounded theory.
Table 1 Characteristics of selected studies
Analytical Findings
Categories Details Total % As seen in Table 2, five components of nursing case
Design of Qualitative studies 10 52.6 management interventions to improve access to health
studies Quasi-experimental 3 15.8 care were deduced, namely: 1) bridging health systems into
Analytical studies 4 21.1 the community, 2) providing the process of care, 3)
Others 2 10.5 delivering individually-tailored health promotion and
Year of 2010-2013 6 31.6 prevention, 4) providing assistance in decision making, and
publication 2014-2017 6 31.6
5) providing holistic support. There were also three issues
2018-2020 7 36.8
of nursing case management identified, namely: 1)
regulation ambiguity, 2) high caseloads, and 3) lack of
Table 1 presents the characteristics of selected studies
continuing case management training. Table 3 presents a
after the final full-text assessment. The majority of studies
detailed summary of the final studies selected.

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

143
 Putra, A. D. M., & Sandhi, A. (2021)

Table 2 Themes and subthemes derived from the selected studies

Studies Components Issues

tailored health promotion and

Providing the process of care
Bridging health systems into

Providing holistic support

Lack of continuing case

Providing assistance in
Delivering individually-

Regulation ambiguity

management training
decision making

High caseloads
community

prevention
Balard et al. (2016) V V V V
You et al. (2016) V V
Williams et al. (2011) V
Uittenbroek et al. (2018) V V V V V V
Tønnessen et al. (2017) V V
Setiawan and Dawson (2018) V V
Setiawan et al. (2016) V V
Manthorpe et al. (2012) V V V V
Klein and Evans‐Agnew (2019) V V V V
Hudon et al. (2015) V V V V
Hensley (2011) V V V V V
Head et al. (2010) V V V V V V
Gage et al. (2013) V
Dhingra et al. (2016) V V V
David et al. (2019) V V V V
Cicutto et al. (2020) V V V
Chapman et al. (2018) V V V V V
Brown et al. (2011) V V V V V
Borgès Da Silva et al. (2018) V V

Bridging Health Systems Into Community problem analysis, planning, implementation, and
Nurse case managers should be able to engage clients and evaluation (Hudon et al., 2015; Klein & Evans‐Agnew,
their families in the health system. This was the most 2019; Toney-Butler & Thayer, 2020). Following those
common role, as mentioned in the 16 studies. Nurse case steps, a nurse case manager should determine the
formulation of a care plan to meet clients’ needs (Head et
managers are responsible for interpreting the information
al., 2010; Brown et al., 2011; Manthorpe et al., 2012; Gage
from the health system to clients and vice versa (Balard et et al., 2013; Balard et al., 2016; Dhingra et al., 2016;
al., 2016). In one case, a nurse case manager becomes Borgès Da Silva et al., 2018; Chapman et al., 2018; David
the only health worker in the designated area; thus, it is et al., 2019; Cicutto et al., 2020). The care plan should be
important to obtain community trust (Setiawan & Dawson, shifted from traditionally task-oriented to person-centered
2018) so that initial treatment could be promptly delivered care (Uittenbroek et al., 2018) and involve family members
to maintain the continuity of care.
(Setiawan et al., 2016). Service provided towards clients
and family members from the vulnerable population would
Delivering Individually-Tailored Health Promotion and
eventually help reduce delays in receiving medical care
Prevention
(Setiawan et al., 2016; Tønnessen et al., 2017). To ensure
Six studies reported that nurse case managers provided
the continuity of this role, a nurse case manager should
personalized health promotion and disease prevention
possess strong collaboration skills with other health
along with case management itself. The development of
professions (Borgès Da Silva et al., 2018; Uittenbroek et
personalized service plans helped the patients and families
al., 2018; Klein & Evans‐Agnew, 2019). Shared care could
understand where they were leading (Hudon et al., 2015).
be in the form of communicating with family physicians or
Furthermore, it indicated that nurse case managers
arranging schedules with general physicians, referrals, or
prepare different approaches to each patients’ condition so
other community health resources (Hensley, 2011;
that the health information obtained would be completely in
Williams et al., 2011; Hudon et al., 2015; Klein & Evans‐
accordance with the patients’ needs. For example, Cicutto
Agnew, 2019).
et al. (2020) presented that the nurse case managers
catered face-to-face visits to teach asthma management
Providing the Process of Care
(asthma control, inhaler utilization technique) for children
As many as 13 studies emphasize the importance of a
diagnosed with asthma, and Brown et al. (2011) provided
nurse case manager in providing the process of care. The
care process includes five essential steps: assessment, additional information besides regular diabetes self-
management education sessions. Moreover, Uittenbroek

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

144
 Putra, A. D. M., & Sandhi, A. (2021)
et al. (2018) showed flexible and creative personalities
were needed in terms of giving chronic care health
education for the elderly into their daily routine. In general,
a nurse case manager should perform promotive and
preventive care to empower clients to be aware of lifestyle
that might cause disturbance in health (Chapman et al.,
2018; Uittenbroek et al., 2018); the goal is not only to
improve patients’ understanding about one’s health but
also to change their health-seeking behavior (Setiawan et
al., 2016).
Providing Assistance in Decision Making
Five studies reported the nurse case manager’s role in
assisting patients and their families in making decisions
regarding the treatment and health status. Patients who
had easy access to nurse case managers were reported to
have better communication with health professions, better
participation in the process of improving their health and
well-being, and better healthcare transition (Hensley, 2011;
Hudon et al., 2015). To be able to do that, a nurse case
manager should own the leadership, articulation, and
mediation skills (David et al., 2019).
Providing Holistic Support
Seven studies reported that the nurse case manager
contributed to provide holistic support towards patients and
their families. As mentioned in one study focusing on the
elderly, patients, and their families emphasized that nurse
case manager’s clinical expertise and psychological
support contributed to the improvement of the continuum of
care provided (Manthorpe et al., 2012). In another study,
elderly and caregivers saw a case manager as a person to
be “present”, “help others”, “respond to all the questions”,
and to be “aware of everything”; thus, it is important for a
case manager to show caring behaviors (Balard et al.,
2016). A nurse case manager should also be aware of any
cultural or environmental barriers that might hamper one’s
health status (Brown et al., 2011).
Issues of Nursing Case Management
Three sub-themes of issues of nursing case management
were identified. First, the regulation ambiguity issue was
raised in terms of the roles and legal aspects. In one study
conducted in Indonesia, the legal aspect for prescribing
becomes an issue since nurses are not allowed to
prescribe medication, yet sometimes they are the only
health provider in the rural areas (Setiawan & Dawson,
2018). In Australia, they consistently agreed that
gatekeeper and direct service provision were not the case
manager roles. This study suggests that case managers
should just coordinate care service and plan (You et al.,
2016). In Norway, case managers often found that
balancing their roles as a care-manager and a provider was
a challenging task, also to set the limits between being
private and professional and consider between patients’
needs and limited resources grant (Tønnessen et al.,
2017).
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145
The second issue of nursing case management is
about the high caseloads; as mentioned in one study, a
nurse case manager should perform multiple roles, thus
working overtime (Klein & Evans‐Agnew, 2019). The third
issue in nursing case management is the lack of continuing
case management training. Experienced nurses should
serve as expert role models and consultants to the case
management staff and help to develop training curriculum
for case managers (Head et al., 2010). It is also mentioned
that the understanding and recognition of a nurse case
manager might depend on one’s adequate training,
although, so far, there is no consensual model of course or
training for nurse case managers (David et al., 2019).
Discussion
This study provided evidence on components of
community-based nursing case management and related
issues within the last ten years. To the best of our
knowledge, this is the first scoping review to describe the
components and issues in the implementation of case
management in improving community access to care.
This study discovered that nurse case managers
connect, coordinate, collaborate, and care for the
patients/community with health care service providers
through holistic and personalized care provision. Also, it
revealed that most of the nursing case management
models cater to specific targeted populations. For example,
elderly (Manthorpe et al., 2012; Gage et al., 2013; Balard
et al., 2016; You et al., 2016), patients with long-term
illness (Hudon et al., 2015; Uittenbroek et al., 2018),
palliative patients (Head et al., 2010; Dhingra et al., 2016),
students/children (Setiawan et al., 2016; Setiawan &
Dawson, 2018; Klein & Evans‐Agnew, 2019; Cicutto et al.,
2020) and people living with mental health problems
(Chapman et al., 2018) are the populations reported as the
beneficiaries in this study. In one study conducted in
Norway, Tønnessen et al. (2017) displayed nurse case
managers as health providers to serve diverse populations
with varied health conditions. Nurse case managers also
play the same role towards adults under certain primary
health care, as presented in a Canadian study (Borgès Da
Silva et al., 2018). This finding showed that nursing case
management could be implemented in bridging a broad
range of cases and ages to improve access to care in
various populations.
Another highlighted finding of this review was related to
the issues that occurred during the implementation of
nursing case management in the community settings. Case
managers struggle with the ambiguity of the nurse case
managers’ roles and deal with high caseloads as well as
limited case management training. A study by Joo and
Huber (2014), which reviewed nursing case management,
also reported unclear and confusing roles for nurse case
managers in the United States. Periodically nurse case
managers wished to set clear boundaries, but due to the
patient’s condition, nurse case managers were still required
 Putra, A. D. M., & Sandhi, A. (2021)

to provide direct care. It shows that the sense of caring
remains a principle among nurse case managers. Advance
training would be required for case managers to equip
themselves in dealing with these issues (Machini et al.,
2020; Muscat, 2020).
This review found the implementations of community-
based case management are different according to each
country’s health care system requirements. Developed
countries like Australia, Norway, and Spain clearly divided
the roles and responsibilities between nurses and nurse
case managers. Case managers are only expected to
perform their natural roles of the case manager. On the
other hand, several countries' nurse case managers are
also counted on to provide direct care services to the
community besides performing their role as case
managers. For example, in England, nurses can hold their
role as case managers while simultaneously working as
practice nurses in the clinic (Iliffe et al., 2011), as district
nurses providing visits towards housebound clients in the
community (Challis et al., 2011), and as disease-specific
nurses in either secondary care settings or the community
(Whittingham & Pearce, 2011). Also, in Indonesia, nurse
case managers could be the only health professional in the
particular area, so one should be familiar with disease
management and treatments. Differences in roles of nurse
case managers among countries are seen as the result of
different health system issues and challenges in each
nation.
There is a limitation to this scoping review. The
terminology of community nursing management may vary
among countries. As a result, it is plausible that several
essential articles might not be included in this study.
Therefore, future review studies should include more
terminologies for the keywords in literature searching.
Implications for Nursing Management and Health
Policy
In the era of UHC reform, many countries committed to
provide accessible health services for all populations
despite the consequences of high spending. This
commitment should be accompanied by efforts in
strengthening the community-based health care services.
This study showed that nurse case managers improve the
access of care for different populations in the community in
both urban and rural areas. Besides, previous studies have
provided evidence on the implementation of case
management to reduce health care spending and the
number of readmissions or rehospitalization (Joo, 2014;
Duarte-Climents et al., 2019). This is the starting point for
the government to incorporate the implementation of
community-based nursing case management into the
policy level. In addition, the government still has to consider
the needs and challenges in determining which case
management model is most suitable to the population.

Table 3 Detailed summary of the final studies selected

Study Sample Design Objectives Major findings

Balard et al. Elderly, Qualitative, To explore the users’ Case managers delivered care to clients and
(2016) caregivers, opened- (elderly and their subsequently helped patients and their families engage
case ended, and informal caregivers) and with the health system, be familiarized with health
France managers guided case managers’ first information and administrative processes, and make
interviews experiences of case decisions. Case managers were also seen to perform
management caring behavior such as responsive, helpful, present, and
aware.
You et al. Case Qualitative To explore the The study reported 16 essential roles of case manager
(2016) managers study, semi- perceptions about case (CM) in Australia for community aged care. However,
(with nursing, structured managers’ role in CM felt that the roles of broker, mediator, and counselor
Australia social work, interview establishing community were ambivalent. Moreover, they consistently agreed
Allied Health, aged care in Australia that gatekeeper and direct service provision were not the
and other case manager roles. This study suggested that case
backgrounds) managers coordinate care services and plans.
Williams et al. Patients An inductive To explore patients' The study showed that community matrons (CMs) assist
(2011) receiving or qualitative views and experiences the patients in the community to obtain easier and
had recently design using a of the community shorter coordination and communication with general
United Kingdom received care semi- matrons' roles in one physicians, including the referral to advanced health
by community structured primary care provider facilities.
matrons interview organization
Uittenbroek et District A qualitative To explore how district The reflection of the case manager about providing case
al. (2018) nurses study of in- nurses and social management was related to the central element of
(nurses and depth workers experience new person-centered and integrated care, such as proactive
The social interview professional roles as and preventive care delivery that includes monitoring,
Netherlands workers) case managers within self-management support, care coordination, and
embrace a person- network collaboration. Case management followed the
centered and integrated nursing process framework. District nurses focused more
care service for on healthcare and medical problems, while social
community-living older workers focused more on psychosocial aspects.
adults

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 Putra, A. D. M., & Sandhi, A. (2021)

Table 3 (Cont.)
Tønnessen et Group Qualitative To investigate the The study identified the responsibility of care managers
al. (2017) meetings with conflicting expectations in providing services to vulnerable populations. However,
care and ethical dilemmas balancing between the task of care manager and health
Norway managers and to discuss future provider appears as a challenge.
(nurses, clinical implications
occupational
therapists,
physiotherapi
sts, and
social
workers)
Setiawan and Primary Interpretative To report on the Nurses and midwives gained confidence and trust from
Dawson (2018) healthcare qualitative implementation of the community because they were often the only ones
workers methodology community case who could administer medication in the village. CCM
Indonesia (nurse, management (CCM) to reportedly thrived the primary health care workers
midwives, reduce infant mortality in (PHCWs) clinical reasoning despite the confusion of their
kader - cadre) a rural district prescription role.
Setiawan et al. Mothers and Qualitative To investigate the Treatment provision could be initiated by primary health
(2016) health implementation of care workers (PHCWs) in villages; therefore, it reduced
workers community case delays in receiving medical help. Besides, participants
Indonesia management (CCM) in were more likely to seek help from PHCWs than
the Kutai Timur district traditional birth attendants since PHCWs were employed
from the perspective of in the village. Moreover, under the CCM scheme,
mothers who received families with sick babies were frequently visited by
care PHCW.
Manthorpe et Nurse case Case study To understand the The opinions of older people receiving nurse case
al. (2012) managers, effects of nurse case management revealed the value of high-intensity
older people, manager (NCMS) assistance to individuals with major health and social
England family carers working in primary care needs. Older people or their carers reported the
in the English national improvement of continuity of care provision and
health service (NHS) psychosocial support. NCM supplemented social
from multiple services by identifying unmet needs.
perspectives and how
this new role impacts
social workers
Klein and School Grounded To develop a theory Nurses provided direct nursing care in several forms for
Evans‐Agnew nurses theory describing the processes children in the school.
(2019) and actions for school
case management
United State of targeting children with
America chronic conditions
Hudon et al. Patients and Descriptive, To examine experience Easy access to the CM nurse facilitated communication.
(2015) family qualitative, in- of patients and their This also allowed closer follow-up when needed. The
members depth family members with privileged access to CM nurses fostered better
Canada interview care integration as part communication with their family physicians. Participants
of a primary care case reported improved access to personalized information,
manager (CM) communication, coordination, and decision-making
intervention assistance, as well as better healthcare transition.
Hensley (2011) Case Qualitative, To explore the These managers saw themselves as an essential bridge
managers focus group perceptions and in the process of medication utilization for their clients.
United States of with nursing interview experiences of Case managers allocated their time to talk with clients by
America background community-based phone and browse the Medicare websites, assisting the
and mental health case client in understanding the information and making
professionals managers in the field of decisions about Medicare benefits.
from other Medicare prescription
disciplines drug benefits
Head et al. Users, nurses Quasi- To integrate palliative Provision of palliative care case management included
(2010) experiment care principles and assessment of physical and psychosocial complications
practices into the daily experienced by patients with serious illnesses,
United States of routines of a Medicaid pharmaceutical interventions, identification of community
America managed care provider resources to assist palliative care patients, and
assistance in hospice referrals.
Gage et al. Elderly, Case study To compare community The roles of case management were varied among
(2013) nurses matrons in holding case nurses. Meanwhile, community matrons were working
management roles for more intensively on the elderly and those taking more
England impact on service medication than nurse case managers.
utilization and costs

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 Putra, A. D. M., & Sandhi, A. (2021)

Table 3 (Cont.)
Dhingra et al. Adult users Retrospective To evaluate a diverse Case managers played roles in conducting a
(2016) cohort study population served by an comprehensive assessment (medical evaluation and
interdisciplinary model of mental health wellness of patients and their family),
United States of community-based formulation of goals of care and advance care plans,
America specialist palliative care evaluation of the need for home care, and evaluation of
and the variation in the need for care coordination and hospice eligibility. In
service delivery over delivering care, the duties were assigned to an
time and identify interdisciplinary team including nurses, physicians, social
subgroups with distinct workers, nurses who provided telephone support, and
illness burden profiles chaplains. Individuals who received more home visits
and telephone calls had greater health improvement.
David et al. Nurses Literature To present and discuss As case managers, nurses should understand the
(2019) review and the central aspects of health-illness process as a result of a complex
qualitative the case manager nurse interaction of factors at various levels of life; perform
Spain approach work process in three care beyond individual needs because the scope is
including Spanish autonomous broad and include not only patients but also the
individual communities caregivers; own the leadership, articulation and
interviews mediation skills.
Cicutto et al. Users, Quasi- To describe the A school nurse provided case management and case
(2020) caregivers, experiment elements of asthma care coordination, including delivering care (asthma
school nurses program and its management, asthma control, and medication
United States of utilization by school management) and providing asthma education to both
America nurses and school health clients and parents/guardians. Barriers in conducting
teams in two urban case management, among others, are difficulty in
school districts making contact with carers, restricted access to health-
care records outside school settings, and time limitations
experienced by school health teams.
Chapman et al. Public county- Mixed To describe how A PMHNP provided case management services,
(2018) based mental methods psychiatric mental health including formulating care plans (medication
health approach, nurse practitioners management, crisis stabilization, and crisis intervention),
United States of delivery including a (PMHNP) are made use assisting clients in administrative issues, and performing
America system semi- of, determine obstacles promotive functions (empower clients to be aware of
structured to full access, and lifestyles that might cause disturbance in health).
interview evaluate PMHNP's
economic contribution to
public health systems
Brown et al. Adult users Quasi- To explore the feasibility Roles of a nurse case manager, among others, are:
(2011) experiment of adding a nurse case providing health education and consultation about
manager to diabetes diabetes self-management, assisting patients in coping
United States of self-management with cultural and environmental barriers, assisting
America education to foster users' patients in locating and accessing health care facilities,
attendance and increase as well as collaborating with health care teams.
utilization of other Individuals who had higher contacts with nurse case
available health care managers attended diabetes self-management
services education sessions more often. In addition, participants
expressed preference of having face-to-face contact with
the nurse case managers than by telephone.
Borgès Da Silva Adult users, Cross- To evaluate patients’ Patients experienced better access to primary health
et al. (2018) primary sectional experience of care in facilities as nurses acted as case managers and
health care primary care as it systematically followed patients. In addition, sharing care
Canada organizations pertained to the nursing between nurses and general physicians could enhance
role primary care access.

Conclusion consider the issues, needs, and challenges of each country

Care coordination and care planning were the most
components of nursing case management frequently
associated with access to care. This scoping review
showed that nurse case managers improve the access of
care for different populations in the community, both urban
and rural areas, besides reducing health care spending
and the number of readmissions or rehospitalization.
However, the initiation of implementation still has to
in determining which case management model is most
suitable to the population. Also, clear regulation and
continuing training for case management should be
provided by the authorities to reduce the occurrence of
possible constraints during the implementation. Further
research is needed to find a nursing case management
model according to primary health care to accelerate
achieving UHC and develop validated measurement tools
to measure access to care based on the components of the
community nursing case management model.

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 Putra, A. D. M., & Sandhi, A. (2021)
Declaration of Conflicting Interest
The authors have no conflict of interest to declare.
Funding
This study did not obtain any grant from a funding agency.
Authors’ Contribution
All authors contributed equally to the study conceptualization,
methodology, article search, data analysis, writing, and editing of
the manuscript. All authors approved the final version of the article.
Authors’ Biographies
Alenda Dwiadila Matra Putra, RN is an Assistant for Publication,
Research, and Collaboration at the Department of Nursing,
Faculty of Medicine, Public Health, and Nursing, Universitas
Gadjah Mada, Indonesia.
Ayyu Sandhi, RN, MSc is a Lecturer at the Department of
Pediatric and Maternity Nursing, Faculty of Medicine, Public
Health, and Nursing, Universitas Gadjah Mada, Indonesia.
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Cite this article as: Putra, A. D. M., & Sandhi, A. (2021).
Implementation of nursing case management to improve
community access to care: A scoping review. Belitung Nursing
Journal, 7(3), 141-150. https://doi.org/10.33546/bnj.1449
Theory and Concept Development
BNJ
Self-control in old age: A Belitung Nursing Journal
Volume 7(3), 151-162

grounded theory study © The Author(s) 2021

https://doi.org/10.33546/bnj.1412

Laarni A. Caorong*

Abstract
Background: Self-control is associated with multiple positive outcomes. There are several studies on self-control,
yet no literature describing the mechanism of self-control in old age.
Objective: This study aims to develop a substantive theory on the exercise of self-control in old age.
Methods: Grounded Theory methodology developed by Glaser & Strauss was utilized in the conduct of this study
with ten (10) older adults as participants following the set of inclusion and exclusion criteria. Individual in-depth
interviews of 30-45 minutes were observed to gather the needed verbatim narrative responses from each participant
after careful consideration of the ethical procedures approved by the University research ethics board. Major themes
with their respective sub-themes were generated after rigorous analysis of the participants’ responses following the
steps provided by Glasser & Strauss in conducting grounded theory studies.
Results: This study resulted in the formulation of three propositions such as: (1) Older adults exercise self-control
differently, (2) several personal motivations are involved in the exercise of self-control, and (3) the exercise of self-
control leads to life satisfaction. From the propositions emerged the Theory of Self-control in Old age, which states
that the process of self-control encompasses the human capability of exercising self-restraint to overrun different
types of desires, passions, and temptations. The theory posits that older adults vary in their exercise of self-control
depending upon their personal motivations. The theory also assumes that the exercise of self-control results in life
satisfaction as displaying self-control is attributed to a host of positive life outcomes.
Conclusion: The present study has important implications in the field of gerontology and health care services since
the older population is growing, and so does the demand for health care services. The need to understand the
choices and decisions of older adult clients is fundamental in individualizing the health care services that may be
designed and provided for them.

Keywords
self-control; grounded theory; old age; inductive approach; nursing

In life, human beings struggle to make optimal decisions so
often, which require the exertion of self-control. Self-control
is crucial before making any personal decision or choice
(De Ridder et al., 2012). The decisions may involve
economic choices, decisions about lifestyle preferences,
moral choices, and personal predilections (Baumeister et
al., 2007). Self-control is mainly the restraint that people
use on their desires and impulses (Baumeister, 2012).
More specifically, it is the capability to overrule or override
one’s response. Self-control is a self-initiated practice in
which the individual himself instigates the process
(Duckworth et al., 2014).
Late-life is often seen as a stage where there are
multiple losses in various life domains. Empirical evidence
shows that a decrease in physical function and cognitive
ability is prevalent in late life, attributed to the biological
changes in aging (Baltes & Mayer, 2001; Sadang &
Palompon, 2021; Salthouse, 1996; Schaie, 1989).
Considerably, the decline of the physical function of old
people as well as the older adults’ mental agility is linked
with the aging changes at the biological level (Baumeister
& Alquist, 2009). Resultantly, there is a decrease and loss
of physical and cognitive functioning. As defined in this
study, self-control is a cognitive process governing one’s
emotions, actions, and feelings. Notably, the exercise of

College of Health Sciences, Mindanao State University – Marawi, Article Info:

Philippines Received: 28 February 2021
Revised: 29 March 2021
Accepted: 3 May 2021
Corresponding author:
Dr. Laarni A. Caorong, RN, MAN This is an Open Access article distributed under the terms of the Creative
College of Health Sciences, Mindanao State University – Marawi Commons Attribution-NonCommercial 4.0 International License which allows
others to remix, tweak, and build upon the work non-commercially as long as
5th East Tubod, Iligan City 9200, Philippines
the original work is properly cited. The new creations are not necessarily
Mobile: +639-213-403-270 licensed under the identical terms.
Email: laarni.caorong@msumain.edu.ph
E-ISSN: 2477-4073 | P-ISSN: 2528-181X

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 Caorong, L. A. (2021)
self-control involves cognitive function. The link between
the cognitive decline in aging and the capacity to exercise
self-control in old age remains largely unknown although
this might have a bearing on the older adults’ decisions
affecting health, financial, social, and other life domains.
Self-control is consequential; thus, this essential concept
needs further investigation (Baumeister et al., 2007).
Population growth and longevity of older people mean
that the health care decisions they make, the investments
they focus on, and the general choices they take in life will
become increasingly important to the society other than
themselves (Boals et al., 2011). The exercise of self-control
comes into the picture when an older adult is faced with a
decision to take. The decisions to control, restrain,
suppress or act out are but consequential and will affect the
older adult himself and other people (Tangney et al., 2004).
Remarkably, older adults display various life decisions in
terms of their physical health, how they engage socially
with others, in financial matters, and others (Sadang &
Palompon, 2021). Varied life avenues require the
demonstration of self-control. The practice, according to
many researchers, yields positive outcomes (Tangney et
al., 2004). Although this is common knowledge, yet many
older adults come up with poor choices in terms of health
practices, fail in financial management, and sometimes
have a strained relationship with other people as a result of
the poor exercise of self-control (De Ridder et al., 2012).
This requires deeper understanding and investigation.
Since the exercise of self-control is consequential, the idea
of delving deeper into this concept is not only vital but
relevant.
Existing literature states that self-control is an essential
element for attaining one’s goals, being successful in one’s
undertaking, and resisting ones’ selfish and one’s
potentially harmful impulses. Since desires and
temptations are ever-present, there is a need to exercise
self-control. Although there were studies on children’s self-
control in relation to their success in later life (Mischel &
Ebbesen, 1970; Mischel et al., 1989), the mechanism of
self-control in old age has not been well documented.
Hence, the knowledge on the exercise of self-control in old
age in terms of their health practices and behaviors and
their social and financial dealings requires deep
elaboration. The foregoing clearly shows the need to
investigate the mechanism of self-control in old age to
provide an elaborate description of how it is exercised in
later life and its impact on the various life aspects of older
adults. Hence, the purpose of this study was to generate a
substantive theory of self-control among older adults in old
age. The knowledge thereof will provide a succinct idea
and understanding about this human quality trait which is
deemed essential before making optimal life decisions.
The present study has important implications in the field
of gerontology and also in health care services since the
older population is growing over the past years. Hence,
there is an expectation obviously of a growing demand for
health care services. So, there is a need for health care
professionals to understand elderly clients. The need to
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152
understand the choices and decisions of older adult clients
is fundamental in individualizing the health care services
that may be designed and provided for them.
Methods
Design
The Grounded Theory method developed by Glaser and
Strauss (1967) was followed in undertaking this research
study with the main aim of generating a substantive theory
of self-control in old age. Systematic collection of
qualitative data was employed to selected participants to
gather datasets by carrying out a one-on-one in-depth
interview to obtain a rich description of how people in old
age exercise self-control. In this research study, the
participants’ subjective experiences were explored to
better understand their exercise of self-control in late life
(Streubert & Carpenter, 2011). The purpose of Grounded
Theory is to explore and describe a phenomenon in
naturalistic settings. The target of Grounded Theory is to
reach a conceptual theory that can explain and predict the
experiences of the interview persons in relation to their life
conditions (Glaser & Strauss, 1967). Moreover, an
inductive approach to theory development was utilized.
The process involved in this study included gathering
qualitative data, analyzing the data collected, developing
hypotheses and propositions, and finally generating a
substantive theory (Streubert & Carpenter, 2011). The
theory develops and evolves during the actual research
process as an interplay between data collection and
analysis ensues.
Participants
The participants were selected following inclusion criteria,
which included the following: (a) willingness to participate
in the research study, (b) 60 years old and above, (c)
resident of Iligan City, (d) no cognitive disabilities, and (e)
able to articulate and express thoughts, ideas and
experiences. The cognitive level was assessed through the
usage of a short portable mental questionnaire (Pfeiffer,
1975). Exclusion criteria were: (a) those who were
cognitively impaired, (b) physically and psychologically
frail, and (c) those who were unwilling to participate in the
study.
Sampling
Theoretical sampling was employed in the study involving
ten (10) older adults from Iligan City, Philippines.
Theoretical sampling is the process of generating theory
from the data (Glaser & Strauss, 1967). In this study,
theoretical sampling was methodologically followed
throughout the interview process.
Data Gathering Process
A face-to-face interview using an in-depth interview was
conducted by the researcher in collecting qualitative data.
The interview session was carried out within 30-45 minutes
until data saturation was reached and theoretical sampling
 Caorong, L. A. (2021)

was attained. The conversation was recorded in an audio commenting about the codes. Reflections and ideas about
recorder, and permission was sought to record the codes and relationships between codes were made, which
conversation explaining its necessity to capture every created the link between raw data and formal theorizing
single detail of the dialogue. A semi-structured interview and hypothesis creation (Streubert & Carpenter, 2011).
style was employed, and guide questions were used. The research participants’ perceptions, ideas, and
experiences of self-control were explored and investigated
Ethical Considerations using open ended-questions. The guide questions were
Ethics approval of the protocol by the Cebu Normal primarily rooted from the main research question, which
University- Research Ethics Committee (CNU-REC) with was ‘how do individuals in old-age exercise self-control’.
CNU-REC code 229/2019-02 Caorong was secured as The idea was to ground the data which were systematically
part of the research protocol. Permission and approval collected to describe self-control in old age. Moreover,
from the Office of the Senior Citizens Affairs (OSCA) – probing questions or statements were used to prompt
Iligan Chapter president was also observed prior to the answers and explanations. Statements such as ‘please
conduct of this study. Each of the participants was given a elaborate or expound’, ‘tell me more’, ‘can you please
copy of the informed consent duly approved by the CNU- clarify’, ‘what was the outcome’, ‘please, expound’, ‘I’d like
REC. The researcher comprehensively explained the to hear more’, etc. were used.
content of the informed consent in the dialect that the
participant understood. After a thorough explanation and Results and Discussion
discussion, the participants were asked to sign the
informed consent form. The researcher assured that In this section, the basic description of the participants and
participation is voluntary and that at any given rate if the their self-control process are presented. Ten older adults
study participant should wish to stop participating, it should who were residents of Iligan City were recruited to join the
be recognized and respected. research. All of the older adults who participated were
within the age range of 62-92 years. Fifty percent (50%) of
Analysis the participants were male. Table 1 indicates the basic
After having gone through some initial analysis of the data information of the participants.
gathered, the researcher made some notes on what key
concepts needed elaboration. The research participants Table 1 Participants’ Profile
were then asked about the concepts that needed
elaboration until key and important concepts were Code Age Gender Religion Marital
described, elaborated, and clarified. When there was a status
redundancy of the information gathered from the research TOM 64 Male Islam Married
participants, this signaled that there was already data ZEN 69 Female Iglesia ni Cristo Widowed
saturation. Constant comparison was made by comparing ROB 63 Male Roman Catholic Widowed
REM 76 Female Roman Catholic Widowed
the findings with the existing findings. This method was
DEB 64 Female Seventh Day Married
essential in constructing theoretical categories which Adventist
represented the core categories or concepts of the study DAN 92 Male Islam Married
on self-control in old age (Streubert & Carpenter, 2011). MAX 78 Male Roman Catholic Married
Grounded Theory involves several steps such as TEL 62 Female Protestant Widowed
coding, memo writing, theoretical sampling, and the CEL 70 Female Islam Separated
method of constant comparison (Glaser & Strauss, 1967). TED 78 Male Roman Catholic Married
In this study, reading the qualitative data several times was
done, and for chunks of data that had been gathered, Through constant comparative analysis, theoretical
labels were then made. The labels were based on the categories emerged, which were essential in the
meaning that emerged from the data. After open coding identification of the core theoretical categories which would
one set of data, interconnections between categories and substantiate the theory of control in old age. Four
codes were created. The process is called axial coding. At theoretical categories were formulated from the sixteen
this stage of the data analysis, the researcher integrated sub-categories identified about the theory of self-control in
the categories identified in the axial coding process. The old age, namely: (1) self-introspection and assessment, (2)
selection of the core categories was made by decision and choice of action, (3) action, reaction and
systematically relating the categories discovered. conduct as an indication of self-control, and (4) outcome
Moreover, the categories were then validated through and impact of self-control.
finding existing relationships. Further development was
made by filling in categories that require more refinement Theoretical Category 1: Self-introspection and
and development (Streubert & Carpenter, 2011). Assessment
Memo writing was an essential aspect of the coding The process of self-control is initiated by an older adult who
process (Glaser & Strauss, 1967). This was initiated as engages personally in self-introspection and assessment.
soon as coding was started. It involved theorizing and By introspection, the cognitive thought process is activated

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 Caorong, L. A. (2021)
when a situation arises. This involves self-appraisal by an
older adult concerning the advent of the situation or
experience. Self-introspection primarily involves
examination or assessment of one’s thought and emotional
processes. The reflection involves looking into and
considering one’s experience, valuing one’s moral
standards, and taking into consideration the lessons
gained from the past experiences.
Sub-category 1: Involvement of thinking and
assessment
In exercising self-control, the older adults engaged the
thought process through thinking and considering the next
course of action or response. The display of self-control by
the older adults involves not only the concept of thinking
but also discerning in deep thought the possibilities and
consequences of one’s action or response. This stage of
the process encompasses the process of assessment.
“You really have to engage in thinking. Thereafter, you can
make a decision. It is really a personal decision and that you
are aware that there are consequences of your choices and
decision which would impact you.” ROB
Sub-category 2: Valuing moral standards
This pertains to the strong influence and consideration
of moral standards in self-control exercised by the older
participants. As many older adults have a strong sense of
spirituality, their exercise of self-control is driven by a highly
personal motive of being afraid to commit sins and because
of the fear of God and wanting to please Him.
“Well, the motivation for a religious person, for example, is
avoidance of sin because the moment you don’t control
yourself, you transgress the criteria of moral… or you violate
the sharia (law). That’s the bottom line.” TOM
Sub-category 3: Knowledge and lessons gained
through experience
The learnings gained from their past experiences gave
them significant reasons to avoid experiencing the same
situation again, such as having experienced conflict within
the family as well as suffering due to poor health choices
before.
“Hypothetically, you can control, or you can tame yourself to
exercise self-control. You learn from exercising it. And you
develop already that kind of self-discipline. You can now
internalize through yourself the virtue of discipline or the virtue
of self-control how to attain self-control.” TOM
Theoretical Category 2: Decision and Choice of Action
Self-control as a process involves the ability of an individual
to govern one’s actions, feelings, or emotions. The process
also involves deciding and choosing the next course of
action. The choice of action comes out after having
engaged in self-introspection or assessment. The decision
is as well influenced by thinking of the positive and negative
consequences of the actions. Furthermore, deciding the
next course of action includes the consideration of the
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health-related changes as well as the current circumstance
that the older adult is experiencing. The decision is also
driven by outer and inner personal motives.
Sub-category 1: Involvement of personal decision
and choice
The exercise of self-control involves decision-making
and choosing the next course of action or behavior to
employ. The individual himself does the exercise of self-
control. Older adults view self-control as a process
involving personal decisions and choices. The decision
process includes weighing the pros and cons of a certain
action or the negative or positive consequences of the
decision before coming up with a choice on what to take
and do as the next course of action.
“Self-control is a mental process. For instance, in a certain
situation, I choose not to get affected since I am afraid of
another (heart) attack. In such a case, I really weigh things out.
For example, I would not readily react to provocations to abate
a situation because it could very well lead to conflict. Self-
control is a cognitive process. It is a self-initiated process.”
ROB
Sub-category 2: Thinking of the consequence of
one’s decision
In the exercise of self-control, before the older adult
decides what to do next, he looks at the possible
consequences of his decision and his choice of action. The
older adult’s choice of action is in consideration of the
consequences both positive and negative of one’s decision
and choice of action.
“Before going to America, I was actually engaged in all sorts
of vices. I was involved in drinking intoxicants and gambling. I
did all those vices, but when I left the country, I also left those
vices. I controlled myself to leave those vices so that I would
not have any problems with my family and children. My family
remains intact after leaving those vices. I actually now live a
comfortable life.” TED
Sub-category 3: Consideration of age and health-
related changes
Older adults go through several changes in cognition,
emotion, physical strength, and health, among other
human aspects. The decision and choice of action by the
study participants were actually influenced by their current
state of health as they now are keen on considering the
different changes they are experiencing. Current changes
in the aspect of health, for instance, had made them
become motivated to demonstrate more self-control. They
have changed their old practices to what now is necessary
and recommended for them to do.
“I usually do physical exercises every morning for 15-20
minutes. I usually force myself to get up so that I could expose
my body to the sunlight before 8 am. This is so that I would be
exposed to the sunlight for Vitamin D.” REM
 Caorong, L. A. (2021)
Sub-category 4: Consideration of current life
circumstance
This category reflects that older adults go through
varied life circumstances. Obligations and duties do not
stop with aging. Certain responsibilities and obligations by
older adults need to be fulfilled and accomplished. Many
older adults exercise self-control to carry through their
responsibilities in life.
“If I won’t control my spending and just squander my money
carelessly, then for sure I will not have enough money for
future use. Although I wanted to eat rice, I restrain myself
because eating rice could potentially cause my sugar to rise. I
am also financially incapable of affording rice for myself and
my helper’s consumption.” REM
Sub-category 5: Inner motivations of the exercise
of self-control
According to the participants, their exercise of self-
control includes inner motivations. Such inner motivation
included the want to avoid sin and to abide by moral
standards. Fear of God also surfaced as an inner motive in
self-control exercise as well as giving value to the Divine
commands.
“The number one reason why I exercise self-control is
because of fear to commit sin to God. I also don’t like any
trouble, and I don’t want to experience a headache.” REM
Sub-category 6: Various outer motivations of the
exercise of self-control
Other than the inner motives of exercising self-control,
various outer motivations of the exercise thereof were also
discovered. The various outer motivations in the exercise
of self-control among the study participants included
wanting to maintain social relationships intact, promoting
health status, and managing financial resources well for
future use.
“If I would not control my spending and just squander my
money carelessly, I would not have enough funds for future
use. There are really times that I suffer an asthma attack.
During those times, there is really a need for me to purchase
my asthma medication which costs over a thousand pesos.
So, I really need to have some money on those times.” REM
Theoretical Category 3: Action, Reaction or Conduct
as Indications of Self-control
The third theoretical category reflects the decision and
choice of the individual who exercises self-control. These
are manifested or indicated in his or her actions, reactions,
or conduct. Under this theoretical category are sub-
categories such as restraining the self from acting out,
resisting temptation and passion, and suppressing inner
feeling, involving struggles to control the self as well as the
changing degree of self-control. The third theoretical
category is supported by the following subcategories
below:
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Sub-category 1: Restraining self from acting out
This sub-category reflects the manifestation of self-
restraint by an individual who exercises control in terms of
his actions. By restraining himself, he is engaged in a
deliberate action of his choosing. The choice of action is
processed within himself taking on different considerations
such as the possible consequences.
“Sometimes I get angry with my husband over minor things
such as when our kitchen is messy. At home, I really like things
to be in their proper places, but my husband has this habit of
putting candy wrappers on my vases which I dislike. When that
happens, I gently reprimand him. I now have self-restraint, but
before, I usually throw things at him and sometimes even give
him a smack.” DEB
Sub-category 2: Resisting temptation and passion
Human beings are surrounded by different and varying
types of desires, passions, and temptations. However,
there are temptations and desires that need to be resisted
because of the harm they could bring. This is where the
exercise of self-control is needed. The exercise of self-
control against the desires and passion of an individual
entails struggle and effort.
“Well, of course, with the basic control is fasting. It should also
be observed throughout your daily life. For example, if you can
control partaking food like this one (points at the food on the
table) … learning from this virtue for your daily life, you can
control not taking any food like taking any sweets, palatable
food, cold drinks and all that. You can control yourself even if
it is palatable or satisfying through drinking cold water. I don’t
even care for cold water or sweets or chocolate. I don’t care
for those. I just take vegetable, and I cannot even finish a cup
of rice. So that is the result of fasting.” TOM
Sub-category 3: Suppressing inner feelings
Expressing emotions and feelings are inherent in a
man. There are constant engagements and interactions
among people anytime and anywhere. The experience
may often evoke the expression of feelings and emotions,
yet, consequently, certain situations necessitate the
exercise of self-control to keep the good social relationship
going and avoid unnecessary expressions of words that
may not be received well by others.
“I know how to control myself. For instance, when provoked, I
am aware that I should not get angry because it could cause
my blood pressure to rise. In such a case, what I do is restrain
myself. When it comes to food prohibitions, I just eat a little to
ease my desire. That, I think is practicing self-control.” ROB
Sub-category 4: The changing degrees of self-
control
This subcategory entails the varying degrees and levels
of the display of self-control among older adults. There are
older adult participants who had more self-control, or their
level of self-control now had increased due to age. Yet,
some older adults also are less able to control themselves
by giving in to desires and whims. Hence the older
 Caorong, L. A. (2021)
participants really have varying degrees or levels of self-
control.
“There is actually a great impact that my self-control now has
increased. For instance, before I really wanted that those who
are indebted to me will really pay me back. Nowadays, I still
allow other people to borrow money from me, yet I consider
lending people money like an act of charity.” REM
Sub-category 5: Struggles in controlling self
For older people, exercising self-control involves the
element of struggle. This occurs because there are
outward and inward pressures of either satisfying one’s
desire or refraining from doing something or acting out,
which requires effort and conscientiousness.
“For example, I am not in contact with my wife, and you are
still an organism (me). What is the mechanism of self-control
that you are not in contact with your wife? No cohabiting. No
sexual pleasure. You cannot also commit Zina (adultery)
because that is haram (prohibited)…I don’t look at naked
bodies. If it’s in front of me, I look away, and it’s very hard,
especially for the male. I turn away. I have interest, but I
refrain. Who is not interested after all?” TOM
Theoretical Category 4: Outcome and Impact of Self-
control
The final theoretical category encompasses the different
outcomes, results, and impact of exercising self-control.
Many of the older adults expressed that exercising self-
control led to positive outcomes. However, there are
negative outcomes as well of displaying low self-control.
Additionally, the results of displaying self-control as
emphasized by the older adults do not only impact other
people but also relatively impact them. They even
conveyed that exercising self-control made them feel
happy and satisfied.
Sub-category 1: Feeling of satisfaction and
happiness
This subcategory is the reflection of the ultimate result
of exercising self-control which is the feeling of happiness
and satisfaction. Several older adults who joined the study
stated when asked, ‘what do they feel upon exercising self-
control?’, that they feel happy and satisfied. This may be
due to them doing actions they are so strongly motivated
to act about or behave a certain way that they feel strong
about, giving them happiness and satisfaction.
Furthermore, not all older adults happen to have perfect
self-control. There are older people who display a lesser
degree of self-control given a situation. The next
subcategory under this last theoretical category exhibits
the consequences of not practicing control or having less
self-control.
“I feel happy because I can please Allah. I can please the Lord,
and Allah loves the people who exercise self-control. He loves
people who renounce the world. So…you control, you fast, you
renounce, you deprive yourself… that would make Allah very
happy.” TOM
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Sub-category 2: Consequences of losing control
The results of having less or no self-control are
generally linked to negative consequences such as
conflicts with other people, trouble, and strained
relationships with others people. These occurrences were
experienced by the older adults themselves, as discovered
from the in-depth interview.
“I really cannot control my self especially when it comes to
reprimanding my children. I will not stop saying things until I
have said what I needed to say to my children, even if it is
hurtful to them. That is my weakness. I also am not able to
control myself when I am angry at my spouse.” DEB
With the establishment of the core categories
supported by the identified subcategories and the
participants’ narrations, comes now the understanding of
the process of self-control in old age. The process begins
with the older adults engaging initially in what is called self-
introspection followed by the act of choosing and deciding.
The decision and choice of the older adults will then be
reflected in their actions and conduct, which would then
yield some outcome and impact.
Hypotheses Derived from the Results
The generation of the substantive theory was derived
through employing the constant comparative analysis
method of the qualitative data, which were systematically
gathered. The analysis resulted in the identification and
formulation of subcategories and theoretical categories
respectively, which in turn became the basis of developing
and generating the research hypotheses. The developed
hypotheses showcase the relationships between variables
identified which emerged from grounding the qualitative
data sets. The exploration and analysis resulted in the
following hypotheses:
Hypothesis 1: Self-control is a personal decision
which is self-initiated by an older adult driven by one’s
own personal motive
The hypothesis identified depicts that the exercise of
self-control by an older adult is self-initiated—each older
adult exercises self-control differently. The driving force for
the exercise and practice of self-control depends on one’s
own personal motives or specific personal goals. This
assumption was induced from the narratives of the
selected study participants. Some participants practice or
exercise self-control in order to maintain good relations
with other people, while others practice self-control to
follow moral standards or in consideration of the health-
related changes they experience.
The different personal motivations of the older adults in
their exercise of self-control are highly personal. They
significantly vary in their personal motivations. The
personal motivations to exercise self-control are influenced
by past experiences and the lessons gained from those
experiences.
 Caorong, L. A. (2021)

Axial Coding Process

The Self-Control Process in Old-Age

Involvement of thinking and assessment

SELF- Knowledge & lessons gained through

INTROSPECTION & experience
ASSESSMENT

Valuing moral standards

Involvement of personal decision & choice

Thinking of the consequences of one’s

action

Consideration of current life circumstance

DECISION &
CHOICE OF
ACTION Consideration of age & health related
changes

Inner motivations of the exercise of self-

control

Various outer motivations of the exercise of

self-control

SELF-
CONTROL
PROCESS
Restraining self from acting out

Resisting temptations and desires

ACTION,
REACTION &
CONDUCT AS
INDICATORS OF Suppressing inner feeling
SELF-CONTROL
Changing degree of self-control

Struggles in controlling self

Feeling of satisfaction & happiness

OUTCOME &
IMPACT OF SELF-
CONTROL
Consequence of losing control

Figure 1 The schematic diagram of the axial coding process

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 Caorong, L. A. (2021)
Hypothesis 2: There is a relationship between
health status, interpersonal relationships, spirituality,
financial status, and the exercise of self-control among
older adults
It was established from the data collected one
motivation of the older adults in their exercise of self-
control is the consideration of the health-related changes
they now experience in late life. Some research
participants revealed that they are now more careful in
terms of their food intake. They avoid doing things that may
aggravate their current health condition or health issues.
They further revealed that they had to struggle to engage
in physical exercises to improve their health status and
avoid foods not recommended for them to eat even if the
food is of their liking.
On the other hand, they are aware that they are already
in their sunset years, and this realization increases their
spiritual connection. Many participants said that they
restrain themselves from giving in to some of their desires
since they are afraid of God and are therefore afraid to
commit sins. When confronted with situations where giving
in would lead them to commit sin, they would readily
exercise and practice self-control to avoid sinning.
Hypothesis 3: Older adults who have high self-
control have better life satisfaction
When asked what emotions they feel when they
exercise self-control in a given situation, several
participants answered that they feel happy and have
personal satisfaction. As an example, they said that
avoiding argumentation or refraining from speaking back ill
words has preserved their good relationships with other
people, and as a result, they feel happy. Maintaining good
relationships with loved ones, family, relatives, neighbors,
and other people are considerable factors for life
satisfaction.
Propositions Derived from the Hypotheses
The following are the propositions formulated from the
generated hypotheses grounded from the qualitative data
obtained.
Proposition 1: Older adults exercise self-control
differently
The first proposition was derived from the first
hypothesis, which states that self-control is a personal
decision which is self-initiated by an older adult driven by
one’s own personal motive. People exert self-control on a
daily basis across different life domains such as in health,
in their interpersonal relationships and dealings, in financial
matters, and others. Since human beings are in constant
interaction with their environment, the exercise of self-
control is vital. Human beings possess the capability of
exercising self-control which involves the thought process
of decision making and choosing which action or behavior
to exercise, display or demonstrate. The exercise of self-
control differs from one older adult to another as individuals
have different personal motives and capabilities and are
unique in many ways.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
158
Self-control, according to Vohs and Baumeister (2004),
is the ability of a person to suppress or inhibit behaviors or
responses intentionally and consciously. Similarly, self-
control is seen as the capacity of an individual to alter
responses in terms of morals, values, ideals, and
expectations of other people behind some long-term goals
(Baumeister et al., 2007). In the field of psychology and
philosophy, there is a contention that self-control is needed
to suppress an immediate urge to consume. Not smoking
cigarettes, not drinking alcoholic beverages, or not
consuming fatty foods are just some examples of exhibiting
self-control. Those who claim to show self-control prefer
rewards or benefits in the future, such as longer lives and
better health (Henden, 2008).
The term self-control is often used in many disciplines,
which may often also refer to self-regulation, conscience,
willpower, and delayed satisfaction (Moffitt et al., 2011). As
defined by Henden (2008), self-control refers to a person’s
capacity in a lesser or larger degree. There are individuals
with a low level of self-control who may have distinct
characteristics in terms of attitude and behavior. These
individuals may also have the tendency to pursue
immediate gratification rather than delaying it. There are
also explorations in the behavioral science that inspect
self-control demonstration in early childhood and
determine the changes of the self-control practice during
the life course (Jackson et al., 2009; Kochanska et al.,
2001). Persons with high self-control, on the other hand,
are seen to be more successful in handling relationships
with other people as well as having more satisfying
relations with them (Finkel & Campbell, 2001). The impact
of exercising self-control also to cope with stress and
maintain psychological health is also found to be positive
(Englert & Bertrams, 2015).
Several researches consider self-control to range from
poor to good behavioral control (Dick et al., 2010). Many
investigators had the assumption which suggests that an
individual’s ability to regulate self or not differs in a
qualitative sense (Friese & Hofmann, 2009; Hofmann et al.,
2009; Strack & Deutsch, 2004). Good self-control is said to
involve a conscious regulatory process that includes
several subcomponents. They include one’s ability to
adjust and monitor one’s behavior when anticipating
results, delaying gratification, suppressing problematic
behavior, and being goal-directed. On the other side,
individuals who are unable to control themselves are more
spontaneous with their actions sidetracking the necessity
of conscious planning. They are also unable to delay
gratification or even appropriately modify responses
(Pearson et al., 2013).
In accomplishing daily-mundane tasks, which often
require decision-making, self-control is indeed needed.
However, many people find it extra challenging to exert
self-control which leads to failure in accomplishing tasks
such as eating healthy, doing exercise to saving money
(Baumeister et al., 1998; Baumeister et al., 2007; Carver &
Scheier, 2001).
 Caorong, L. A. (2021)
Proposition 2: There are various motivations
involved in the exercise of self-control
The next proposition was developed from the
assumption that there is a relationship between health
status, interpersonal relationships, spirituality, financial
status, and the exercise of self-control among older adults.
It could be argued that there are various motivations
behind the exercise of self-control by an individual. The
inner drives and motivations come in different forms as
human beings inherently have different aspirations and life
goals and aims.
Self-control is established as a person’s ability to
regulate his own thoughts, actions, and feelings (De Ridder
et al., 2012). Moreover, the practice of self-control helps
resolve motivational conflicts experienced by an individual
between short-term and long-term goals (Fujita, 2011).
Persons who are good at controlling themselves easily
resist temptations that would otherwise be in conflict with
the valued long-term pursuits. Essentially, persons of this
type are certainly engaged in action and behaviors that
help achieve or attain goals and motivations.
Motivations are classified as either intrinsic or extrinsic.
The reason behind the action or behavior of a person in a
particular way is driven by his or her motivations. Intrinsic
motivation implies that an individual engages in activity
because the person finds it enjoyable, satisfying, or
interesting as his or her inner motivation. On the other
hand, extrinsic motivation means that a person is driven to
do things that will lead him to achieve some personal gains
such as money (Deci & Ryan, 1985; Ryan & Deci, 2000).
Henden (2008) suggested that self-control involves the
notion of a person having the capacity to bring one’s action
in line with his intention in seemingly competing
motivations. This could be elucidated when a person has
the intention to resist, for instance, another cigarette and
was able to resist it despite having a strong desire for it.
Edmund argues that self-control is a form of intentional
control over one’s behavior; thus, self-control is a person’s
ability to control himself.
According to Baumeister et al. (2007), there is a need
to resist temptations as these may bring about long-term
consequences. For instance, one must attempt to resist
the temptation to eat unhealthy food, or to go to sleep for
extended hours or act in a violent manner since undeniably
failure to repel impulses and temptations may lead to
crime, alcoholism, teen pregnancy, drug addiction,
venereal diseases or underachievement in education
among other (Baumeister & Alquist, 2009; Baumeister et
al., 2007).
Proposition 3: The exercise of self-control leads to
life satisfaction
The hypothesis that older adults who exercise self-
control have better life satisfaction is the basis for the
above proposition. Findings of this current study show that
older adults who exercise self-restraint on matters they feel
strong about and are motivated to do about find
themselves feeling happy after exercising self-control. The
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
159
feeling of happiness is associated with the positive
outcomes of the exercise of self-control, such as
maintaining good interpersonal relationships.
Self-control is a strong determining factor for success
in life (De Ridder et al., 2012). There are a number of
adaptive outcomes associated with the exercise of self-
control which include better interpersonal relationships,
better physical health, and better intellectual performance
(Finkel & Campbell, 2001; Schmeichel et al., 2003; Will
Crescioni et al., 2011). Exercising high self-control is a
pertinent aspect of a person’s behavior for a person to
have a successful and healthy life (De Ridder et al., 2012;
Tangney et al., 2004). It was found out that behaviors such
as minimized aggression, reduced criminality (Dewall et
al., 2007), better interactions (Finkel & Campbell, 2001),
less abuse of alcohol, smoking, and other prohibited
substances (Sayette, 2004), and high self-esteem and
improved interpersonal skills were all related to the practice
of high self-control. Moreover, Hofmann et al. (2014) stated
that self-control is a person’s ability to override one’s inner
response and to interrupt undesirable behavioral
inclinations or impulses.
Additionally, greater self-control is also positively
attributed to psychological adjustments and negatively
predicts psychopathology (Tangney et al., 2004). It was
also found out that the more self-control a person exhibits,
the fewer are the experiences of symptoms and stress
while having better mental health (Boals et al., 2011). This
finding was corroborated by the results of the study by
Jensen-Campbell and Malcolm (2007) and Bogg and
Roberts (2004), that there is a link between self-control and
higher quality and satisfying relationships. The essence of
self-control in reaching significant life outcomes is widely
known. Empirical evidence shows that high self-control
practice positively predicts well-being, satisfaction with life,
and positive affect. High self-control here means the ability
of a person to regulate his thoughts, feelings, and
behaviors (De Ridder et al., 2012; Hofmann et al., 2014).
There is a well-established relationship between self-
control and optimal functioning (Tangney et al., 2004).
They also posited that people’s capacity to practice self-
control displays their adaptive nature, which has some
implications that they also live more happy and healthy
lives. Moreover, there is also evidence pointing out that
people with a higher level of self-control are seen to feel
satisfied with their lives as well as experience positive
emotions more than those who have low levels of self-
control (De Ridder et al., 2012; Hofmann et al., 2014).
Additionally, self-control was seen by many researchers to
be elemental in one’s personality trait. Having
conscientiousness is attributed to longevity, physical
health, and other relevant health behaviors (Bogg &
Roberts, 2004; Friedman et al., 1993; Goodwin &
Friedman, 2006). Succinctly, self-control is a catchall
essential human trait necessary for attaining a good life;
thus, self-control demonstration is associated with a
number of positive life outcomes.
 Caorong, L. A. (2021)
The Theory of Self-control in Old age
The theory of self-control in old age assumes that self-
control is a self-initiated process of governing one’s
actions, emotions, and feelings driven by one’s own
personal motives. It is also assumed that older adults
exercise self-control differently as there are various
personal motivations involved in the exercise thereof.
Moreover, it is posited that the exercise of self-control
among older adults leads to life satisfaction. The theory
suggests that the ability to exercise self-control involves
introspection and assessment and the thought process of
deciding and choosing what actions or behavior to display,
and the individual himself does the exercise of self-control.
The theory suggests that self-control involves deciding and
choosing an action or behavior that is highly grounded on
the person’s inner drive and personal motivations. It also
involves weighing and assessing possible consequences
of one’s action before initiating a response or action.
Figure 2 Schematic diagram of the Theory of Self-control in Old age
The diagram shows that the exercise of self-control among
older adults entails the involvement of varying motivational
factors. It is assumed in the theory that the motivating
factors include the aspect of wanting to maintain health,
accomplishing obligations, maintaining social status,
having better relationships, and attaining general well-
being. As seen in the figure, attaining life satisfaction is an
outcome for exercising self-control, as presented in Figure
2.
Conclusion
The exercise of self-control in old age is a necessary
aspect of any choices and decisions in life besides being
consequential. The choices and decisions of older people
in varied life avenues necessitate the practice of self-
control as outcomes will have an impact not only on them
but also on other individuals and society in general. Older
people are not exempt but are also faced constantly with
life decisions and choices in terms of their physical health,
social relationships, and economic choices as such the
practice of self-control is necessary as positive outcomes
are expected. The present study has important implications
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
160
The theory generated could be classified as a middle-
range theory since it addresses specific phenomena by
explaining what exercise of self-control is in old age, why it
occurs, and how it occurs among older adults. This middle-
range theory on the exercise of self-control in old age
suggests that older adults vary in their exercise of self-
control. The degree of self-control is linked to one’s own
personal motives and one’s attainment of specific aims and
life objectives. The theory further suggests that there are
different factors and motivations involved in the exercise of
self-control among older adults. The display of self-control
presupposes various personal motives such as attaining
personal interest and general well-being, maintaining
social status or standing, having better interpersonal
relationships, accomplishing personal obligations and
responsibilities, and having better health. Furthermore, the
theory assumes that the practice or exercise of self-control
results in personal satisfaction as displaying self-control is
attributed to a host of positive life outcomes.
in the field of gerontology and health care services since
the older population is growing, and so does the demand
for health care services. The need to understand the
choices and decisions of older adults is foundational in
individualizing health care services. Further, the theory
also provides a broader view and a better perspective in
understanding older adults in their life choices and
decisions.
Declaration of Conflicting Interest
There is no conflict of interest.
Funding
This research work was supported by Mindanao State University
– Marawi under the APDP Scholarship.
Acknowledgment
The author would like to acknowledge the support and contribution
of the following organization and individuals: (1) Mindanao State
University – Marawi headed by the System President, Dr. Habib
W. Macaayong, (2) Cebu Normal University in Cebu City,
Philippines where she took up her terminal doctoral degree in
nursing, (3) the dean of her home College, Dr. Naima D. Mala, (4)
her dissertation adviser, Dr. Daisy R. Palompon, (4) her
dissertation panel members, (5) Dr. Jonaid M. Sadang for his
 Caorong, L. A. (2021)
assistance during the processing of this publication, (6) family and
friends, (7) BNJ editors & peer-reviewers for their great
contribution in refining this work, and of course (8) all the
participants who have been generous in sharing their respective
rich experiences during the data collection process.
Author Biography
Dr. Laarni A. Caorong, RN, MAN is an Associate Professor V at
the College of Health Sciences, Mindanao State University –
Marawi, Philippines. She is currently designated as BSN Program
Level – I Coordinator and a member of various working
committees in the said College.
Data Availability Statement
The full transcribed verbatim responses of the participants were
kept in a password-protected computer during the analysis of this
research work and was permanently deleted after the completion
of her dissertation paper for confidentiality and ethical purposes.
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Cite this article as: Caorong, L. A. (2021). Self-control in old
age: A grounded theory study. Belitung Nursing Journal, 7(3),
151-162. https://doi.org/10.33546/bnj.1412
Theory and Concept Development
BNJ
The development of Spiritual Belitung Nursing Journal
Volume 7(3), 163-170
© The Author(s) 2021
Nursing Care Theory using https://doi.org/10.33546/bnj.1456

deductive axiomatic approach

Ashley A. Bangcola*

Abstract
The concepts of spirituality and spiritual well-being are not novel ideas as they have been subjects of scrutiny in
several studies. However, there has yet to be a formalized framework of spiritual nursing in the Philippines despite
its importance. Developing such a framework is significant, especially since holistic nursing believes in the
relationships among body, mind, and spirit. Thus, the Spiritual Nursing Care theory was conceptualized, which
states that every person has holistic needs, including spiritual needs that must be satisfied to attain spiritual well-
being. It forwards that for the patient’s spiritual needs to be met, what is required is the triumvirate interconnection
among the nurse, the external environment, and the spiritual nursing care which may be provided by the nurse as
a healthcare provider and the significant others or family as part of the external environment. The theory has two
propositions that were subjected to validation studies that either strengthened or repudiated the propositions
presented: (1) the meaning of spirituality differs from person to person, and (2) the patient’s spiritual well-being is
influenced by the nurse’s spiritual care competence, as well as the patient’s internal and external variables.

Keywords
Spiritual Nursing Care Theory; spirituality; holistic nursing; health personnel; Philippines

Spirituality is an evolving concept that has significance in
relation to bodily health. It is also considered an aspect of
health. Gone are the days when spirituality was limited to
the esoteric; it has now been deemed to have practical
applications, such as in nursing care. There is extensive
literature about the connection between spirituality and its
influence on health and well-being (Puchalski, 2001;
Koenig & Cohen, 2002; Chaves & Gil, 2015; Ebrahimi et
al., 2017). Furthermore, strong spirituality has been linked
to resilience (Koenig, 2012). Thus, it would be remiss not
to incorporate the spiritual component in the practice of
nursing care, which considers the holistic care of the
person to be its goal. Yousefi and Abedi (2011), in their
study, posit that real and complete healthcare can only be
possible through sensitivity to the patient’s spiritual needs.
The concept of spirituality has gained increasing
interest from researchers. Although it has significance in
the healthcare profession in general, the spiritual
component is still most often associated with nursing care
(Timmins & McSherry, 2012). History would show that
even in the past or ancient forms of nursing, patient care
was always holistic, including both spiritual and religious
care. This may be because caring is an important
component of nursing practice. Although some measure of
care is to be expected in other forms of healthcare, it can
be said that in nursing, the nurse takes a more active and
invested role in their patient’s well-being as their task is not
just to diagnose or dispense, but to provide holistic care.
This is also an important factor to consider as to the
rationale of developing a Spiritual Nursing Care Theory.
Spiritual care is compatible with nursing care as patient
care is more than just the medical aspect of nursing. The
nurse has to meet not just the medical needs of the patient
but all aspects which deal with the patient’s well-being. Not
only is it demanded from nurses by nature of their
profession, but studies would show that they are also well-
suited for the task.
In a study that compared how doctors and nurses
provided emotional care, it was found that the respondent
doctors would reassure their patients by continuing clinical

Mindanao State University – Marawi City, Philippines Article Info:

Received: 20 March 2021
Revised: 30 April 2021
Corresponding author: Accepted: 21 May 2021
Dr. Ashley A. Bangcola, RN, MAN, DScN
Mindanao State University – Marawi City This is an Open Access article distributed under the terms of the Creative
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Email: ashley.bangcola@msumain.edu.ph E-ISSN: 2477-4073 | P-ISSN: 2528-181X

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

163
 Bangcola, A. A. (2021)
care and explaining the curative nature of the treatment.
Furthermore, they believed that they could not reassure
patients if they discussed the latter’s fear with them. In
contrast, nurses relied on psychological and social skills,
often being open and discussing patients’ concerns with
them, this being their way of providing reassurance and
emotional support (Forsey et al., 2013).
Furthermore, the majority of the international literature
and studies have supported the increasing importance of
spiritual care and recognize it as an important component
of nursing care that is well-rounded and holistic (Koenig,
2012; Chaves & Gil, 2015; Ebrahimi et al., 2017). The
concepts of spirituality, spiritual needs, and spiritual well-
being have also been discussed and defined in various
studies. Fisher defines spirituality as a “personal quest for
understanding answers to ultimate questions about life,
about the meaning and about relationships that are sacred
or transcendent” (Fisher, 2011). Meanwhile, according to a
study by Guerrero-Castaneda and Flores (2017) on
spiritual nursing care as perceived by older persons, older
people make use of spirituality and religiosity to find a
sense of life amidst all of the radically developing
circumstances brought about by advancing age.
(Narayanasamy et al., 2004) identified specific spiritual
needs of older persons, including religious beliefs and
practices, absolution, seeking connectedness and comfort,
and healing or looking for meaning and purpose. Spiritual
Well-Being was defined as the “ability to experience and
integrate meaning and purpose in life through a person's
connectedness with self, others, their environment, or a
power greater than oneself and the totality of
circumstances that would lead a person to say that his life
is going well” (Fisher, 2011).
It can thus be inferred that studies generally agree that
spirituality is a state of being of a person; however, there is
still an evident lack of consistency in the definition of
spirituality (Timmins et al., 2015). In addition, while there
have been studies conducted to investigate the spiritual
needs of aged persons in residential homes and those at
the end of life stage in intensive care units (Erichsen &
Büssing, 2013), there is unexplored potential in studying
their spiritual well-being. According to the National Health
Service Scotland (2009), all healthcare staff, caregivers,
and families could provide spiritual care. However, there is
also a significant lack of literature concerning the three-way
relationship between the nurse, the patient, and his or her
family as current studies on spiritual nursing care tend to
be general and broad. In light of all of these, there seems
to be a great need to address these huge gaps in nursing
literature related to Spiritual Nursing Care. For these
reasons, the researcher wanted to develop a Spiritual
Nursing Care Theory.
In this study, the author wanted to explore another
perspective that considers the interconnection of the
healthcare provider, specifically the nurse, the family, and
the patient himself or herself. There has yet to be a
formalized framework of Spiritual Nursing Care in the
Philippines despite its importance. Developing such a
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
164
framework is significant because compared to traditional
forms of healthcare which make use of equipment and
facilities that may not be available, spiritual nursing care
requires only the competency of the healthcare provider,
specifically the nurse, in giving spiritual care. As of now,
spiritual needs are considered only a small component of
the holistic needs of a person. However, the author argues
that the concepts of spirituality, spiritual needs, and
spiritual well-being, which have been studied in previous
literature, can all be interconnected in one formal
theoretical framework. One way of understanding
spirituality is the perception of a person on the importance
of or how strong his or her spiritual practices or beliefs
make up a part of his life. Spiritual needs are specific needs
that must be addressed by the healthcare provider, in this
case, the nurse, so that the patient can attain meaningful
well-being, or be more specific, spiritual well-being. When
spiritual needs are satisfactorily addressed, spiritual well-
being is achieved and contributes to holistic health care.
The author posits that spiritual well-being is as important
as physical, emotional, and mental health, which deserves
due consideration.
This paper was meant to explore the patient’s
understanding and perception of the concept of spirituality,
the influence of the cultural elements of the patient’s
external environment on the practice of spiritual nursing
care, as well as the competencies of the nurse in providing
spiritual care, and its link to attaining spiritual well-being for
the patient. The eventual aim of this paper was to develop
a comprehensive, holistic, and spiritually inclusive nursing
care framework, which values the importance of each
stakeholder. This paper can be of help to patients, the
family, nursing practitioners, scholars, learners, and
curriculum planners who may decide to incorporate
spiritual nursing care as a part of the curriculum and the
nursing profession as a whole. It would serve to add to the
minimal knowledge of spiritual nursing care within the
Philippine context.
Methods
The theory proposed in this paper on spiritual nursing care
was conceptualized through the deductive form of
reasoning. Deductive reasoning is the systematic and
logical process whereby a conclusion is reached based on
the concurrence of multiple premises that are generally
assumed to be true (Sternberg, 2009). According to
Creswell and Plano Clark (2007), utilizing deductive
reasoning by the researcher would involve the researcher
working from the ‘top down’ starting with a theory to
hypothesis and then to data to add to or contradict the
theory.
The deductive method is used to construct a deductive
axiomatic system or theory. The essence of an axiomatic
approach as used in the field of logic and mathematics is
that a group of statements, called propositions, are derived
through the use of deductive logic applied to another more
fundamental set of statements serving as basic
 Bangcola, A. A. (2021)
assumptions, also known as axioms. Axioms represent the
foundation statements in a deductive system. Meanwhile,
a concept is defined as representing views or descriptions
of some aspect of the real world. A concept of something
is not the same as the thing itself (Lambert, 1973).
Finally, a theory is a set of logically related statements,
including some law-like basic assumptions having testable
implications, are an explanation and description of some
concept. All theories are deductive systems. Kerlinger
(1973) defines a theory as a set of interrelated constructs
or concepts, propositions, as well as a systemic view of
phenomena through specifying relations among variables
with the objective of explaining and predicting such
phenomena. Theories are those which knit together
observations (Thompson, 2005).
The Spiritual Nursing Care Theory was developed
following a deductive axiomatic approach. Within the
framework of nursing theories and models, the author also
used an empirical quantitative approach in her theory
generation (Jacox, 1974) in developing the Spiritual
Nursing Care Theory. The researcher identified the
phenomena that she wanted to investigate within her field
of study, specified, then classified concepts used when
describing these phenomena. A broad topic in the field of
nursing was chosen, specifically in gerontology, which was
of interest to the researcher and which had the potential for
further study. The topic chosen was the role of spirituality
in nursing care. The next step was to research and gather
related literature on the selected topic. The researcher then
developed propositions on how two or more concepts are
related. To elaborate, by identifying patterns among the
studies made by prominent scholars in the field, the
researcher was able to single out statements that were
generally accepted to be true (axioms) to serve as a
starting point for deducing and inferring other truths which
would be the building blocks of the theory (propositions).
The researcher then linked propositions to each other in a
systematic way to come up with the theory.
Walker and Avant (1995) identified four levels of
nursing theories, which include practice theories, mid-
range theories, grand theory, and metatheory. The term
‘grand theory’ is an alternative term to ‘model’. In contrast
to grand theories, which do not easily find an application
and are furthermore broad and abstract, mid-range
theories are more restricted in their focus. Mid-range
theories are also abstract, but only moderately so.
Moreover, they are composed of measurable variables.
The Spiritual Nursing Care Theory developed is an
example of a mid-range theory that specifies how the
propositions, and the concepts of spirituality, spiritual
needs, spiritual well-being, and spiritual nursing care are
related to each other, but which propositions remain
measurable. The Spiritual Nursing Care Theory may also
easily be applied in actual nursing practice.
The related literature in the succeeding discussion was
gathered to formulate the premises to base the more
specific propositions, which made up the foundation of the
proposed theory on Spiritual Nursing Care.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
165
Results and Discussion
Five axioms were generated after thoroughly reviewing the
literature and studies and were used as a basis for
generating the two propositions, which served as the
framework for the development of the Spiritual Nursing
Care Theory. The connection between spirituality and
health has been the subject of study since time
immemorial. In the past, and even until now, the caring for
the body and the spirit was done by the same person acting
as both therapist or counselor and religious leader
(Fradelos et al., 2014). Spirituality is linked to the human
spirit and is an important component of human existence
(McKee & Chappel, 1992). Many people consider their
spirituality and religion as a crucial part of their existence.
Spirituality also serves as a source of support and
contributes to people’s well-being, and helps them cope
with everyday struggles (Purdy & Dupey, 2005).
Health professionals also recognize the part spirituality
plays in healthcare (Monareng, 2012). Monareng, in her
study, goes on to state that it is the holistic perspective on
human functioning and in nursing which demands that
nurses take into account aspects of spirituality when they
provide nursing care (Monareng, 2012).
Studies exploring spirituality from a holistic approach
revealed that patients use religious or spiritual beliefs and
practices to cope with suffering such as illness and stress
(Koenig, 2012). One of the findings from Koenig (2012)
was that religious people tend to spend less time in the
hospital. He then claims in his study that healthcare
providers, including nurses, have an obligation to the
patient to include the patient’s religious beliefs in their care
and incorporate their faith (spirituality) in promoting
healing. The nature of nursing is to care, and thus it would
make sense for nurses to have a more direct hand in
attending to the spiritual needs of patients.
Various studies also show that people who are more
spiritual have better adaptive capabilities. They tend to
adapt more quickly to health complications compared to
their counterparts, who are less spiritual (Strandberg et al.,
2007). Levin et al. (1996) meanwhile explored connections
between spiritual beliefs and practices and health. His
findings are corroborated by studies that revealed the
many ways spirituality can prevent illness and promote
well-being, such as by positively impacting physical health,
lessening the risk of disease, and influencing
responsiveness to treatment (Baker et al., 2015).
Holistic approaches in healthcare take into
consideration all aspects of the individual, and his or her
needs, including mental, social, and spiritual needs.
Research regarding spirituality suggests that meeting
patients’ spiritual needs has a positive contribution to their
adaptation to illness and improving rehabilitation (Levin et
al., 1996). Based on the literature mentioned above (Purdy
& Dupey, 2005; Strandberg et al., 2007; Koenig, 2012;
Baker et al., 2015), it can be said that every person has
holistic needs, which may include spiritual needs (Axiom
1).
 Bangcola, A. A. (2021)
As people grow older, some tend to contemplate more
on matters of mortality and spirituality (Axiom 2).
Researchers posit that the natural process of aging comes
with it the consciousness that life will eventually end. This
creates a context where older adults are more accepting of
deepening their understanding of their mind, body, or spirit
(Atchley, 1999).
Spirituality is a complex and abstract subject with many
perspectives. It is something that touches all people in
different degrees. By sex, various studies have suggested
that females are more spiritual than males. The same study
revealed that people with higher educational attainment
tend to be less spiritual than those who finished lower
levels. Furthermore, this same study demonstrated that
spirituality decreases as income levels increase. As for
health status, some studies indicate that religiosity or
spirituality appears to positively correlate with physical
health (Ellison & Levin, 1998). While patients and their
families have different understandings and degrees of
spirituality, individual nurses also have different levels of
spirituality. Nurses are primarily trained in the physical and
nursing care of the patient; however, their levels of
spirituality can also impinge positively on their care of the
older person. Other studies have also shown how providing
spiritual care is influenced by multiple factors, including the
spirituality of the healthcare provider and their
understanding of the spiritual practices of the patients
(Schleder et al., 2013). A study by Kisvetrová et al. (2013)
found that nurses living in a predominantly secular country
would tend to see themselves as non‐religious and, as a
consequence, therefore, believe that providing
spiritual/religious care was not something they were likely
to do. Thus, what the literature would show is that nurses
are indeed aware of the concept of spiritual care or spiritual
nursing; however, they may differ in their interpretation and
how they administer such care because of their differing
understandings of spirituality. Therefore, it helps to
understand that people have different understanding and
levels of spirituality (Axiom 3).
Internal and external environment contributes to a
person’s spirituality (Axiom 4). People can find meaning in
life in different ways and through different avenues
(Eckersley, 2005). People would often have many things
which are important to them, such as their family, friends,
career, hobbies, interests, and desires. All of these are
avenues through which people can find meaning in life.
People can also find spirituality in their connection with
their nation or ethnic group since spirituality is one of the
deepest forms of interconnection. There is a link between
interconnectedness and physical well-being. For example,
it was found that socially isolated people five times likelier
to die compared to those who have strong ties with their
family, friends, and or community (Berkman & Glass,
2000).
In addition, empirical studies would show that health
cannot be reduced to just an organic and natural objective
process, but rather is connected to the experiences of
individuals and groups, which are in turn related to the
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
166
cultural characteristics of a society (Minayo, 2006).
The literature affirms that healthcare practices vary
depending on a person’s culture and that culture is the
basis for their explanations for their suffering and illness,
their search for meaning in these occurrences, treatment
choices, and life reevaluation (Mello & Oliveira, 2013). In
1996, the World Health Organization (WHO), as well as the
United Nations Educational, Scientific and Cultural
Organization (UNESCO), recognized the importance and
significance of cultural aspects in international health
(Mello & Oliveira, 2013). The two international
organizations stated that health care, which includes
nursing care, and culture should be approached in a way
that integrates the two from the perspective of benefiting
individuals and countries (Mello & Oliveira, 2013).
Based on the above literature, it can be seen how the
internal and external environment of a person, both his
socio-cultural and physical environment, can influence his
spirituality.
Holistic nursing care includes spiritual care (Axiom 5).
Taylor (2002), as cited in Monareng (2012), defines
‘spiritual nursing care’ as those activities that facilitate and
provide for a healthy balance between the bio-
psychosocial and spiritual aspects of the person, and thus
contributing to a sense of wholeness and overall well-
being. To adequately address the concerns of their older
patients, nurses must be knowledgeable of their patient’s
spiritual needs, meet these needs and contribute to
maintaining their patient’s positive spirituality. The concept
of spirituality has gained researchers’ interest in recent
years. Although spirituality is present in general healthcare
literature, the spiritual component of healthcare is still
mostly associated with nursing care (Timmins & McSherry,
2012). Even in the oldest forms of nursing, patient care was
said to be holistic and included spiritual and religious care
as well. During the Byzantine era, the patients in the
hospitals received physical and spiritual care
(Papathanasiou et al., 2013). In addition, theories of
nursing recommend a holistic model for healthcare. It has
already been substantiated that patient care cannot be and
should not be one-dimensional but should be holistic and
composed of all aspects such as the biological,
psychological, social, and spiritual dimensions
(Papathanasiou et al., 2013). Florence Nightingale, who
can be said to be the founder of modern nursing,
introduced important elements necessary for the healing
process. Some examples included the environment, touch,
light, scents, music, silent reflection, and even birds. Each
of those elements helped the patient connect with others,
with nature, and with the divine (Nightingale, 1860).
Holistic care may be defined as a comprehensive
model of caring and is the heart of nursing (Strandberg et
al., 2007; Albaqawi et al., 2021). Holistic care is built upon
the principle of holism which puts forward the idea that for
people, the whole is greater than the sum of its parts. In
addition, mind and spirit both affect the body (Tjale &
Bruce, 2007). Holistic care then is that care that recognizes
that the patient is a whole. Furthermore, it acknowledges
 Bangcola, A. A. (2021)
that there is interdependence and interconnection between
and among the patient’s biological, social, psychological,
and spiritual dimensions. Holistic care, being a
comprehensive model of caring, includes the following
components – education, self-help, medication,
complementary treatment, and communication (Morgan &
Yoder, 2012).
Holistic care is also applied in nursing. In the context of
holistic nursing, the patient’s attitude, opinions, emotions,
thoughts, and even culture and spiritual beliefs and
practices are factored in the care plan and are considered
essential to the recovery, happiness, satisfaction, and well-
being of the patient (Selimen & Andsoy, 2011).
From the axioms generated, the following ideas were
put forward as propositions to form the backbone of the
theory on Spiritual Nursing Care. The first proposition
posited states that the meaning of spirituality differs from
person to person (Proposition 1).
The second proposition posited is that the patient’s
spiritual well-being is influenced by the nurse’s spiritual
competence as well as the patient’s internal and external
variables (Proposition 2).
Spiritual Nursing Care Theory
The theory being proposed in this paper on Spiritual
Nursing Care states that every person has holistic needs,
which may include spiritual needs that must be satisfied for
the person to attain spiritual well-being. The theory
forwards that in order to achieve spiritual well-being and for
the person’s spiritual needs to be satisfied, what is required
is the triumvirate interconnection among the nurse, the
external environment, and the spiritual nursing care which
may be provided by the nurse as the healthcare provider
and the significant others or family as part of the external
environment.
The Spiritual Nursing Care theory claims that spiritual
needs are part and parcel of the totality of needs of the
patient; it is not lesser than any other need. They should
be considered and dealt with holistically and accorded
great weight. The theory postulates that satisfaction of
spiritual needs contributes to the overall well-being, as it
may contribute to the improvement of the physical and
emotional well-being of the patient (Bangcola, 2019). Thus,
it is assumed that people who find themselves spiritually
satisfied would have a more positive attitude towards
healing, both emotionally and physically, and are therefore
more responsive to healthcare interventions.
The schematic diagram of the theoretical framework for
this study was based on the work of the author, the Spiritual
Nursing Care theory, which proposed that holistic care for
patients is composed of three interlocking factors that
contribute to the satisfaction of the patient’s spiritual needs
to attain spiritual well-being: the external environment
which includes the nurse as the healthcare provider, and
which necessitates that he or she must have enough
spiritual competency to provide spiritual nursing care; the
culture of the patient’s family or significant others; and at
the center is the spiritual nursing care itself.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
167
Figure 1 Spiritual Nursing Care Framework
Figure 1 illustrates the Spiritual Nursing Care Framework,
which involves the tripartite relationship between the nurse
as the healthcare provider, the family as providers of
support, and the patient having spiritual needs.
The theoretical framework is composed of four
components: (1) spiritual nursing care, (2) the nurse’s
spiritual competency, (3) the cultural background of the
patient, both as part of the external environment, and (4)
the patient’s spiritual needs.
The Spiritual Nursing Care theory proposes that
patients have spiritual needs as part of their holistic needs.
When these needs are satisfied, they will have a more
positive attitude towards healing and thus are more
responsive to healthcare interventions which may be
manifested in their satisfaction with the spiritual nursing
care provided by the nurse. The trust between the nurse
and the patient will help in the nursing aspect by creating
an atmosphere of rapport between the nurse and the
patient, thereby making the patient support the decisions
of the nurse when it comes to the spiritual aspects of
nursing care. As illustrated in the above schematic
diagram, there must be trust between the nurse and the
family members of the patient also because they both act
as a healthcare provider and support system for the
patient.
Furthermore, there must be trust since the nurse is
expected to provide spiritual nursing care, which must be
sensitive to the patient’s needs and the cultural
background of the patient’s family. This, in turn, will help
make the patient’s family trust that the spiritual nursing
care provided by the nurse will redound to the benefit of the
patient. On the part of the nurse, as a healthcare provider,
he or she must have spiritual competency in order to
address the spiritual needs of his or her patient adequately.
Competence refers to a set of traits and characteristics
which form the basis for optimal performance. In other
words, spiritual competency then is that defined set of
 Bangcola, A. A. (2021)
attitudes, knowledge, and skills in the domains
of spirituality that every nurse should have to effectively
and ethically practice nursing, regardless of whether or not
they consider themselves spiritual or religious.
There must be congruence between the nurse’s
spiritual competency and the spiritual nursing care to be
provided in order to satisfy the patient’s spiritual needs. As
defined in nursing, culturally congruent practice is that
application of evidence-based nursing, which is in line with
the preferred cultural values and practices, beliefs, and
worldview of patients (Marion et al., 2016). Therefore, the
spiritually congruent practice would be nursing which is
sensitive to the preferred spiritual or religious beliefs of the
patient and his or her significant others. Meanwhile,
spiritual competence is the process wherein nurses
demonstrate congruent spiritual practice. In other words,
the nurse needs to be spiritually competent in providing
spiritual nursing care that is congruent with the patient’s
spiritual needs.
In whatever healthcare setting, the nurse is likely to
have patients with culturally diverse beliefs and practices
concerning their own health, wellness, and illnesses. This
is where the interaction between the nurse and the external
environment (socio-cultural) would also be essential. Not
only must the nurse provide culturally sensitive spiritual
nursing care, he or she must also provide spiritually
congruent nursing care. There may be instances where the
personal belief system of a nurse may not match those of
his or her patient. In this instance, there may be a
conundrum since the nurse may have difficulty relating to
his or her patient, which in turn may hinder the nurse from
providing adequate spiritual care. Hence, it is necessary for
the nurse to interact with the external environment of the
patient or his family to be more specific. This is because,
in the family setting, most persons develop and form their
values and belief systems as influenced by their socio-
cultural background.
Meanwhile, the family members may not be expected
to have the same spiritual competence as the nurse as they
are already in a unique position of being the primary and
fundamental emotional support of the patient. What is
required is that they be sensitive to the spiritual needs of
the patient and assist them as much as they are able. They
should also assist the nurse in understanding how best to
satisfy the spiritual needs of the patient and handle any
confusion the nurse may have as to specific cultural and
religious practices, as the family members are likely to
come from the same socio-cultural environment as the
patient.
It is only with the nurse’s spiritual care competence that
is congruent with the nursing care provided and is sensitive
to the cultural background of the patient’s family, which
would complete the holistic spiritual nursing care provided
to the patient. It is through this three-way symbiotic
relationship that holistic spiritual nursing care may be
perfected. If the nurse is able to provide optimum physical,
pharmacological and spiritual assistance to the patient and
the family environment delivers spiritual guidance, then the
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
168
patient can attain positive health status within his given
physical illness or bodily condition.
Conclusion
The essence of spiritual nursing care is the understanding
that spirituality can mean different things to different
people, especially considering the physical and socio-
cultural environment. The Spiritual Nursing Care
theoretical framework involves three groups: the patient,
the nurse, and the family or significant others as part of the
external environment. It is also composed of three
components: the nurse’s spiritual care competence, the
cultural elements of the external environment, and the
spiritual nursing care, the intersection of which directly
influence the satisfaction of the patient’s spiritual needs.
The higher the spirituality or how much the patient
believes himself to be faithful, the higher the impact the
corresponding faithfulness of his significant others would
impact him. In providing holistic nursing care that includes
spiritual care, there must be congruence between the
nurse’s spiritual competency as well as the spiritual nursing
care provided to meet patients’ spiritual needs. In other
words, the spirituality inclusive nursing care provided
would be the practical application of the nurse’s spiritual
competency, the former’s effectiveness in meeting the
patient’s spiritual needs to attain spiritual well-being, being
directly influenced by how competent the nurse may be.
Declaration of Conflicting Interest
The author declares no conflict of interest in this study.
Funding
This research received no specific grant from any funding agency
in the public, commercial, or non-profit sectors.
Acknowledgment
I would like to acknowledge Ashyanna Alexine Bangcola for her
valuable input and advice, without which I could not have
completed this manuscript.
Author Biography
Dr. Ashley Ali Bangcola is a holder of a Doctor of Science in
Nursing degree major in Gerontology Nursing from the Cebu
Normal University in the Philippines. She graduated with a Master
of Arts in Nursing major in Nursing Administration from the
Mindanao State University in 2011. She is an Assistant Professor
at the Mindanao State University – College of Health Sciences and
the current Research Coordinator of the same. Her research
interests include gerontology nursing, nursing education, nursing
administration, spiritual health care, and mental health.
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Original Research
BNJ
Barriers to exclusive breastfeeding: Belitung Nursing Journal
Volume 7(3), 171-178

A cross-sectional study among © The Author(s) 2021

https://doi.org/10.33546/bnj.1382

mothers in Ho Chi Minh City,

Vietnam
Nhan Thi Nguyen* , Huong Thi Do, and Nhu Thi Van Pham

Abstract
Background: Exclusive breastfeeding provides numerous benefits to the health of infants, mothers, economics,
and the environment. However, during the exclusive breastfeeding period, the mothers face many barriers.
Objective: This study aimed to describe the perceived barrier of breastfeeding and compare its differences among
mothers in Vietnam according to demographic and individual characteristics.
Methods: A cross-sectional study was conducted among 246 women in Ho Chi Minh City, Vietnam. Data were
derived from the original survey using a self-administered questionnaire asking about the barriers of breastfeeding
in three aspects: maternal, infant, and socio-environment. Descriptive statistics, Independent t-test, and ANOVA
were used to describe the mothers’ characteristics and the breastfeeding barriers.
Results: The barrier from the infants was the most noticeable, followed by socio-environment and maternal barriers,
respectively. Breastfeeding in public places (M = 2.93, SD = 0.92), baby’s illness (M = 2.74, SD = 0.99), and
insufficient milk supply (M = 2.70, SD =0.99) were considered as major barriers to six-month exclusive
breastfeeding among mothers in Ho Chi Minh City, Vietnam. Among the age groups, mothers who were more than
35 years old perceived had lower breastfeeding barriers than the younger mothers (F = 3.67, p = 0.03).
Conclusion: The investigation of the barriers against exclusive breastfeeding practice can help nurses and
midwives develop breastfeeding promotion programs to promote exclusive breastfeeding rate for women in
Vietnam.

Keywords
barrier; exclusive breastfeeding; perception; mothers; nurses; midwives; Vietnam

Breastfeeding is the most efficacious feeding method for
the child, especially the exclusive breastfeeding in the first
six months of infant’s life provides irrefutable benefits for
the infant’s health, mother’s health, economics, and the
environment. To illustrate, a baby who receives only breast
milk in the first six months of life is less mortality and
morbidity of gastrointestinal infection diseases,
pneumonia, asthma, or diarrhea compared to non-
breastfed infants (Ballard & Morrow, 2013; Biks et al.,
2015). Additionally, exclusive breastfeeding for infants in
the first six months is also significantly associated with
higher scores in the intelligence quotient test than those
who have no exclusively breastfed (Tasnim, 2014).
Regarding the mother’s health, exclusive breastfeeding
significantly reduces breast cancer and ovarian cancer,
and it postpones returning the menstrual period as a
lactational amenorrhea method (Labbok, 2016; Victora et
al., 2016). For economics, Walters et al. (2016) estimated
the economic benefits of breastfeeding across seven
countries in Southeast Asia; the results found that the

Faculty of Nursing and Medical Technology, University of Medicine and Article Info:
Pharmacy at Ho Chi Minh City, Vietnam Received: 26 February 2021
Revised: 23 March 2021
Accepted: 3 May 2021
Corresponding author:
Dr. Nhan Thi Nguyen This is an Open Access article distributed under the terms of the Creative
Faculty of Nursing and Medical Technology, University of Medicine and Commons Attribution-NonCommercial 4.0 International License, which allows
others to remix, tweak, and build upon the work non-commercially as long as
Pharmacy at Ho Chi Minh City. 201 Nguyen Chi Thanh Street, Ward 12,
the original work is properly cited. The new creations are not necessarily
District 5, Ho Chi Minh City, Vietnam licensed under the identical terms.
Mobile: (+84)907307358
Email: nguyennhan@ump.edu.vn | nguyennhan.ump@gmail.com E-ISSN: 2477-4073 | P-ISSN: 2528-181X

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 Nguyen, N. T., Do, H. T., & Pham, N. T. V. (2021)
health care treatment could be saved 300 million US
dollars annually by reducing the incidence of diarrhea and
pneumonia by providing adequate breastfeeding.
Furthermore, breastfeeding is assumed as climate
compatible because of the nature of breast milk, e.g., no
need for heating, no need the refrigeration to store, and
breast milk can be used at any time with the right
temperature.
Because of the advantages of breast milk, World Health
Organization (WHO) recommends mothers worldwide
exclusively breastfeed their infants during the first six
months after birth (WHO, 2011). However, globally only
40% of infants aged 0-6 months are exclusively breastfed
(WHO, 2017). In Vietnam, only 24% of infants are
breastfeeding exclusively for the first six months despite
the multiple breastfeeding promotion programs that have
been launched by the government (UNICEF, 2016).
During six-month exclusive breastfeeding, the mothers
could face many challenges, barriers, or difficulties. The
common barriers are the perception about insufficient
breast milk, and breast milk does not provide all the
necessary vitamins and supplements (Kim & Chapman,
2013; Nguyen et al., 2018; Xuan & Nguyen, 2018). Another
barrier of exclusive breastfeeding is the mother’s
perception about foods and other liquids more nutritious
than breast milk; therefore, formula milk, water, and solid
food are commonly introduced before six months of age
(Lundberg & Thu, 2012). In addition, mothers also face the
barrier to exclusive breastfeeding due to the need to return
to work outside the home or the feeling of uncomfortable to
breastfeed in public places, such as restaurants,
workplaces, shopping centers, and public transport
(Coomson & Aryeetey, 2018). Besides, physical breast
problems, such as mastitis, breast engorgement, sore
nipples, and cracked or inverted nipples, become the
challenge for mothers who breastfeed their children
exclusively for six months (Babakazo et al., 2015; Karkee
et al., 2014).
Additionally, each culture has its own belief when it
comes to breastfeeding. Some of these are helpful to
mothers and babies, while others could negatively impact
a baby’s health. For example, there is a widespread belief
among Vietnamese mothers that colostrum is dirty milk and
should throw away (Dixon, 1992). Discarding colostrum is
associated with higher odds of non-exclusive
breastfeeding during six months (Tamiru et al., 2012).
According to Health Promotion Model, perceived
barriers to action are anticipated, imagined, or real blocks
and costs of understanding a given behavior (Pender et al.,
2011). In the context of exclusive breastfeeding, perceived
barriers refer to perceptions about inconvenience,
difficulty, or obstacles in performing exclusive
breastfeeding to the babies; the higher the perceived
barriers to breastfeeding, the less implementation of
exclusive breastfeeding among them (Kim & Chapman,
2013). Few studies documented the barriers of exclusive
breastfeeding in the Vietnam context (Kim & Chapman,
2013; Nguyen et al., 2018). These studies were conducted
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
172
in the Northern and Middle of Vietnam, where they have
different cultures from the Southern of Vietnam. Therefore,
conducting research in identifying the barriers of exclusive
breastfeeding practices among mothers in the Southern of
Vietnam was important. The findings from this study give
comprehensive pictures about barriers of exclusive
breastfeeding for six months among mothers in Ho Chi
Minh City, Vietnam. It also provides baseline information
for future researches on the relevant topic. In addition, the
findings can help nurses and midwives to manage the
exclusive breastfeeding practice and develop appropriate
intervention to minimize the perception of barriers among
Vietnamese mothers; hence, promoting the rate of
exclusive breastfeeding among infants in Vietnam.
Methods
Study Design
This was a quantitative study with a cross-sectional design
to identify breastfeeding barriers among mothers in Ho Chi
Minh City, Vietnam. It relied on secondary data of the
research on “Factors predicting six-month exclusive
breastfeeding among mothers in Ho Chi Minh City,
Vietnam”, conducted by Nguyen et al. (2021). The data
were collected from three hospitals named University
Medical Center, Hung Vuong hospital, and Tu Du hospital
at Ho Chi Minh City, Vietnam.
Sample Size and Sampling Method
The population of the study was mothers who were having
babies aged from six to nine months. The study inclusion
criteria for mothers included a mother from 18 years old or
older, having a baby from six to nine months, being able to
communicate in the Vietnamese language. For infants, the
criterion included a singleton baby with a gestational age
of at least 37 weeks. The exclusion criteria for mothers
were mothers with chronic disease or other diseases in
which breastfeeding was not allowed by physicians. The
exclusion criteria for infants were infants with congenital
disabilities or admission to the hospital during the first six
months.
The sample size was calculated using Cochran’s
formula (Cochran, 1977). The estimated proportion of
exclusive breastfeeding in Vietnam was 20% (UNICEF,
2016), the error of precision was accepted at 5%, and the
confidence interval of 95% was assumed. Therefore, the
total sample size in the current study was 246 mothers.
Instruments
The samples of this study were drawn from the secondary
data of the original research, which was mentioned
previously. The original survey was conducted using a self-
administered questionnaire for collecting data. The
Perceived Barriers to Breastfeeding Scale was developed
by the first author based on the literature review (Babakazo
et al., 2015; Coomson & Aryeetey, 2018; Kim & Chapman,
2013) and the concept of perceived barriers to action from
the Health Promotion Model (Pender et al., 2011) to
 Nguyen, N. T., Do, H. T., & Pham, N. T. V. (2021)

measure mothers’ perceptions of factors which were (no.992/HĐĐĐ-ĐHYD) approved this study. Furthermore,
considered as breastfeeding barriers. The content validity this study also received the mothers’ agreement to
of the scale was tested with three breastfeeding experts, participate in the study. Mothers were also informed that
and the item-level content validity (I-CVI) index of this scale they had the right to withdraw from the research and were
was 0.91. Originally, this scale was developed in English assured about confidentially of the obtained information.
and translated into the Vietnamese language using the
back-translation technique. Results
The Perceived Barriers to Breastfeeding Scale
consisted of 20 items that covered three aspects of Participant’s Characteristics
breastfeeding barriers: maternal barriers (item 1-10), infant Among 246 mothers, 61.4% of them aged 26 to 35 years.
barriers (item 11-14), and socio-environment barrier (item Slightly half of the mothers achieved the high school or
15-20). The maternal aspect reflects the negative attitude diploma educational levels (52.0%), got the normal delivery
or belief of mothers about breastfeeding practice, the lack (53.7%), and were the primiparous mothers (52.0%).
of breastfeeding technique or skills, lack of confidence,
mother’s physical and psychological changes that would Table 1 Mothers’ characteristics by frequency and percentage
bar the exclusive breastfeeding practice. The infant aspect (N =246)
reflects the false belief of mothers about the benefits of
breast milk for infants and infant’s physical and Individual Characteristics n %
psychological conditions. The socio-environment aspect Mother’s age
reflects the negative mothers’ perception of inadequate < 25 years old 46 18.7
support from family and health care providers, working 25 – 35 years old 151 61.4
> 35 years old 49 19.9
status, and the adverse effect of formula advertisement
Mother’s education
against the exclusive breastfeeding practice. The response Less than high school 62 25.2
scale to each item was scored from 1 (strongly disagree) High school or diploma 128 52.0
to 4 (strongly agree). Therefore, the total scores were Bachelor or higher 56 22.8
ranged from 20 to 80, which a higher score means a higher Delivery method
level of perceived breastfeeding barrier. The psychometric Normal delivery 132 53.7
properties of the scale were tested with internal Cesarean section 114 46.3
consistency reliability of the scale was 0.92. Parity
Primiparous 128 52.0
Multiparous 118 48.0
Data Collection
Data were derived from the secondary data of the original
Perceived Barriers to Breastfeeding
research; hence, the detailed information of the data
The average total score of perceived barriers to
collection could be seen in the study of Nguyen et al.
breastfeeding was 49.24 (SD = 14.57), which was ranged
(2021).
from 22 to 76. The score in each item was varied from 1 to
4, which a higher score means a higher level of perceived
Data Analysis
breastfeeding barrier. The details of each item were
Data were coded and analyzed using SPSS (statistical
presented in Table 2.
package for the social sciences) software program version
For the maternal aspect, the results revealed that the
18.0. Descriptive statistics were used to describe the
item “My breastfeeding is not successful as expected due
participant characteristics, compute the mean and
to insufficient breastmilk” had the highest mean score (M =
standard deviation of the Perceived Barriers to
2.70, SD = 0.99), followed by the item “Lack of knowledge
Breastfeeding Scale. Independent t-test, one-way ANOVA
about breastfeeding technique results in my unsuccessful
were used to determine the different means between
practice” (M = 2.69, SD = 0.99). The item “During
mother’s characteristics and perceived barriers to
breastfeeding, I often have negative emotion (such as
breastfeeding. If a statistically significant difference was
feeling anxious, agitated, angry, disgusted, or rageful)” had
found when running ANOVA, a post hoc test was done to
the lowest mean score (M = 2.04, SD = 0.90).
find a specific difference between the groups. Prior to
For the infant aspect, the item “My baby’s illness makes
performing the ANOVA, the assumptions were tested to
breastfeeding very hard” was the highest mean score (M =
ensure the accuracy of the findings and confirm no
2.74, SD = 0.99), followed by the item “My baby’s irritating
violation of statistical assumptions.
mood makes the breastfeeding harder” (M = 2.60, SD =
0.97), and the item “Exclusive breastfeeding does not
Ethical Consideration
provide my baby with enough nutrition” had the lowest
The current study obtained approval for secondary use
mean score (M = 2.26, SD = 0.92).
from the first author of the original survey with the
For the socio-environment aspect, the results showed
agreement for using the data. Additionally, the Institutional
that item “Breastfeeding in public places is uncomfortable
Review Board (IRB) Committee from the University of
to me” had the highest mean score (M = 2.93, SD = 0.92),
Medicine and Pharmacy at Ho Chi Minh City
followed by the item “Lack of support from family members

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 Nguyen, N. T., Do, H. T., & Pham, N. T. V. (2021)

makes my breastfeeding practice more difficult” (M = 2.45, feel unsure of continuing breastfeeding” (M = 2.31, SD =
SD = 0.89). The lowest mean score was the item “Formula 0.88).
advertisement from TV, parent magazines, etc., makes me

Table 2 Descriptive statistics of perceived barriers to breastfeeding (N = 246)

Do you think that the following items were barriers to your breastfeeding? M SD
Maternal
1. Breastfeeding is an exhausting process 2.34 0.84
2. Breastfeeding interferes with my sleeping pattern 2.56 0.97
3. Breastfeeding in front of family members is an embarrassing process for me 2.42 0.99
4. Experiencing physical breast problem (for example, sore or cracked nipple, breast engorgement)
2.52 1.01
discourages me from continuing breastfeeding
5. Lack of knowledge about breastfeeding technique results in my unsuccessful practice 2.69 0.99
6. Breastfeeding makes me feel nervous about my body changes (such as weight gain, saggy breast) 2.27 0.87
7. I haven’t enough skills to practice breastfeeding 2.45 0.92
8. My breastfeeding is not successful as expected due to insufficient breastmilk 2.70 0.99
9. Breastfeeding interferes with my daily life activities 2.31 0.83
10. During breastfeeding, I often have negative emotion (such as feeling anxious, agitated, angry,
2.04 0.90
disgusted, or rageful)
Infant
11. Exclusive breastfeeding does not provide my baby with enough nutrition. 2.26 0.92
12. It is difficult for me to keep my baby latch on my breast 2.46 0.94
13. My baby’s irritating mood makes breastfeeding harder 2.60 0.97
14. My baby’s illness makes breastfeeding very hard 2.74 0.99
Socio-environment
15. Breastfeeding in public places is uncomfortable to me 2.93 0.92
16. Breastfeeding limits my social activities with others 2.43 0.83
17. Lack of support from family members makes my breastfeeding practice more difficult. 2.45 0.89
18. Return to work affects my breastfeeding adversely 2.43 0.79
19. Formula advertisement from TV, parent magazines, etc. makes me feel unsure of continuing
2.31 0.88
breastfeeding
20. Lack of support from healthcare personnel makes my breastfeeding practice more difficult. 2.34 0.91

One-way ANOVA test showed a statistically significant
difference between the mother’s age and breastfeeding
barriers score (F = 3.67, p = 0.03). The post hoc (LSD) test
calculated the smallest significance between two means as
if a test had been run on those two means (as opposed to
all of the groups together in the case of Tukey’s test). This
enabled us to make direct comparisons between two
means from two individual groups. The post hoc (LSD) test
revealed that the mothers who less than 25 years old and
from 25 to 35 years old had higher breastfeeding barrier
scores than those who greater than 35 years old (Table 3).

Table 3 The difference in breastfeeding barriers scores and mothers’ characteristics (N =246)

Breastfeeding barriers Post hoc

Variable n
M±SD t/F p
Mother’s age 3.67 0.03*
< 25 years old 46 53.30±15.31 (1), (2) > (3)
25 – 35 years old 151 49.28±13.92
> 35 years old 49 45.29±15.03
Mother’s education 0.81 0.45
Less than high school 62 51.13±15.17
High school or diploma 128 48.94±14.44
Bachelor or higher 56 47.84±14.57
Delivery method -0.90 0.37
Normal delivery 132 48.46±14.86
Cesarean section 114 50.14±14.23
Parity 0.68 0.50
Primiparous 128 49.84±14.29
Multiparous 118 48.58±14.90
*p <0.05, t = t-test, F = ANOVA, post hoc (LSD)

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 Nguyen, N. T., Do, H. T., & Pham, N. T. V. (2021)
Discussion
The mothers in the current study were young adults, and
the majority of them were in the appropriate range of
childbearing ages between 25 to 35 years old. Slightly
more than half of them were new mothers. The mothers’
perception of breastfeeding barriers was at a moderate
level. According to Health Promotion Model, perceived
barriers mean the perception of an individual about the
inconveniences or difficulties of an action (Pender et al.,
2011). In a breastfeeding context, perceived barriers
represent the perception of mothers about the difficulties,
the inconveniences, the challenges that the mothers face
during the breastfeeding period; the more perceived
barriers to breastfeeding, the less breastfeeding for the
babies (Al-Darweesh et al., 2016).
The top barrier by the perception of Vietnamese
mothers in the current study with the highest score (M =
2.93, SD = 0.92) was “breastfeeding in public places was
uncomfortable to the mothers”. It seems to be a common
barrier from the perceptions of Vietnamese mothers and
mothers from other countries. Coomson and Aryeetey
(2018) conducted mixed methods research to describe the
breastfeeding experience in public among 300 women in
Accra, Ghana; these women reported difficulties in
breastfeeding baby in public places due to the feelings of
shyness, embarrassment, discomfort to expose the
breasts (Coomson & Aryeetey, 2018). According to the
literature review, there are controversial views of
breastfeeding in public places; some support this practice
while others do not. The rejection or acceptance of
breastfeeding in public places depends on the requisite
social norms. For example, a study by Morris et al. (2016)
in the United Kingdom revealed that breastfeeding in public
places was inappropriate because breasts were viewed as
sexual objects. Whereas people in China claimed to
breastfeed in public was appropriate and did not violate
social morality (Zhao et al., 2017). In Vietnamese culture,
it is acceptable for mothers to breastfeed in public places
with covered-up breasts to avoid the exposure of their
breasts. Vietnamese mothers would find a discreet place
to feed their baby to prevent discomforting others, guard
against judgment, and protect themselves from males’
unwanted gaze. Once a mother feels inconvenient or
uncomfortable about breastfeeding in public, she is less
likely to breastfeed her baby in public, which, in turn, more
likely to stop exclusive breastfeeding before six months.
Similarly, a study by Scott et al. (2015) indicated that
mothers in European countries who had a negative attitude
toward breastfeeding in public places were nearly never
breastfed their babies in public (AOR = 0.05, 95% CI [0.12,
0.50]). Those mothers were also more likely to cease
breastfeeding earlier compared to the others.
The second highest score was baby's illness and
irritating mood (M = 2.74, SD = 0.99). These Vietnamese
mothers identified this barrier as one of the most common.
One can theorize that when a baby becomes ill, mothers
feel uncertain about caring for him, including feeding.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
175
Simultaneously, the baby's mood and appetite are likely to
be altered, and the common baby/mother interactions
towards feeding (Paintal & Aguayo, 2016). The best thing
as we know that she should continue breastfeeding a sick
baby to help the baby shorten the length of the illness and
quickly recovery because breast milk contains antibodies
(Manning et al., 2013). However, it is not easy to
breastfeed an ill, irritated baby. To illustrate, the baby has
a cold and stuffy nose; when he suckles the breast, it can
be frustrating the baby, and he is fussier at the breast since
he cannot breathe during suckling. Sharmin et al. (2016)
reported that 64.8% of mothers in Bangladesh did not give
exclusive breastfeeding during the baby’s illness time. In
the belief of Vietnamese people, breastfeeding is
unnecessary for the sick baby since it is difficult to feed the
baby during the baby’s illness. Not surprisingly, the infant’s
illness is highly correlated to the inadequate practice of
exclusive breastfeeding in Vietnam.
The third-highest score of barriers of exclusive
breastfeeding from Vietnamese mothers’ perception was
the insufficient breast milk (M = 2.70, SD = 0.99).
Interestingly, perception about insufficient milk seems to be
a global barrier for exclusive breastfeeding among mothers
worldwide. In a study by Osman et al. (2009), mothers in
Lebanon perceived that they had insufficient breast milk
because their babies still felt hunger and cried after
feeding. Similarly, a study by Nasser et al. (2018) reported
that 78% of the mothers in Qatar stopped giving exclusive
breastfeeding for babies because they thought they did not
have enough breast milk. A study in Vietnam reported that
60.9% of the mothers felt that their breast milk was not
enough for the child and the child would be hungry;
consequently, they considered stopping exclusive
breastfeeding during the first six months (Nguyen et al.,
2018). There are various reasons for insufficient milk
supply, such as poor nutrition due to poor appetite of the
mothers (Lou et al., 2014), poor sucking (Sharmin et al.,
2016), not breastfeeding often enough, over anxiety,
excessive fatigue, and lack of support and guidance from
nurse-midwives (Sultana et al., 2013). However,
insufficient milk is preventable; the finding implied the
importance of educating, supporting, and coaching the
mothers to overcome this barrier and successfully
exclusive breastfeed for the first six months. A previous
study confirmed that mothers having sufficient breast milk
for the baby in the first six months were 24.89 times more
likely to give exclusive breastfeeding than mothers with the
perception of insufficient breast milk (Kim & Chapman,
2013).
Next, lack of knowledge about breastfeeding
techniques resulting in unsuccessful practice was a barrier
by the view of Vietnamese mothers in the current study (M
= 2.69, SD = 0.99). A study by Nasser et al. (2018)
revealed that approximately 53% of the mothers stopped
exclusive breastfeeding their babies between zero and six
months due to not knowing how to breastfeed the babies
appropriately. Likewise, Sharmin et al. (2016) reported that
92.3% of mothers in Bangladesh who were in the non-
 Nguyen, N. T., Do, H. T., & Pham, N. T. V. (2021)
exclusive breastfeeding group using faulty breastfeeding
techniques led to poor suckling and attachment. In
Vietnam, the mothers with normal delivery will be
discharged from the hospital after two to three days; with
the short period, the mothers might not learn and absorb
the breastfeeding techniques provided by the hospital. In
fact, breastfeeding is a “learned skill”, more than instincts.
Thus, it is difficult to be successful in the breastfeeding
practice if the mothers have less knowledge and fewer
skills about breastfeeding techniques. Mothers in the
current study were new mothers who had no breastfeeding
experience before, and that is why lack of techniques in
breastfeeding was their concern as a barrier of
breastfeeding. Therefore, the teaching about
breastfeeding techniques for mothers during antennal care
visits is suggested for the hospital policy.
Last but not least, the fifth-highest score was the lack
of support from family (M = 2.45, SD = .89). The
Vietnamese mothers exposed this barrier as one of the
most common. Researches have proved that family
support played an essential role in the exclusive
breastfeeding practice of mothers. For instance, a study by
Yenti et al. (2018) revealed that mothers in Indonesia who
got family support for breastfeeding were 2.67 times
(95%CI [1.1, 6.4]) more likely to give exclusive
breastfeeding than those who did not have. Likewise,
another study in Yogyakarta, Indonesia, found that
mothers who received family support were 2.86 times
(95%CI [1.25, 6.58]) more likely to practice exclusive
breastfeeding compared to those who did not (Ratnasari et
al., 2017). Similarly, a study in Ethiopia reported that
mothers who were supported by their husbands were 2.67
times (95%CI [1.04, 6.95]) more likely to breastfeed
exclusively (Tewabe et al., 2016). Family plays a crucial
role in breastfeeding practice; thus, receiving support from
family was important during the breastfeeding period for
the mothers. Not surprisingly, lack of support from family
was perceived as one of the barriers of exclusive
breastfeeding practice.
The current study provides the picture of perceived
barriers to breastfeeding among mothers in Ho Chi Minh
City, Vietnam; it is a piece of the puzzle to complete the
picture of breastfeeding in Vietnam. In addition, it gives
some implications for nursing and midwifery practice as
mothers perceived they had insufficient milk and
breastfeeding techniques to feed their babies. Therefore,
nurses and midwives need to be with them in the first hours
and days after birth to build their confidence when
breastfeeding the babies. Also, nurses and midwives can
develop the nursing interventions, such as the
enhancement breastfeeding self-efficacy programs for
mothers and students to build and boost self-efficacy so
that the mothers or future mothers can confidently practice
reaching the six-month exclusive breastfeeding. The top
barrier perceived by mothers in this study was
uncomfortable when breastfeeding in public places. It
implies that the policy needs to have room for
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
176
breastfeeding in public places, such as hospitals,
restaurants, parks, cinemas, etc.
The data from this study were drawn from convenience
sampling; thus, the representativeness of this study was
limited. It evokes a recommendation for further research. A
cluster random sampling method should be used to obtain
a sample with the best representativeness for the entire
population in Vietnam. Besides, for comparison with the
current study, further research should be conducted with
the mothers in rural areas or other regions of the country
to capture a broader picture of perceived barriers to
breastfeeding practice in Vietnam.
Conclusion
The failure of exclusive breastfeeding practice in the first
six months was derived from the mothers’ perception of
different barriers. These barriers come from the three main
factors, including maternal, infant, and socio-environment
factors. The embarrassment, insufficient milk, baby’s
illness and irritating mood, lack of knowledge about
breastfeeding techniques, and lack of support from family
were the most perceived barriers. The investigations in this
study help nurses, midwives, and healthcare providers
identify the barriers that obstruct the exclusive
breastfeeding practice; hence, the breastfeeding
promotion program could be proposed and implemented to
improve the exclusive breastfeeding practice.
Declaration of Conflicting Interests
The authors declare that there is no conflict of interest in this study.
Funding
Funded by the University of Medicine and Pharmacy at Ho Chi
Minh City, Vietnam.
Acknowledgment
We thanked the University of Medicine and Pharmacy for
providing the fund for conducting this research. We also
acknowledged the experts for their valuable time to evaluate the
content of the questionnaire.
Authors’ Contribution
NTN made significant contributions to the literature review (review
of theory which can be applied in the study, recommendation from
WHO, policies of Vietnamese government about exclusive
breastfeeding, current situation of exclusive breastfeeding in
Vietnam), design of the study, data acquisition,
analysis/interpretation of the study. HTD and NTVP made
significant contributions to the literature review (review the benefits
of exclusive breastfeeding, the barriers of breastfeeding in other
countries and Vietnam), study design, data acquisition,
interpretation of the study findings. All authors drafted the
manuscript, revised it critically for important intellectual content,
approved the final version of the paper, and agreed to its
submission for publication.
Authors’ Biographies
Dr. Nhan Thi Nguyen is a Lecturer at the Midwifery Department,
University of Medicine and Pharmacy at Ho Chi Minh City,
Vietnam.
 Nguyen, N. T., Do, H. T., & Pham, N. T. V. (2021)
Huong Thi Do, MEd is Dean of Midwifery Department, University
of Medicine and Pharmacy at Ho Chi Minh City, Vietnam.
Nhu Thi Van Pham, MPH is a Former Lecturer at the Midwifery
Department, University of Medicine and Pharmacy at Ho Chi Minh
City, Vietnam.
Data Availability Statement
The datasets generated during and/or analyzed during the current
study are available from the corresponding author on reasonable
request.
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46/bnj.1382
Original Research
BNJ
Influence of self-esteem, Belitung Nursing Journal
Volume 7(3), 179-185
© The Author(s) 2021
psychological empowerment, and https://doi.org/10.33546/bnj.1424

empowering leader behaviors on

assertive behaviors of staff
nurses

Ryan Michael F. Oducado*

Abstract
Background: Being assertive is essential skill nurses need to learn and develop. While many studies exist on
nurses’ assertiveness, there is limited research on the factors associated with Filipino nurses’ assertive behaviors.
Objective: This study examined the correlation of self-esteem, psychological empowerment, and leader
empowering behaviors on staff nurses’ assertiveness in the workplace.
Methods: This cross-sectional study conducted in 2019 involved 223 staff nurses working in two tertiary hospitals
in the Philippines. Data were gathered using four validated self-reported scales: self-esteem scale, psychological
empowerment scale, leader empowering behavior questionnaire, and workplace assertive behavior questionnaire.
Correlational analysis using Pearson’s r was performed to test the relationship between the key variables.
Results: The composite scores for the self-esteem, psychological empowerment, empowering leader behaviors,
and workplace assertiveness were 32.06 (SD = 3.65), 4.22 (SD = 0.43), 3.86 (SD = 0.51) and 3.61 (SD = 0.55),
respectively. Self-esteem (r = 0.216; p = 0.001), psychological empowerment (r = 0.455, p = 0.000), and
empowering leader behaviors (r = 0.269; p = 0.000) were significantly correlated with staff nurses’ assertiveness in
the workplace.
Conclusion: Self-esteem, nurse leadership behaviors, and empowerment play vital roles in staff nurses’
assertiveness. Understanding the factors influencing nurses’ assertiveness is important, and looking into these
variables can be beneficial for nursing management when developing strategies to build nurses’ assertiveness.
Thus, it is vital to focus on helping nurses nurture healthy self-esteem and initiate empowering conditions at work
to aid nurses in setting healthy boundaries and supporting assertive behaviors at work.

Keywords
assertiveness; leadership; nurses; self-concept; workplace; Philippines

Assertiveness is the ability to express your ideas, interests,
thoughts, feelings, beliefs, and needs freely, clearly,
confidently, and honestly, without denying or violating
others’ rights (Alberti & Emmons, 2008; Oducado, 2021).
Assertiveness is an important skill that nurses must learn
to acquire and need to develop (Oducado, 2021;
Yoshinaga et al., 2018). With the advancements and
developments in healthcare, nurses are expected to exhibit
assertiveness to work with other health care professionals
effectively, thereby impacting positively patient safety and
outcome (Okuyama et al., 2014a). Being the largest
workforce in the hospital settings, nurses are uniquely
positioned to speak up for changes in the care plan of their
patients if they see it deemed necessary (Hall, 2016). In

West Visayas State University, College of Nursing, Iloilo City, Article Info:
Received: 15 March 2021
Philippines Revised: 16 April 2021
Accepted: 3 May 2021
Corresponding author:
Dr. Ryan Michael F. Oducado This is an Open Access article distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 International License, which allows
West Visayas State University, College of Nursing, La Paz, Iloilo others to remix, tweak, and build upon the work non-commercially as long as
City, Philippines, 5000 the original work is properly cited. The new creations are not necessarily
Email: rmoducado@wvsu.edu.ph licensed under the identical terms.

E-ISSN: 2477-4073 | P-ISSN: 2528-181X

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

179
 Oducado, R. M. F. (2021)
other words, nurses need to speak up or call the attention
of the healthcare team member when they see a problem
with regards to patient care, when standard processes are
not followed, or when improper practices are observed.
However, being assertive and speaking up can be
challenging for nurses, and that silence still prevails in
many nursing situations (Okuyama et al., 2014b; Rainer,
2015; Schwappach & Richard, 2018).
The importance of assertiveness in nursing cannot be
overemphasized. Firstly, assertiveness is necessary for
establishing a trusting nurse and patient relationship and
communicating effectively with patients and members of
the health team (Larijani et al., 2017; Mushtaq, 2018).
Assertiveness is required for openness to speak up, is
instrumental in ensuring patient safety, and is integral to
professional accountability (Nacioglu, 2016; Reid &
Bromiley, 2012). Additionally, nurses are ethically, morally,
and legally bound to question an inappropriate or incorrect
doctor’s order and speak up to protect patient’s rights and
safety (Rainer, 2015; Reuter & Fitzsimons, 2013). Patient
advocacy is an important nursing responsibility (Gerber,
2018). Nurses have the critical role as patient advocates,
serving as voices of their patients (Palatnik, 2016). The
State Practice Acts in other countries like the United States
of America mandate that nurses act as patient advocates
(Gerber, 2018). The Code of Ethics of Filipino Registered
Nurses explicitly states that nurses should take appropriate
steps to safeguard the rights and privileges of their patients
(Board of Nursing of the Philippines, 2004). Being assertive
means nurses are defending and safeguarding the rights of
their patients. Nurses have to be assertive enough to
preserve their rights as well as the rights of their clients
(Mushtaq, 2018). Lastly, assertiveness is a means which
can be used to combat negative and stressful situations like
mobbing, conflict situations, to communicate better, and to
enhance empowerment (Asi Karakas & Okanli, 2015;
Deltsidou, 2009).
Given the importance of assertiveness in nursing,
identifying variables that influence or promote
assertiveness is therefore necessary. Some prior studies
conducted elsewhere studied the factors affecting
assertiveness among nursing students (Ibrahim, 2011;
Larijani et al., 2017). Other scholars investigated the
effectiveness of assertiveness training on nurses (Asi
Karakas & Okanli, 2015; Kanade, 2018; Nakamura et al.,
2017; Shimizu et al., 2004; Yoshinaga et al., 2018) and
nursing students (Omura et al., 2019). Variables such as
self-esteem (Binuja, 2020; Maheshwari & Gill, 2015;
Shrestha, 2019) and psychological empowerment (Azizi et
al., 2020; Bostanabad et al., 2018; Ibrahim, 2011) were
found to be associated with assertiveness. However, for
most studies, these variables were correlated with general
assertiveness and not specifically with workplace
assertiveness of nurses. Studies have also shown that
leadership, managerial, and administrative support
influenced speaking-up and voicing behaviors (Darawad et
al., 2020; Lee et al., 2021; Okuyama et al., 2014a; Wong et
al., 2010), but the role of leader empowering behaviors on
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
180
assertiveness has not been investigated. Besides, the
studies earlier cited were conducted in other countries and
not in the context of Filipino nurses.
Although there has been growing research on nurses’
assertiveness abroad, there is a scarcity of published
research looking into the factors associated with nurses’
assertiveness in a generally collectivist culture like the
Philippines. In general, the Filipino culture and their Asian
counterparts are predisposed to be conformist, collective,
and group-oriented instead of individualistic and assertive
(Niikura, 1999). Assertiveness is frowned upon as it can be
suggestive of pride, and some Filipino traits work against it.
Alongside this backdrop, this study was conducted to
determine the influence of self-esteem, psychological
empowerment, and empowering leader behaviors on staff
nurses’ workplace assertiveness.
Methods
Research Design
A cross-sectional study design was adopted.
Sample and Setting
The participants were registered nurses with staff nurse
positions (N = 403) from two randomly selected tertiary
hospitals in the Western Visayas part of the Philippines.
Tertiary or teaching and training hospitals were chosen
since these hospitals had a greater number of nurses
compared to other hospital levels. The Slovin’s formula n =
N/(1+Ne2) cited in Almeda et al. (2010) was used to
compute the sample size yielding the desired sample size
of 201. Also, priori power analysis using G*Power 3.1
software suggested that a sample size of 84 staff nurses
would already be sufficient to achieve a statistical power of
0.80 in bivariate correlation analysis with 0.05 alpha and
0.30 medium effect size (Faul et al., 2009). However, to
enhance the geographical diversity per hospital unit or
department, the researcher included more than the desired
sample size. A total of 230 questionnaires were randomly
distributed and administered to staff nurses; 223
responded, obtaining a response rate of 97%. This study
only involved staff nurses. Nurses occupying supervisory
positions, trainees, volunteers, over 65 years old and
employed in other hospitals were excluded from the study.
Instruments
Data were gathered using four validated self-reported
scales used among nurses in studies conducted in other
countries. The authors of the scales granted permission to
use the instruments in the current study through email
correspondence.
Self-esteem Scale (SES) (Rosenberg, 1965). The 10-
item SES was used to measure nurses’ global self-worth.
Nurses were asked to rate each item using a 4-point scale
(1 = strongly disagree to 4 = strongly disagree). The SES
had a fairly acceptable internal consistency of 0.75 in
nursing samples (McMullen & Resnick, 2013) and 0.77
 Oducado, R. M. F. (2021)
among Filipino youths and adolescents (Reyes et al.,
2017).
Psychological Empowerment Scale (PES)
(Spreitzer, 1995). This 12-item scale with four subscales
(meaning, competence, self-determination, and impact)
was used to measure nurses’ psychological empowerment.
All items were answerable in a 5-point Likert scale format
(1 = strongly disagree to 6 = strongly agree). Studies
conducted among nurses reported fairly high Cronbach’s
alpha values of 0.80 and above (Shapira Lishchinsky &
Benoliel, 2019; Uner & Turan, 2010).
Leader Empowering Behavior Questionnaire
(LEBQ) (Konczak et al., 2000). This scale was
administered to measure staff nurses’ perception of the
empowering behaviors of their leader. The LEBQ by
Konczak et al. (2000) originally consisted of 17 items, but
Bester et al. (2015) recently added two items. The 19-item
version of the scale was utilized in this study, consisting of
six subscales: accountability for outcomes, self-directed
decision-making, information sharing, skills development,
delegation of authority, and coaching for innovative
performance. Nurses responded using a 5-point Likert
scale (1 = strongly disagree to 5 = strongly agree). The
LEBQ was previously pilot-tested among Filipino nurses
(Oducado, 2019). Konczak et al. (2000) reported reliability
coefficients that range between 0.82 and 0.88.
Workplace Assertive Behavior Questionnaire
(WABQ) (Timmins & McCabe, 2005a, 2005b). This scale
was utilized to assess nurses’ assertiveness in the
workplace. The participants were asked to indicate how
often they use the eight assertive behaviors towards their
nursing colleagues or co-staff nurses, the nursing
management (head nurses or supervisors), and the
medical personnel (doctors or physicians). Nurses were
asked to answer using a 5-point Likert scale (1 = never to
5 = always). Timmins and McCabe (2005a, 2005b) stated
an acceptable internal consistency (α = 0.88) of items
within the questionnaire.
For all the scales in this study, higher scores indicate a
higher level of self-esteem, psychological empowerment,
leader empowering behaviors, and assertiveness in the
workplace. The personal characteristics of nurses were
also collected.
To make sure that the result of this study will be
culturally sensitive and to increase its scientific accuracy,
the instruments were subjected to face and content
validation and pilot testing. Seven local experts with
master’s or doctoral degrees and relevant experience and
training in nursing, management, and psychology
evaluated the items in the instruments to be relevant, clear,
and culturally appropriate. A survey instrument validation
rating scale was used in the validation of instruments
(Oducado, 2020). Pilot testing was done among 30 nursing
staff in another hospital. Preliminary reliability testing and
actual survey revealed acceptable to high internal
consistency values of SES (α = 0.87, α = 0.71), PES (α =
0.88, α = 0.88), LEBQ (α = 0.91, α = 0.89) and WABQ (α =
0.95, α = 0.92). Five participants during the pilot test were
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
181
interviewed to share their comments about the instruments.
No further changes were made to the instruments as per
the acceptable result of pilot testing.
Data Collection
The survey was conducted between June to July of 2019.
Before actual data gathering, administrative clearance to
conduct the study was obtained from the Hospital Director
through the Director of Nursing. In coordination with the
Nursing Service Office, the researcher and trained data
gatherers distributed the survey instruments inside a
sealed envelope to staff nurses either before they go on
duty or after shift. Staff nurses were briefly oriented
regarding the purpose of the study, were allowed to ask
questions, and were given the opportunity to refuse to join
the study. The participants were asked to answer the forms
at their most convenient time and place and were asked to
return them sealed to the researcher or data gathers to
ensure confidentiality of responses. The researcher
allocated sufficient days for data collection to allow the
adequate representation of staff nurses despite shifting
schedules of staff nurses, and the participants were given
ample time to answer the survey. During retrieval, the
completeness of data entry was checked.
Data Analysis
After data checking and cleaning, the responses were
encoded and computer-processed via the IBM Statistical
Package for the Social Sciences (SPSS) software version
23. Frequency (n), percentage (%), mean (M), and
standard deviation (SD) were used to quantify and describe
the data. Kolmogorov-Smirnov (p = 0.20) and Shapiro-Wilk
(p = 0.31) indicated that data do not significantly deviate
from normal distribution. The Pearson’s r correlation
coefficient was used to determine the relationship between
the key variables of the study. The correlation coefficient
was interpreted following the work of Schober et al. (2018):
+ 0.90-1.00 = very strong positive (negative) correlation, +
0.70-0.89 = strong positive (negative) correlation, + 0.40-
0.69 = moderate positive (negative) correlation, + 0.10-0.39
= weak positive (negative) correlation, and + 0.00 to 0.10 =
negligible positive (negative) correlation. A p-value equal to
or less than 0.05 was considered the level of acceptable
significance.
Ethical Consideration
The study was reviewed and approved by the Ethics
Committee of the West Visayas State University. A written
informed consent form was obtained from all participants.
No personal identifiers were collected to protect the
anonymity of the participants and the confidentiality of the
data. This report is part of a larger study exploring Filipino
nurses’ assertiveness.
Results
Table 1 shows that the mean age was 32.34 years (SD =
8.14), and the average number of years of nursing work
 Oducado, R. M. F. (2021)

experience was 7.36 years (SD = 6.41). The majority were 110, 49.3%) hospitals. There were 126 (56.5%) staff
female (n = 153, 68.6%) and Bachelor’s degree holders (n nurses assigned in specialty areas and 97 (43.5%) in
= 150, 67.3%). There was an almost equal number of medical and surgical units.
participants from public (n = 113, 50.7%) and private (n =

Table 1 Profile of staff nurses

Profile Categories M SD n %
Age 32.34 8.14
Years of experience 7.36 6.41
Sex Male 70 31.4
Female 153 68.6
Education Bachelor’s degree 150 67.3
Bachelor’s degree with Master’s units 73 32.7
Type of hospital Public 113 50.7
Private 110 49.3
Hospital unit Specialty Areas 126 56.5
Medical and Surgical 97 43.5

Overall, the composite scores of the key variables in this Table 3 Correlation of independent variables to assertiveness
study were above midpoint (Table 2). The composite score
of nurses’ self-esteem was 32.06 (SD = 3.65), whereas the Independent variables Pearson’s p-value
correlation
composite scores of the measures of psychological
(r)
empowerment and leader empowering behaviors were
Self-esteem 0.216 0.001*
4.22 (SD = 0.43) and 3.86 (SD = 0.51), respectively.
Psychological Empowerment 0.455 0.000*
Assertiveness in the workplace had a composite score of Competence 0.434 0.000*
3.61 (SD = 0.55). Impact 0.412 0.000*
Self-determination 0.351 0.000*
Table 2 Description of the key variables Meaning 0.272 0.000*
Leader Empowering Behaviors 0.269 0.000*
Scales/Subscales M SD Accountability for outcomes 0.355 0.000*
Self-esteem 32.06 3.65 Delegation of authority 0.262 0.000*
Psychological Empowerment 4.22 0.43 Self-directed decision-making 0.200 0.003*
Meaning 4.51 0.50 Information sharing 0.192 0.004*
Competence 4.26 0.52 Coaching for innovative 0.173 0.010*
Self-determination 4.13 0.52 performance
Impact 3.97 0.58 Skills development 0.111 0.098
Leader Empowering Behaviors 3.86 0.51
Accountability for outcomes 4.07 0.63 Discussion
Self-directed decision-making 3.89 0.69
Information sharing 3.88 0.66
Skills development 3.87 0.73 The present study looked into the influence of self-esteem,
Delegation of authority 3.85 0.58 psychological empowerment, and leader empowering
Coaching for innovative performance 3.62 0.72 behaviors on nurses’ workplace assertive behaviors. This
Assertiveness in the Workplace 3.61 0.55 study demonstrated that self-esteem had a positive, weak,
Toward nursing colleagues 3.78 0.55 yet significant correlation with nurses’ workplace
Toward medical personnel 3.65 0.65 assertiveness. Healthy self-esteem is important to learning
Toward management personnel 3.40 0.68
to be assertive, or being assertive can lead to high levels of
self-esteem. Healthy self-esteem represents a critical asset
or necessary quality in developing assertiveness (Darjan et
The correlation between variables is presented in Table 3. al., 2020). It can be difficult for nurses to assert themselves
There was a positive, weak, significant correlation between when nurses have low self-esteem. Those with low self-
nurses’ level of self-esteem (r = 0.216; p = 0.001) and esteem are likely to encounter problems defending their
assertiveness and staff nurses’ perception of the opinions or making decisions for themselves (Darjan et al.,
empowering behaviors of their leaders (r = 0.269; p = 2020). Studies among Japanese and Indian nurses found
0.000) and assertiveness. Moreover, statistical analysis that nurses’ self-esteem improved after assertiveness
revealed a positive, moderate, significant correlation training (Kanade, 2018; Shimizu et al., 2004). Similarly, a
between psychological empowerment (r = 0.455, p = 0.000) significant positive correlation between assertive behavior
and assertiveness in the workplace. and self-esteem was reported in a study conducted in India
among nurses (Binuja, 2020; Maheshwari & Gill, 2015) and
in Nepal among nursing students (Shrestha, 2019). This

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

182
 Oducado, R. M. F. (2021)
study proposes that efforts should be made to improve and
to achieve healthy and balanced self-esteem among
nurses to better communicate and assert themselves in the
workplace.
This study also found that psychological empowerment
was significantly related to assertiveness in the workplace
with a moderate positive correlation. Results of the current
study also indicated a significant correlation between all the
components of psychological empowerment and workplace
assertiveness. This finding indicates that a higher level of
psychological empowerment, such as giving nurses the
authority to make decisions and enhancing their
competence, results in higher levels of assertiveness. This
finding is relatively consistent with that of the study of Azizi
et al. (2020) and Ibrahim (2011). The authors found a
significant positive relationship between psychological
empowerment and assertiveness with samples of
midwifery and nursing students in Iran and nursing students
in Egypt. A similar finding was reported among Iranian
neonatal nurses (Bostanabad et al., 2018). The result of
this study suggests the importance of empowering nurses
for them to act more assertively. Accordingly, it is
necessary to pay attention to improving nurses’
competence, independence, and autonomy, likewise
creating better opportunities for nurses to appreciate the
impact and value of their work for them to exhibit
assertiveness.
Finally, it was shown in this study that there was a
positive, weak, but significant relationship between leader
empowering behaviors and workplace assertiveness of
staff nurses. It has been disclosed that managerial and
organizational support enables nurses to become more
assertive, empowered, and speak up against unsafe
practices, and the process of becoming assertive or
learning to speak up tends to be influenced by the
management’s approach toward nurses (Darawad et al.,
2020). Garon (2012) likewise discovered that the strongest
theme for nurses to speak up was related to a climate of
openness that is generally created by the leaders
(managers and administration). The role of a supportive
working culture in facilitating nurses’ ability and willingness
to voice concerns was also noted in another study
(Mansour et al., 2020). Correspondingly, the study of Wong
et al. (2010) revealed that authentic leadership influenced
nurses’ trust in their manager, which predicted voicing
behavior. Review studies similarly noted that hospital
administrative support and attitude of leaders or superiors
were actors influencing health care professionals and
nurses’ speaking-up behavior for patient safety (Lee et al.,
2021; Okuyama et al., 2014a). The finding of this current
study indicates the valuable role of nurse leaders and
managers in supporting nurses to exhibit assertive
behaviors. Nurses tend or are likely to assert themselves
when assertive behavior is supported in the workplace. It
is, therefore, vital for the nursing management to set up
empowering conditions at work, such as increasing nurses’
accountability, autonomy, and self-directed decision-
making to support nurses’ assertive behaviors. In the
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
183
process of becoming more assertive, managerial and
organizational support should also be in place to grant
nurses the necessary power, autonomy, and access to
resources to exercise assertive behaviors (Darawad et al.,
2020).
Some shortcomings were encountered in this study that
could be addressed by future scholars. This research was
limited among nursing staff in two tertiary hospitals. Caution
is recommended when results of the present study are
extrapolated with all Filipino nurses and nurses working in
other countries and other healthcare sectors. It might be
useful to replicate the study on a larger scale involving
nurses from different countries. Another limitation is the
study design (cross-sectional) has temporal limitations and
cannot establish causality between the variables. The use
of survey questionnaires is subjected to self-reported bias.
Validating self-reported data through method triangulation
may be conducted in future studies. There may also be
other factors influencing nurses’ assertiveness, such as
personality and emotional intelligence not included in this
analysis. Nevertheless, this research has contributed to a
better understanding of the factors influencing nurses’
assertiveness in the workplace.
Conclusion
This research highlighted that higher levels of self-esteem,
psychological empowerment, and empowering behaviors
of the leader result in higher workplace assertiveness
among nursing staff. Nurse leadership behaviors and
empowerment play vital roles in staff nurses’ assertiveness.
The results suggest that empowered nurses are assertive
nurses. Also, helping nurses nurture healthy self-esteem
and improve their confidence can potentially lead to better
assertive behaviors in the workplace and assist nurses in
setting and maintaining healthy boundaries. Nurses’
evaluation of themselves and empowering conditions
significantly contribute to nurses’ assertiveness or their
chosen method of communicating with others in social
interactions. Understanding and looking into these factors
can help the nursing management develop strategies to
build and improve nurses’ assertiveness. Interventions and
necessary platforms aimed at enhancing nurses’ self-worth
should be initiated. At the same time, efforts must be
directed towards fostering greater empowerment at the
individual and organizational levels to promote
assertiveness in the workplace.
Declaration of Conflicting Interest
The author has no conflict of interest to declare.
Funding
This research received funding from the West Visayas State
University – University Research and Development Center.
Acknowledgment
The author would like to thank the Hospital Administration and
Nursing Directors for allowing the researcher to conduct the study
and all the staff nurses who participated in the study. The author
 Oducado, R. M. F. (2021)
would also like to express his gratitude to Dr. Hilda C. Montaño for
her guidance in the completion of this study. Lastly, the author
wishes to acknowledge the Philippine Commission on Higher
Education for the support awarded to the researcher.
Author Contribution
The author made a substantial contribution from the conception,
finalization, and writing of the final version of this article.
Author Biography
Ryan Michael F. Oducado, PhD, RN, RM, LPT is an Assistant
Professor at West Visayas State University, College of Nursing,
Iloilo City, Philippines.
Data Availability Statement
The datasets generated during and/or analyzed during the current
study are available from the corresponding author on reasonable
request.
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CIte this article as: Oducado, R. M. F. (2021). Influence of self-
esteem, psychological empowerment, and empowering leader
behaviors on assertive behaviors of staff nurses. Belitung
Nursing Journal, 7(3),179-185. https://doi.org/10.33546/bnj.
1424
Original Research
BNJ
Lived experiences of Overseas Belitung Nursing Journal
Volume 7(3), 186-194

Filipino Worker (OFW) nurses © The Author(s) 2021

https://doi.org/10.33546/bnj.1427

working in COVID-19 intensive care

units
Jane Marnel Pogoy and Jezyl C. Cutamora*

Abstract
Background: Limited studies focus on the effects of the pandemic on the nurses' overall risks and wellbeing. At
present, no single study has been published on Filipino nurses’ experiences outside the country during the COVID-
19 pandemic.
Objective: This descriptive phenomenological study explored the Overseas Filipino Worker (OFW) nurses’
experiences working in COVID-19 intensive care units.
Methods: The study was conducted in Dubai, United Arab Emirates, where there is a high number of COVID-19
cases. This study utilized a qualitative Husserlian phenomenological approach to describe and explore the lived
experiences of the OFW nurses’ caring for COVID-19 critically ill patients. The research key interview informants
were eight ICU nurses who cared for COVID-19 patients in Dubai hospitals. Data saturation was reached. Data
collection was done in 2020, and Collaizi’s method of data analysis was utilized.
Results: A total of 135 significant statements were extracted from the interview transcripts. There were 36
formulated meanings generated, and four themes emerged from this study. The first theme is Challenges During
the Pandemic with the following subthemes: Away from Home, Caring for the COVID-19 Patients, and Fear of the
Unknown. The second theme is Patient Care during COVID-19 with the following subthemes: COVID-19 ICU
Patient Care and The Nursing Profession. Third, Adapting to Change with the subthemes: Living the New Normal
and Protecting One’s Self from COVID-19. Lastly, Resilience Amidst the Pandemic with the following subthemes:
Being with Others and Seeing Oneself.
Conclusion: Despite the existing challenges like cultural differences and homesickness faced by these OFW
nurses and the new challenges they are faced with the pandemic today, they were still able to continue living and
do what is expected of them. From the hassle of wearing the PPEs, shortage of PPE, and being transferred from
one unit in the hospital to another, the OFW nurses were able to adapt to these changes. The nurses already got
used to the routine, but the fear of getting infected by the virus is still there.

Keywords
lived experiences; OFW nurses; COVID-19; intensive care units; hospitals; United Arab Emirates; patient care

According to the World Health Organization (WHO, 2020a),
COVID-19 is a highly transmissible disease caused by a
SARS-CoV 2 strain. Literature has shown that nurses need
to sacrifice their own needs to prioritize the crisis
management strategies and a need to make selfless and
significant contributions out of moral and professional
responsibility (Aliakbari et al., 2014). There are limited
studies focusing on the effects of the pandemic on the
nurses' overall risks and wellbeing. At present, no single
study has been published on Filipino nurses’ experiences
outside the country during the COVID-19 pandemic. Thus,
this descriptive phenomenological study will describe and

Cebu Normal University, Philippines Article Info:

Received: 16 March 2021
Revised: 18 April 2021
Corresponding author: Accepted: 3 May 2021
Jezyl C. Cutamora, PhD
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Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

186
 Pogoy, J. M., & Cutamora, J. C. (2021)
explore Overseas Filipino Workers (OFW) nurses working
in COVID-19 Intensive Care Units.
COVID-19 infection has quickly spread globally, and
due to the sudden outbreak, nurses are faced with a lot of
pressure and new challenges like being transferred to new
units or wards and adjusting to what is presently called the
new normal (Sun et al., 2020). Some studies have shown
that when nurses are caring for patients with highly
transmissible diseases such as SARS (Chung et al., 2005)
and MERS-Cov (Kim, 2018), nurses tend to suffer from
psychological issues such as loneliness, anxiety, fear,
fatigue, sleep disorders, and other physical and mental
health problems. A study found the prevalence rate of
psychological effects among nurses involved in the
treatment of infectious disease (such as SARS patients),
namely: depression at 38.5%, insomnia at 37%, and post-
traumatic stress at 33% (Sun et al., 2020). Furthermore,
among the psychological status of Ebola patients’
caregivers, 29% of respondents felt lonely, and 45%
received psychological counseling. On the contrary, the
positive experience and growth brought by the collective
anti-epidemic efforts were also demonstrated (Sun et al.,
2020).
Presently, many studies are published on how the
COVID-19 pandemic has strained the world’s healthcare
systems that include nurses. As cited by Mo et al. (2020),
among the healthcare workers, nurses are found to be the
most anxious and stressed in caring and treating patients
infected with the COVID-19. Nurses who provided direct
patient care seemed to be more stressed, overworked, and
psychologically disturbed and less fulfilled in their job
compared to nurses in other areas of assignment (Zerbini
et al., 2020). Hospital women nurses who performed
diagnosis, care, treatment, and management of patients
with COVID-19, have shown psychological disturbances
such as anxiety, lack of sleep, and depression (Lai et al.,
2020).
For many years, Filipino nurses have been migrating
abroad to meet the very high demand in other countries.
The Philippine Overseas Employment Administration
estimates more than 13,000 health care professionals
leave the country every year. Many Filipino families view
the nursing profession as their ticket to a better life earning
15 times more than their salary while working in our local
hospitals (Lorenzo et al., 2007). As other countries have a
shortage of nurses, they began hiring Filipino nurses
because it is more cost-effective than training their own
nurses (Lorenzo et al., 2007). With Filipinos being fluent in
English, innately caring for the elderly and the sick, being
adept in adjusting to new cultures and learning new
languages, and not minding working longer hours, they
perfectly fit the bill for nursing.
The ongoing COVID-19 pandemic poses great
pressure, most especially in the critical care areas due to
the large number of patients requiring critical care (Shang
et al., 2020). As observed, Filipino nurses assigned in these
areas face a lot of struggles in managing these critical
patients in terms of implementing new practices, frequent
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
187
changes in the medical and nursing management, and the
virus is not readily studied yet. On top of the mentioned
challenges, these nurses also are worried about their
families in the Philippines, adjusting to the environment,
interacting with people with different cultures, and so much
more.
Overseas Filipino Workers (OFW) nurses are already
faced with challenges every day, especially because they
are working away from their country. They worry about their
safety while working and at the same time worry about their
families back at home. A lot of changes have been
implemented in the hospital to address staffing problems.
Some of the nurses are being pulled out to other units, and
leaves were canceled. In this time of the pandemic, they
are forced to find means to adapt to the present situation.
As nurses are placed in demanding situations, fulfilling their
roles on the frontline while at higher risk just to save others,
this study will explore and describe the lived experiences of
the OFW nurses working in COVID-19 Intensive Care
Units. This study can help hospital administrators and
government agencies understand the situation of OFW
nurses and serve as a basis for them to develop new or
revised policies that are beneficial to the welfare of the
nurses and the patients.
Methods
Study Design
This study utilized the qualitative Husserlian
phenomenological approach to describe and explore the
meaning of OFW nurses’ lived experiences caring for
critically-ill patients with COVID-19. Descriptive
phenomenology was used for it has laid the foundation for
theoretical knowledge and methodological clarity and rigor
in qualitative nursing research Abalos et al. (2016) and
Norlyk and Harder (2010). Husserlian phenomenology
allows the researchers to explore and describe the
structures of consciousness as experienced from the first-
person point of view.
Key Informants
The key informants are OFW nurses assigned in the
COVID-19 intensive care units and interviewed at their
houses and hospitals. The researcher used purposive
sampling in choosing the participants or key informants of
this study. Purposive sampling is a strategy selected that
will give information necessary for the needs of the study
(Polit & Beck, 2017). In this study, the research participants
were eight ICU nurses who cared for COVID-19 patients in
Dubai hospitals. Exclusion criteria of the study included the
unwillingness to participate in the study and nurses with a
COVID-19 diagnosis.
Data Collection
The main instrument of this study is the researchers, as
cited by Polit and Beck (2017). This highlighted the role of
the researcher during interviews and observations. An
English and vernacular semi-structured interview guide
 Pogoy, J. M., & Cutamora, J. C. (2021)
made by the researcher was utilized and expert-validated.
The language used was based on informants’ preference.
This interview guide comprises three parts: warm-up
questions, main questions, and follow-up or probing
questions. Sample grand tour question is “Can you
describe to me your experiences as a Filipino nurse caring
for patients with COIVD-19 in ICU in another country?”.
Probing was done to encourage the respondents to give
more information. Probes were neutral to avoid bias. Open-
ended questions were used to provide the respondents with
ample opportunity to express their feelings.
Prior to starting the interview, bracketing was done. This
is important to mitigate the preconceptions or biases that
may taint the research process. During the interview, the
standard COVID-19 safety protocols were followed.
Important aspects of the research were explained and
discussed with the key informants, such as the use of a
tape recorder, the interview venue, and the time that can be
devoted to the interview. Then informed consent was
obtained from the key informants. The researcher remained
neutral throughout the interview process. The researcher
started the interview with the list of semi-structured
interview questions the researcher has prepared through
one-on-one, face-to-face interviews. The average interview
duration was one hour and 30 minutes and was duly
recorded. The interview was conducted by JMP, spending
one day per informants. Translation and back-translation
with the help of a language expert were done to ensure the
accuracy of the translation.
Data Analysis
Colaizzi’s method of data analysis is deemed most fitting
and was utilized. This method uses components of
Husserlian phenomenology, putting a premium on the
description of the lived experience (Morrow et al., 2015).
Colaizzi’s method of data analysis consists of seven steps.
The first is to read and re-read all the participants’ verbatim
transcripts of the phenomena to acquire a feeling. Second,
significant statements or phrases are extracted from
participants’ transcripts pertaining directly to the research
phenomena. Then, formulated meanings are constructed
from the significant statements. Fourth, formulated
meanings are arranged into cluster themes which evolve
into emergent themes. Then the results were incorporated
into a rich and exhaustive description of the lived
experience. Sixth, the thorough description from the
participants involved in the research was validated. Lastly,
new or pertinent data obtained from participants’ validation
was incorporated and adapted to attain congruence with
the lived experience of the participants studied. This study
is rooted in the phenomenological framework to explore the
OFW ICU nurses’ experiences in caring for the COVID-19
patients to develop a composite description of the essence
of the experience for all the participants. Data was collected
and analyzed using the steps from Colaizzi’s descriptive
phenomenological method. Significant themes and
meanings were interpreted through rigorous analysis of
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
188
data to formulate the composite findings for this research
study.
Rigor of the Study
Multiple semi-structured interviews per informant were
done in different time-points to facilitate qualitative research
rigor. To enhance the trustworthiness of this study, the
following steps were done. First, person triangulation was
done where auxiliary informants confirmed the statements
made by the key informants or participants. Other
colleagues not included in the key informants were also
interviewed for confirmation of the key informants’
statements. The second is time triangulation, where the
same questions were asked at different time points during
the interview. Lastly, method triangulation wherein aside
from multiple individual interviews, observation was done
by the researcher to confirm statements and the
researcher’s reflection. Observations were done by looking
at the congruency of the verbalizations and the facial
expressions and non-verbal cues.
Ethical Consideration
The researcher assures that the study adhered to the basic
ethical considerations. The COVID-19 safety protocols
were implemented throughout the research process. The
data gathering was done after the participants were
informed of the purpose of the study and have provided
informed consent. It was made clear to the OFW COVID-
19 ICU nurses that their participation is voluntary and that
they can choose not to complete the interview without any
consequence. Further, the participants were informed of
their anonymity and that the data provided will be kept
confidential. This study was reviewed and approved by
Cebu Normal University – Ethics Review Committee with
an approval code of 606/2020-11.
Results
Characteristics of Key Informants
Table 1 shows the profile of the informants of the study,
including the code name, age, sex, civil status, and length
of time they were working in the COVID-19 ICU. It shows
that the informants are between 28 and 32 years old, and
most are married. The shortest length of time they spent in
the COVID-19 ICU is six months, and the longest is 11
months. They are all registered nurses. Some are master’s
degree holders.
Thematic Analysis
A total of 135 significant statements were extracted from
the interview transcripts from the eight informants. There
were 36 formulated meanings generated from these
significant statements, and four themes emerged from this
study. The first theme is Challenges During the Pandemic
with the following subthemes: (a) Away from Home, (b)
Caring for the COVID-19 Patients, and (c) Fear of the
Unknown. The second theme is Patient Care during
COVID-19 with the following subthemes: (a) COVID-19 ICU
 Pogoy, J. M., & Cutamora, J. C. (2021)
Patient Care and (b) The Nursing Profession. Third,
Adapting to Change with the subthemes: (a) Living the New
Normal, and ( b) Protecting One’s Self from COVID-19.
Lastly, Resilience Amidst the Pandemic with the following
Table 1 Profile of the Informants
Code Name Age Sex
SN01 29 Female
SN02 29 Female
SN03 29 Male
SN04 30 Female
SN05 32 Female
SN06 32 Female
SN07 31 Male
SN08 28 Male
Theme 1. Challenges During the Pandemic
This discusses the problems faced by the key informants
assigned in COVID-19 ICUs during the pandemic.
According to Sadang (2020), the COVID-19 health crisis
caused an unforeseen paradigm shift in nurses’ life in
healthcare systems, resulting in stressful and
overwhelming challenges in their daily battle against this
illness.
Subtheme 1. Away from Home
This is about the challenges faced by the key informants
working abroad. It includes the feeling of homesickness,
being away from the family, the cultural differences that
they have observed, and the cancellation of plans due to
the pandemic.
SN01 stated that SS2 “Aside from that, being a nurse overseas
means being away from your family and loved ones, so you
miss out on special occasions and holidays.” She added that
“Uhmm, actually church wedding namin dapat ng husband ko
but because of this travel ban, di natuloy.” (Because of this
travel ban, my church wedding was postponed).
SN04 also mentioned that SS39 “Di naman nawawala yung
pagiging homesick” (Homesickness is always there) and
added, “Miss ko na anak ko” (I miss my child).
SN07 mentioned that SS95 “Pero di gihapon mawa ang
kamingaw uy samot nag close jud kaayo mos imong family.”
(But the feeling of missing your family is always there,
especially if you have a close relationship with them).
Lastly, SN08 said SS19 “Kanang homesickness ug cultural
differences given naman.” (Homesickness and cultural
differences are given).
The issue of homesickness has not been addressed by
international human resource management for a long time.
Despite the recognition in the literature that expatriates go
through the critical issue of adjustment (Haslberger et al.,
2014) triggers the feelings of disconnection and missing
home and has been a not-easy-to-achieve situation (Ward
et al., 2001).
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
subthemes, (a) Being with Others and (b) Seeing One self.
These themes will be discussed further in the following.
Civil Status Length of time Working in COVID-19 ICU
Married Eight months
Married Six months
Single Ten months
Married Six months
Married Six months
Married 11 months
Single Seven months
Married 11 months
Subtheme 2. Caring for the COVID-19 Patients
This discusses the concerns faced by ICU nurses
assigned to care for COVID-19 patients. This includes the
hassle of wearing personal protective equipment (PPE),
feeling of anxiety of possibly getting infected, not meeting
the standards of care, and thinking about their families back
home worrying about their safety.
According to SN01, SS4 “At first, I was very anxious to handle
COVID-19 positive patients because I was worried that I might
also contract the disease.” SN03 also stated that “Mas kapoy
lang sad ang sa COVID-19 kay mag PPE kag taas na time.”
(It’s more tiring in COVID-19 units because you have to wear
PPE for a longer period).
SN05 said, SS60 “Naa baya koy newborn sa balay nya
simbako matakdan ko ig duty.” (I have a newborn at home, and
I’m scared to get infected). She also added that “Kapoy pud
kay the usual na daghan na layers na PPE, init kaayo maski
aircon pa. Then if naay procedures sa bedside, lisod pud kay
di kaayo ka kaklaro tungod sa face shield.” (It’s tiring because
of the PPE. It feels really hot wearing them even with the air
conditioner. If there are bedside procedures, it is difficult
because you can’t see properly because of the face shield).
Lastly, SN07 verbalized that SS100 “Hadlok ko uy sa akong
safety.” (I was scared for my safety).
Front-line nurses experience an enormous amount of
work, long-term exhaustion, infection risk, and frustration
with the death of patients they care for. They also face
anxiety or even disagreement among patients and their
family members (Shen et al., 2020).
Subtheme 3. Fear of the Unknown
This tackles the fears of the informants regarding the
disease, the unpreparedness for this pandemic, and the
uncertainty of the future.
SN01 stated that SS5 “Also, it is a new illness so little is known
about the virus, its transmission and effects on different types
of people.”
189
 Pogoy, J. M., & Cutamora, J. C. (2021)
SN02 verbalized that, SS20 “Kuyaw pud kay mas higher imong
chance ma infect unya handtud karon, wala pay mga certain
treatment jud na makaingon kag effective jud plus if ever,
simbako, matakdan ka, layo pa jus imong family.” (It is risky to
get infected because until now there is no certain effective
treatment, and if ever you get infected, you are very far from
your family).
According to SN03, SS34 “In some aspects siguro kay diri sa
UAE naa man jud silay disaster plan and kani na pandemic
considered man na disaster but for sure di jud emotionally
prepare ang tanan.” (In some aspects, because here in the
UAE, they really have a good disaster plan and this pandemic
is considered to be a disaster but one thing is for sure, we are
not all emotionally prepared).
SN04 said, SS42 “Mahirap kasi wala naman talagang
nakapagprepare for this pandemic.” (It’s hard because nobody
was really prepared for this pandemic).
The current COVID-19 pandemic presents a
considerable occupational vulnerability for the health care
team, causing fear or anxiety. These can be brought about
by knowing or having more information and fear of the
unknown related to the virus (Coelho et al., 2020). Fear of
the unknown appears to be a fundamental fear and is a
core component of anxiety (Carleton, 2016; Gallagher et
al., 2014).
Theme 2. Patient Care During COVID-19
Averting a nosocomial outbreak of COVID-19 through
transmission from patients to healthcare workers is
essential. New and improved policies have been
implemented to protect the healthcare worker and the
patient. This section discusses about the changes in the
care provided to the COVID-19 patients and the roles and
responsibilities of nurses.
Subtheme 1. COVID ICU Patient Care
This tackles about the care provided to the COVID-19
ICU patients in comparison to non-COVID-19 ICU patients.
This also includes the support given by the nurses to the
patients.
According to SN01, SS6 “Sa COVID-19 positive patients, mas
clustered yung care na binibigay sa kanila.” (In COVID-19
patients, we provide clustered care). She also added that SS7
”Dapat as much as much as possible, ilessen yung time sa
loob ng patient’s room, to lessen also your exposure.” (As
much as possible, we spend less time inside the patient’s room
to lessen our exposure).
SN02 mentioned, SS24 “Ipafeel nako nila na makarely sila
nako sa scariest time sa ilang life.” (I will let them feel that I am
there at the scariest part of their life).
SN05 verbalized, SS71 “Ang ako lang is ikeep nako in mind na
atimanon lang jud sila ug tarong. Mo empathize lang jud ta
nila.” (I keep in mind to properly take care of them. We should
empathize with them).
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
190
SN07 said, SS102 “And kailangan sad jud tas mga patients
especially karon.” (And the patients need us especially
nowadays).
Although nursing care of patients with COVID-19 is
largely supportive, it should include a strong emphasis on
alleviating the spread of contamination to staff, other
patients, and the community (Deitrick et al., 2020). The first
priority of any nurse should be to protect themselves with
the appropriate PPE. Nursing care should focus on limiting
the exposure and spread of the virus. The whole
experience of COVID-19 infection, in the form of staying in
isolation wards, could be very traumatic, even for patients
who are minimally symptomatic or asymptomatic (Sahoo et
al., 2020). It is important to provide support to these
patients, especially during this time.
Subtheme 2. The Nursing Profession
Nurses are very valuable in the healthcare systems and
are crucial to health promotion, disease prevention, and
treatment (Robertson-Malt, 2020). The World Health
Organization (WHO, 2020b) considers nurses and
midwives as the cornerstone in helping countries meet their
commitments to Universal health coverage.
SN03 stated that SS38 “It also made me realize how noble the
nursing profession is, and I am proud that I have pursued it.”
SN04 mentioned SS58 “Also, dapat din natin alagaan sarili
natin para mafulfill natin ang ating duty.” (We need to take care
of ourselves to fulfill our duties).
SN05 verbalized, SS61 “Worried kaayo ko all the time pero
unsaon ta man, part man nis atong trabaho.” (I am worried all
the time but this is part of our job).
SN07 said, SS117 “And kita nurses di ta dapat moundang ug
educate sa mga taw and should lead by example.” (And we
nurses should not stop educating the others and should lead
by example).
Nurses are usually in the front line of care. They make
a difference in individual patients’ lives and the community
as a whole. Due to their sheer numbers and the locations
where they often work, nurses are key players in improving
public health outcomes around the world (Robertson-Malt,
2020).
Theme 3. Adapting to Change
Change is inevitable, but a drastic one has happened
during this pandemic. The way we live nowadays is
different, and people around the world are starting to adapt
to these changes. But until a safe and effective coronavirus
vaccine is available, there will always be a risk of infection,
especially now that people are starting to go back to work.
Businesses are re-opening, and classes at some schools
were resumed. This part discusses about the present
situation, adjustments made, and self-protection.
 Pogoy, J. M., & Cutamora, J. C. (2021)
Subtheme 1. Living the New Normal
This talks about the experiences of the key informants
with our present situation in this time of the pandemic.
SN03 stated, SS33 “Sauna mogreet with a smile jud kas imong
patients, tabi sa mga kauban, party2x, but karon? Di ka
kastorya sa uban without a mask and social distancing.”
(Before, we used to greet the patients with a smile, talk with
our colleagues and attend parties. But now, we can’t even talk
with others without a mask and social distancing).
SN04 said, SS51 “Wala na din kasi masyadong gala sa labas.”
(We don’t go out that much anymore).
SN05 verbalized, SS77 “Then mask jud bisag asa kay aside
sa protection sa imong self, makabayad tag fine.” (We wear
the mask all the time not only to protect ourselves but also to
avoid paying the fine).
SN06 mentioned about always wearing a mask, SS85
“Wearing a mask is part of my outfit every day since it is now
mandatory.”
Ever since the WHO declared this pandemic, we were
forced to change the way we live. According to the Centers
for Disease Control and Prevention (2021), we have to
practice physical distancing, wearing masks all the time,
and doing hand hygiene all the time to help prevent the
spread of infection. These practices were followed by the
key informants.
The present pandemic pushed the key informants to
look for ways to connect with their families in the Philippines
even if they are far from them and discover new activities
while staying at home most of the time.
SN02 said, SS25 “Ngita jud ug paagi na connected gihapon mi
despite sa distance.” (We find ways to stay connected despite
the distance).
SN03 stated, SS36 “Physical activities and constant
communication lang jud with the family.” (Physical activities
and constant communication with the family).
SN04 verbalized about adjusting to the present situation, SS45
“Ngayon, nakapag adjust naman na.” (I have adjusted now).
She also added that she got more attached to her family, SS48
“Mas attached ako sa kanila ngayon. Sila kasi yung source of
inspiration ko at strength.” (I’m more attached to them now
because they are my source of inspiration ang strength).
SN05 mentioned about constant communication, SS65 “Video
call video call lang kada adlaw.” (We just call each other
through video call every day). She also mentioned, “Kailangan
sad jud mo adapt.” (We need to adapt).
SN07 stated, SS94 “Pero naanad ra sad kadugayan.” (But I
got used to it eventually).
Due to the present situation, the key informants looked
for alternative ways to connect with their families in the
Philippines using different platforms for this will give them
strength while working abroad. They also did more
enjoyable activities with their friends in their respective
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
191
residences or accommodation to pass the time and
verbalized that they have already adjusted to the present
situation.
Subtheme 2. Protecting One’s Self from COVID-19
The following statements made by the key informants
are indicative of ways on how to protect themselves from
being infected with COVID-19.
SN01 stated, SS17 “Aside from religiously drinking vitamins
and minerals, during this pandemic, I sanitize everything that I
brought outside including bags, cards, and cell phone.” She
also added, SS18 “Every after duty, I make sure to take a bath
and disinfect properly the uniform I used in the hospital as well
as clothes worn outside of the accommodation.”
SN04 mentioned, SS54 “As much as possible, healthy diet na
din to boost my immunity.” (As much as possible, I make sure
to have a healthy diet to boost my immunity).
SN07 said, SS116 “Di nato itake for granted ang policies to
prevent infection.” (We should not take for granted the policies
to prevent infection).
Lastly, SN08 stated about the value for health and having a
healthy lifestyle, SS131 “Mas givalue nako akong health ron.
SS132 Di na ko magsmoke. SS133 Maningkamot ko ug tug
jud at least 8 hours a day, and magstart nag kaon ug
vegetables.” (I value my health more. I don’t smoke anymore.
I try to sleep at least 8 hours a day and started eating
vegetables).
According to WHO (2020b), good nutrition and
hydration are very important. People who eat a well-
balanced diet be likely to be healthier with stronger immune
systems and reduced risk of chronic illnesses and
infectious diseases. As mentioned by the key informants,
they are doing steps to protect themselves from the virus
by observing health protocols and boost their immune
systems.
Theme 4. Resilience Amidst the Pandemic
Resilience is an extensive concept that encompasses
individual and social resources to thrive from challenging
circumstances (Callueng et al., 2020). Because Filipinos
often experience different calamities and disasters, they
remain resilient and seemingly immune to such
circumstances (Ang & Diaz, 2018). The current pandemic
arises numerous psychological stressors due to health‐
related, social, economic, and individual consequences
and may cause psychological distress (Petzold et al.,
2020). Strategies such as keeping a healthy lifestyle and
social contacts, recognizing anxiety and negative emotions,
and nurturing self‐efficacy may help with these stressors
(Petzold et al., 2020). Having a good support system and
being more positive and appreciative is helpful for OFWs to
be more resilient in this time of the pandemic.
Subtheme 1. Being with Others
This section discusses the key informants’ support
system, including their relationship with their colleagues
 Pogoy, J. M., & Cutamora, J. C. (2021)
during the pandemic and how this helped maintain their
positive attitude despite being away from home.
SN01 stated about the bond with her colleagues, SS12 “Uhmm
mas nagkabonding kami ng workmates ko actually kasi same
same kami ng sentiments regarding this pandemic.” (We
bonded more with my colleagues because we share the same
sentiments).
SN02 mentioned about teamwork, SS26 “Mas givalue namo
ang teamwork and mas gaan ang trabaho if magtinabangay.”
(We value teamwork more because it makes out work easier).
She also added, SS27 “Mas mofocus ta sa positive kaysa
negative.” (We focus more on the positive than the negative).
SN04 stated about doing activities together with the colleagues
who live with her, SS50 “Sa flat naman, mas nagkaroon kami
ng time magbonding kasi most of the time nasa flat lang talaga
kami kapag walang duty.” (In our flat, we bonded more
because we spend more time together during our days off).
SN07 also shared the same sentiments about doing activities
with his flatmates,
SS12 “Aw duwa mig video games sa flat.” (We play video
games in the flat).
SN 05 said, SS75 “Kita ra sad juy magsinabtanay ug
magtinabangay.” (We understand and help each other).
The ICU is a stressful work environment. Nurses are
experiencing exposure to workplace stress, verbal and
physical hostility, burn-out, moral distress, circadian rhythm
disruption, and depression (Shaw, 2015). The stressful
work environment leads to low-quality nursing care.
Teamwork and collaboration prevent errors and promote
healthy work environments (Shaw, 2015), which was also
experienced by the key informants.
Subtheme 2. Seeing Oneself
This section discusses the realizations of the key
informants, including being more appreciative and giving
importance to life.
SN02 stated that, SS29 “I learned to be more appreciative of
what I have and what really matters.”
SN04 verbalized, SS57 “Narealize ko na life is short, dapat
itreasure natin ito.” (I realized that life is short and we should
treasure it).
SN05 shared the same opinion, SS78 “One, life is short.”
SN08 mentioned about appreciation, SS134 “Ug nalearn sad
diay nakog appreciate ang little things.” (I learned to appreciate
the little things).
According to a survey conducted by the National
Research Group, roughly 90% of the respondents say that
the COVID-19 pandemic “is a good time to reflect on what’s
important to them” (Olin, 2020). The experiences of the
OFW nurses made them realize the value of life that they
have to cherish and appreciate.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
192
Discussions
OFW nurses face a lot of challenges every day, even before
this pandemic started. ICU nurses have to take care of
critically ill patients and are required to be mentally,
emotionally, and psychologically prepared every time they
go to work. When the pandemic started, these OFW ICU
nurses were being pulled out from their respective units and
transferred to the COVID-19 ICU. New protocols were
implemented, adjustments were made, relationships with
the colleagues were stronger, and slowly, resilience was
built with each other’s support. For the key informants,
these situations are very difficult for them.
Challenges during the pandemic discuss the problems
faced by the OFWs nurses being far from their homes, the
issues they encountered when they were transferred to the
COVID-19 ICU, and the fear of the unknown. Even before
the pandemic started, these nurses were already faced with
the problems of adjusting to a different culture, language
barrier, and homesickness. At present, they are faced with
additional problems like being unable to go home because
their leaves were canceled. One informant also mentioned
about her wedding ceremony being postponed because of
this. Aside from these personal modifications, there are
also changes in the workplace settings.
The key informants were then transferred to the COVID-
19 ICU because the number of COVID-19 patients needing
their care increased. They expressed their feeling of anxiety
about being in the new unit and anxiety about contracting
the disease. They also expressed the hassle of wearing
many layers of PPE for long periods. Aside from this, they
also mentioned about having a shortage of PPE. The major
issues facing nurses in this situation are the critical scarcity
of nurses, beds, and medical supplies, including personal
protective equipment, as reviews indicate, psychological
fluctuations and fears of infection among nursing staff
(Al Thobaity & Alshammari, 2020). According to the key
informants, the quality of care given to the COVID-19 ICU
patients was not meeting the standards because they are
spending less time inside the patient’s room to limit their
exposure. As one informant has mentioned, they are not
turning the patients to sides to release back pressure as
often as the patients in the non-COVID-19 ICU.
Furthermore, another challenge the COVID-19 ICU
nurses were facing is the fear of the unknown. During the
time of the interview, there is little information on the
management of the disease. They also expressed the
feeling of uncertainty about the future. An American Nurses
Survey of more than 30,000 nurses reported that 87% of
nurses are very or somewhat afraid to go to work, 58% are
highly concerned about their personal safety, and 55%
about caring for a COVID-19 patient or person suspected
of having the virus (American Nurses Association, 2020).
In addition, the difference in the care of patients in the
COVID-19 ICU was also stated. Clustering of care is done
to limit exposure. The nurses also verbalized to provide
support to their patients, especially during these times. The
importance of nursing as a profession was also realized by
 Pogoy, J. M., & Cutamora, J. C. (2021)
the nurses. They were reminded of their roles and
responsibilities as a nurse and how noble the nursing
profession is. Some expressed that they are just doing what
they have to do because it is part of their job.
With all of these, being adaptive to change helped these
nurses to cope with the present situation. The new normal
when going out includes the wearing of a mask every day
and observing physical distancing. On their days off, they
mostly stay at home. Adjustments have been made for the
current situation. They expressed about staying connected
with the family, and time spent communicating with them
through video calls has increased. After how many months
of being assigned in the COVID-19 ICU, they have already
made necessary changes to adjust to the present situation.
With the ongoing pandemic, it is important to protect
one’s self. Measures to protect one’s health were done like
taking a bath more than usual, having long hours of sleep
and rest, and having a healthier lifestyle. The nurses also
verbalized that they value health now more than ever. That
this also helps building resiliency among them.
Building resilience is possible with the presence of a
support system. The presence of the nurse’s friends as
their second family helped them a lot. Closer bonds with
their colleagues and workmates were formed through
teamwork and doing activities together at home. Having a
more positive outlook also helped them during this
pandemic. Furthermore, the nurses realized the value of life
and how it should not be taken for granted. They also
learned to be more appreciative of the little things they
have.
Lastly, the government and policymakers can possibly
look into the situation of Filipino nurses in their country.
They are currently anxious because they cannot take their
leave or spend their vacation in the Philippines, even during
their end of the contract periods. This factor adds up to their
uncertainty abroad while they are practicing nursing in ICU
amidst pandemics. According to Garcia et al. (2018), the
Filipino culture is one of the main factors on why they have
qualms in working away from their home. However, living
here also means challenges in terms of compensation.
Despite this, true-blooded Filipinos are willing to sacrifice
for the family.
The limitation of the study includes focusing only on ICU
Filipino nurses. Future studies could explore other target
populations. Furthermore, the protection of these nurses is
highly important to be explored by policymakers, and
Philippine Nurses Association, and other relevant
agencies. Providing them with enough PPE could help
lessen the stress they feel being assigned in the COVID-19
ICU. Although the nurses were able to adapt to the present
changes, it is highly suggested to provide an avenue for
them to voice their concerns and make them feel that
support is there from the management. There was no
mention from the interviews about any compensation or
support done by the management.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
193
Conclusion
Despite the existing challenges like cultural differences and
homesickness faced by these OFW nurses and the new
challenges they are faced with the pandemic today, they
were still able to continue living and do what is expected of
them. From the hassle of wearing the PPEs, shortage of
PPE, and being transferred from one unit in the hospital to
another, the OFW nurses were able to adapt to these
changes.
Up until now, the travel ban and cancellation of vacation
leaves are still implemented. These nurses found ways to
be connected with their families through frequent video
calls through the internet. The nurses already got used to
the routine, but the fear of getting infected by the virus is
still there.
Support from peers and a positive outlook were also
helpful to build resilience. They also learned to value life
more and be more appreciative. All of these imply that OFW
ICU nurses are resilient as they did their duties
professionally and that comprehensive support be provided
to safeguard their wellbeing as they continue making their
significant contributions out of moral and professional
responsibility in taking care of the COVID-19 patients.
Declaration of Conflicting Interest
No Conflict of Interest.
Funding
None.
Acknowledgment
We thanked Cebu Normal University, College of Nursing,
Philippines.
Authors’ Contribution
JMP is the lead author from the conceptualization, formulation, and
finalization of the research paper. JCC contributed significantly to
the conceptualization, formulation, critiquing, and completion of the
research paper. All authors agreed with the final version of the
article.
Authors’ Biographies
Jane Marnel Pogoy, RN is a Graduate Study Researcher of Cebu
Normal University, Philippines.
Jezyl C. Cutamora, PhD is a Director of Research Institute for
Ageing and Health, a Vice Chair of Ethics Review Committee, and
a Department Chair at the College of Nursing of Cebu Normal
University, Philippines.
Data Availability Statement
The datasets generated during and/or analyzed during the current
study are available from the corresponding author on reasonable
request.
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Lived experiences of Overseas Filipino Worker (OFW) nurses
working in COVID-19 intensive care units. Belitung Nursing
Journal, 7(3), 186-194. https://doi.org/10.33546/bnj.1427
Original Research
BNJ
Symptom experience of adverse Belitung Nursing Journal
Volume 7(3), 195-202

drug reaction among male and © The Author(s) 2021

https://doi.org/10.33546/bnj.1337

female patients with newly

diagnosed pulmonary tuberculosis
in Thailand
Apichaya Thontham and Rapin Polsook*

Abstract
Background: Patients with newly diagnosed pulmonary tuberculosis often suffer from adverse drug reaction
symptoms, which leads to the automatic discontinuation of anti- tuberculosis drugs. Thus, understanding symptom
experience of adverse drug reactions is necessary.
Objective: This study aimed to examine differences in symptoms experienced in four dimensions: presence,
frequency, severity, and distress of adverse drug reactions, between male and female patients.
Methods: This was a quantitative survey with a cross-sectional design, with data collected between January and
April 2020. A total of 394 patients with newly diagnosed pulmonary tuberculosis was selected through a purposive
sampling technique. The symptom experiences of adverse drug reactions were measured using a validated
instrument. Data were analyzed using mean, standard deviation, and independent t-test.
Results: The most commonly reported symptom was itchiness (24.1% in males and 34.9% in females). Vomiting
occurred as the most frequent symptom among males (𝑥̅ ± SD = 2.73 ± .88), and fatigue was found to be the most
severe and distressing symptom across male patients ( 𝑥̅ ± SD = 2.50 ± 1.61 and 2.06 ± 1.30, respectively). In
contrast, yellowing of the eyes and skin was most frequent and severe among females ( 𝑥̅ ± SD = 3.17 ± .75 and
3.83 ± 1.47, respectively). In addition, flu-like symptoms were evaluated as the most distressing symptom for female
patients (𝑥̅± SD = 2.80 ± 1.09). The symptom burdens of the females ranged significantly and reached higher than
those of the male patients at a p-value of .05 (t = 3.33).
Conclusion: Females taking anti-tuberculosis drugs should be carefully monitored to deal with adverse drug
reaction symptoms. This finding would help to decrease the severity of disease and improve their quality of life.

Keywords
adverse drug reaction; pulmonary tuberculosis; symptom experiences; quality of life; drug-related side effects;
nursing; Thailand

Tuberculosis (TB) is a transmissible disease and one of the
ten leading causes of death worldwide (World Health
Organization, 2020). TB is caused by bacillus
Mycobacterium TB, which spreads through the air by, for
example, coughing. In 2019, the World Health
Organization (WHO) reported 87,789 new TB cases, and
85.0% of these relapses were pulmonary TB (WHO, 2019).
In addition, the WHO indicated that Thailand is one of the
top 20 countries affected by TB and that only 85.0% of new
cases and relapses in 2019 had successful outcomes

Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand Article Info:

Received: 6 February 2021
Revised: 7 March 2021
Corresponding author: Accepted: 10 May 2021
Assistant Professor Police Captain Rapin Polsook, PhD, RN
This is an Open Access article distributed under the terms of the Creative
Faculty of Nursing, Chulalongkorn University, Boromarajonani
Commons Attribution-NonCommercial 4.0 International License, which allows
Srisatapat Building, Rama1 Rd, Floor 11 Patumwan, Bangkok others to remix, tweak, and build upon the work non-commercially as long as
10330, Thailand. the original work is properly cited. The new creations are not necessarily
licensed under the identical terms.
Telephone: 66-22181151
Cell phone: 66-8183-2109-5 E-ISSN: 2477-4073 | P-ISSN: 2528-181X
Email: rapin.p@chula.ac.th; nitinggel@yahoo.com

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

195
 Thontham, A., & Polsook, R. (2021)
(WHO, 2019). Moreover, the Ministry of Public Health of
Thailand reported that, among new TB cases, 68.9% were
males over the age of 15, and 31.1% were female (Health
Data Center, 2020).
TB is treatable and preventable, and about 85.0% of
people who develop TB can be successfully treated with
regimental 6-month drugs, or first-line anti-TB drugs, which
are Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), and
Ethambutol (E) (WHO, 2019). Although most TB patients
are under self-medication, a failure to take medication or
premature discontinuation of medication caused by an
adverse drug reaction (ADRs) from first-line anti-TB drugs
occurs in approximately 60.0-83.5% of cases (Qureshi &
Kausar, 2013; Abhijeet Singh, Prasad, Balasubramanian,
Gupta, & Gupta, 2015). Previous studies have shown that
the most common adverse symptoms of first-line anti-TB
drugs are rashes, peripheral neuropathy, flu-like
symptoms, arthralgia, hyperuricemia, nausea, vomiting,
and optical neuritis (Mathew & Joseph, 2017; Naser et al.,
2016; Saputra, Rakhmawati, Hendrawati, & Adistie, 2020;
Anita Singh, Bhat, & Sharma, 2011). Moreover, drug
interaction of first-line anti-TB drugs is the cause of drug-
induced liver damage (Ramappa & Aithal, 2013).
In addition, the literature shows that significant ADRs
most commonly occur between one and five weeks after
beginning the medication and that ADRs associated with
anti-TB drugs persist, on average, for two months after
patients start taking anti-TB drugs (Mathew & Joseph,
2017; Naser et al., 2016; Anita Singh et al., 2011). ADRs
can also cause severe harm to patients, resulting in
hospitalization. Many patients suffer from ADRs, leading to
the automatic discontinuation of anti-TB drugs. However,
patients who adhere to anti-TB drugs through the
management or control of ADR symptoms increase their
chance of recovery, reduce transmission, and improve their
quality of life (QOL) (Pal, Duncombe, Falzon, & Olsson,
2013).
Furthermore, the literature review found that gender
differences are linked to ADRs in terms of physiological,
hormonal, and genetic conditions, which has an impact on
the pharmacokinetics and pharmacodynamics of a drug
and may be the cause of the difference in ADRs between
females and males. Some studies have focused on gender
differences in the reporting of ADRs and found that females
report ADRs more often than males. Several other studies
have looked at a particular drug or class of drugs to look
more closely at gender differences in the reporting of
ADRs. They found that the reported prevalence was higher
among females compared to males; however, differences
in the rate of reporting by gender varied by category of
event or sub-class of the drug (Rademaker, 2001; Watson,
Caster, Rochon, & den Ruijter, 2019; Zucker &
Prendergast, 2020). Nurses are caring for patients with
newly diagnosed pulmonary TB and playing a role in
assessing the ADRs between males and females in order
to suggest appropriate strategies for the management of
ADRs. Thus, a study of gender differences and symptom
experience of ADRs among patients with newly diagnosed
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
196
TB is needed. This study was undertaken to investigate
related differences between genders in symptoms
experienced in four dimensions: presence, frequency,
severity, and distress of ADRs.
Methods
Study Design
The study employed a cross-sectional survey designed to
compare differences in ADRs according to gender.
Sample and Setting
Purposive sampling was used to approach participants
from among Thai pulmonary TB patients. The study was
undertaken in TB clinics, with permission from the
institutional review board of seven hospitals in Bangkok,
Thailand. The sample size was calculated by using Taro
Yamane (Yamane, 1973); the level of statistics was set at
a p-value of .05, and 10% was added to protect against a
loss of data that could lower than the minimum simple size
below the level that is acceptable to obtain the statistical
power of analysis (Grove & Gray, 2018). Thus, a total of
394 newly diagnosed pulmonary TB patients were
recruited into the study. The inclusion criteria for the
participants were: (1) first-line anti-TB drugs received, (2)
25-59 years of age, (3) not receiving anti-HIV drugs, (4)
being able to communicate in Thai, (5)having no cognitive
impairment, nor complications from the disease; and (6)
being willing to participate. However, participants with any
physical disability (e.g., increased shortness of breath or
increased cough) were excluded from this study. The
purpose of this study, its potential benefits, risks, and the
length of the interview were communicated to all patients.
All participants signed a consent form, and the information
on the topic was encoded for anonymity.
Instruments
In this study, symptom experiences have been defined as
the perception of an individual symptom or a change in how
a patient feels (Armstrong, 2003). The instrument to
measure symptom experiences was developed based on
symptom management by Dodd et al. (2001), along with a
related literature review by the authors. The questionnaire
is composed of two parts: a demographic questionnaire
and a symptom experience questionnaire. The details of
each questionnaire are as follows.
1) Demographic data questionnaire. The demographic
data of participants, including age, gender, marital status,
education, income, and type of health care coverage, were
assessed.
2) Symptom experiences questionnaire. The question-
naire consists of 35 items of symptoms in four dimensions:
presence, frequency, severity, and distress. For presence
dimension, participants were asked to rate as 0 = absent or
1 = present; frequency dimension was rated as 1 = rarely,
2 = sometimes, 3 = often, or 4 = always; severity, and
distress dimensions were rated as 1= very low, 2 = low, 3
= moderate, 4 = high, or 5 = very high. A higher score
 Thontham, A., & Polsook, R. (2021)
indicates higher levels of symptom perception. The internal
consistency reliability of the symptom experiences
questionnaire was in four dimensions: presence,
frequency, severity, and distress, with Cronbach’s alpha of
.86, .81, .84, and .86, respectively.
To calculate the score of symptom experience, we used
a method for calculating symptom burden from the Chronic
Kidney Disease Symptom Burden Index (CKD-SBI)
questionnaire by Almutary, Bonner, and Douglas (2015).
There was no difference between symptom experience and
symptom burden in this study. The dimensions and scales
are completely the same. The presence dimension ranges
between 0 – 35, the frequency dimension ranges between
0 – 140, and severity and distress dimensions range
between 0 - 175. Higher scores indicate greater symptom
presence, frequency, severity, and distress.
A total symptom burden score of the symptom
experiences questionnaire is calculated by summing
subscale score (presence, frequency, severity, and
distress) then divided by 4 (a minimum score of four
dimensions that could be achieved from only one symptom
from a participant report), and then multiplied by a fixed
number of .191 (a constant number - mathematical
maneuver to convert the total of symptom experiences
questionnaire to 100). The total score for the symptom
experiences questionnaire ranged between 0 and 100 for
each participant, which was calculated for all symptoms. In
the interpretation of the symptom burden score, a score of
100 indicates that the participant had the highest symptom
burden.
Data Collection
Simple random sampling was used to generate a
probabilistic sample of newly diagnosed TB. Participants
were selected from among the 50 districts in Bangkok,
Thailand. The researcher divided the 50 districts into three
areas by location in Bangkok: inner-city, urban fringe, or
suburb. There were 23 hospitals in total: 16 inner-city
hospitals, four urban fringe hospitals, and three suburban
hospitals. The following numbers of the hospital in each
zone were required for statistical analysis: inner-city = 3,
urban fringe = 2, and suburb = 2. The number of hospitals
needed in each zone is based on the proportion of affiliation
with hospitals in Bangkok. Then, the proportion of patients
available per hospital in each zone was calculated by quota
sampling. Purposive sampling was used to select the study
participants who met the inclusion criteria.
The study was conducted at the TB clinics in seven
hospitals in Bangkok, Thailand, after approval from each
hospital’s Institutional Board (IRB). The researcher
described the benefits and risks of protecting human rights
in non-technical terms prior to obtaining patient approval to
participate in the study. If patients met the inclusion criteria
and accepted participation, they were asked to sign a
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
197
consent form. Participants were then asked to complete the
symptom experiences of the adverse drug reaction
questionnaire. During the process of data collection,
participants were able to decline or leave without
consequence. It took approximately half an hour to
complete each interview. The data were collected from
January to April 2020.
Data Analysis
Statistical analysis was carried out with the software
package SPSS Statistics version 22. The level of statistical
significance was set at a p-value of .05. Normality testing
used Q-Q Plots. As data were normally distributed,
descriptive statistics and independent t-test were used for
data analysis.
Ethical Consideration
The study was approved by: 1) Human Research
Protection Unit, Faculty of Medicine Siriraj Hospital (REF:
Si 864/2019), 2) The Research Ethics Review Committee
for Research Involving Human Research Participants,
Health Sciences Group, Chulalongkorn University (REF:
287/2562), 3) Nopparat Rajathanee Hospital Ethics
Committee (REF: 4/2563), 4) Lerdsin Hospital Ethics
Committee (REF: LH621088) and 5) Bangkok Metropolitan
Administration Human Research Ethics Committee (REF:
24).
Results
Characteristics of Participants
The baseline study consisted of 394 pulmonary TB
patients, 62.2% of whom were males and 37.8% were
females. Almost half of all males were between 30 and 49
years old. Over half of males were married (58.4%), and
nearly half of males had completed primary education
(40.4%). Almost half of the males had universal health care
coverage (45.7%), and almost a third of males had a
monthly income of between 1,001 and 15,000 Thai baht per
month (28.6%), while more than half of females were aged
30 to 49 years and married (58.4%). Over a third of
participants were attending secondary school (38.3%).
Roughly half of the females were covered by universal
health care coverage (49.7%) and just under one-third of
females had no income (30.9%) (Table 1).
Symptom Experiences in the Presence Dimension
The three symptoms reported by the male patients that
occurred most frequently in the presence dimension were
itchiness (24.1%), decreased appetite (20.0,%) and
numbness of the hands and feet (20.0%). In females, the
three symptoms most frequently reported in the presence
dimension were itchiness (34.9%), nausea (34.9%), and
decreased appetite (24.2%) (see Table 2).
 Thontham, A., & Polsook, R. (2021)

Table 1 Demographic and clinical characteristics of the pulmonary tuberculosis patients (N = 394)

Characteristics Male (N = 245) Female (N = 149)

n (%) ̅
𝒙 SD n (%) ̅
𝒙 SD
Age (Years) 42.7 11.4 41.8 11.0
25-29 49 20.0 25 16.8
30-49 105 42.9 74 49.7
50-59 91 37.1 50 33.6
Marital Status
Single 89 36.3 45 30.2
Widowed 5 2.0 6 4.0
Divorced 5 2.0 9 6.0
Separate 3 1.2 2 1.3
Married 143 58.4 87 58.4
Education
Uneducated 5 2.0 4 2.7
Primary School 99 40.4 53 35.6
Secondary School 85 34.7 57 38.3
Diploma 33 13.5 15 10.1
College or More 23 9.4 20 13.5
Occupation
Unemployed 60 24.5 46 30.9
Employee 111 45.3 54 36.2
Merchant 21 8.6 18 12.1
Company Employee 45 18.4 28 18.8
Government Service 8 3.3 3 2.0
Type of Healthcare Coverage
Universal Coverage 112 45.7 74 49.7
Civil Servant Medical 14 5.7 5 3.4
Benefit Scheme
Social Security 110 44.9 62 41.6
Scheme
Pay by Yourself 9 3.7 8 5.4
Monthly Income (Thai Bath) 11,791.4 9,747.7 9,776.5 8,757.4
No income 60 24.5 46 30.9
2,000 – 5,000 1 0.4 2 1.3
5,001 – 10,000 56 22.9 45 30.2
10,001 – 15,000 70 28.6 32 21.5
15,001 – 20,000 33 13.5 13 8.7
≥ 20,000 25 10.2 11 7.4

Symptom Experiences in the Frequency Dimension
The three symptoms that occurred most frequently in
males were vomiting (𝑥̅ ± SD = 2.73 ± .88), fatigue (𝑥̅ ±
SD = 2.65 ± .95), and insomnia (𝑥̅ ± SD = 2.62 ± .8. In
comparison, the three most common symptoms among
females were yellowing of the eyes and skin, insomnia, and
fatigue (𝑥̅ ± SD = 3.17 ± .75, 2.88 ± .85, and 2.78 ± .90,
respectively) (see Table 3).
Symptom Experiences in the Severity Dimension
The three symptom experiences in the severity dimension
that were found to be the most severe among males were
fatigue, vomiting, and yellowing of eyes and skin (𝑥̅ ± SD =
2.50 ± 1.61, 2.30±1.04, and 2.10 ± 1.55, respectively).
Yellowing of eyes and skin, flu-like symptoms, and
abdominal pain were the three symptom experiences
found to be most severe in the symptom severity
dimension among females (𝑥̅ ± SD = 3.83 ± 1.47,
2.80±1.10, and 2.67 ± 1.21, respectively) (see Table 4).

Table 2 The top 20 highest symptom experiences that participants reported in present dimension(N = 394)

Present Dimension Gender

(N = 394) Male (N = 245) Female (N = 149)
Symptom
n % n % n %
1. Itchiness 111 28.2 59 24.1 52 34.9
2. Nausea 94 23.9 42 17.1 52 34.9
3. Decreased Appetite 85 21.6 49 20.0 36 24.2
4. Numbness of the Hands and Feet 79 20.1 49 20.0 30 20.1
5. Rash 70 17.8 39 15.9 31 20.8

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 Thontham, A., & Polsook, R. (2021)

Table 2 (Cont.)
6. Fatigue 57 14.5 34 13.8 23 15.4
7. Vomiting 53 13.5 22 9.0 31 20.8
8. Joint Pain 53 13.5 27 11.0 26 17.4
9. Insomnia 50 12.7 26 10.6 24 16.1
10. Muscle Pain 48 12.2 37 15.1 11 7.4
11. Dry Mouth 41 10.4 20 8.2 21 14.1
12. Blurred Vision 17 4.3 10 4.1 7 4.7
13. Headache 16 4.1 11 4.5 5 3.4
14. Abdominal Pain 15 3.8 9 3.6 6 4.0
15. Yellowing of Eyes and Skin 14 3.6 8 3.3 6 4.0
16. Dysuria 11 2.8 8 3.3 3 2.0
17. Mood Change 10 2.5 1 0.4 9 6.0
18. Flu-like Symptoms 8 2 3 1.2 5 3.4
19. Tinnitus 6 1.5 3 1.2 3 2.0
20. Swollen Face, Hands, and Feet 6 1.5 3 1.2 3 2.0

Table 3 The top five highest symptom experiences that participants reported in frequency dimension (N = 394)

Male Female
Symptom Frequency Dimension Symptom Frequency Dimension
1 2 3 4 ̅ ± SD
𝒙 1 2 3 4 ̅ ± SD
𝒙
1) Vomiting 2 6 10 4 2.73±.88 1) Yellowing of eyes and skin 0 1 3 2 3.17±.75
2) Fatigue 4 11 12 7 2.65±.95 2) Insomnia 1 7 10 6 2.88±.85
3) Insomnia 2 10 10 4 2.62±.85 3) Fatigue 1 9 7 6 2.78±.90
4) Rash 6 12 16 5 2.51±.91 4) Rash 3 12 8 5 2.68±.98
5) Yellowing of eyes and skin 3 1 1 3 2.50±1.41 5) Vomiting 3 13 11 4 2.52±.85
Note: Possible range for symptom score was 1 to 4 (1 = rarely 2 = sometimes 3 = often 4 = always )

Table 4 The top five highest symptom experiences that participants reported in severity dimension (N = 394)

Male Female
Symptom Symptom Severity Dimension Symptom Symptom Severity Dimension
1 2 3 4 5 𝒙 ± SD
̅ 1 2 3 4 5 𝒙 ± SD
̅
1) Fatigue 1 13 5 8 1
2.50 ± 1.61 1) Yellowing of 0 2 0 1 3 3.83 ± 1.47
Eyes and Skin
2) Vomiting 5 9 4 4 0 2.30 ± 1.04 2) Flu-like 1 0 3 1 0 2.80 ± 1.10
Symptoms
3) Yellowing of Eyes 5 0 0 3 0 2.10 ± 1.55 3) Abdominal 1 2 1 2 0 2.67 ± 1.21
and Skin Pain
4) Flu-like Symptoms 1 1 1 0 0 2.00 ± 1.00 4) Vomiting 8 12 5 3 3 2.39 ± 1.26
5) Abdominal Pain 2 5 2 0 0 2.00 ± .71 5) Fatigue 6 8 4 4 1 2.39 ± 1.20
Note: Possible range for symptom score was 1 to 5 (1 = very low 2 = low 3 = moderate 4 = high 5 = very high)

Table 5 The top five highest symptom experiences that participants reported in distress dimension (N = 394)

Male Female
Symptom Symptom Severity Dimension Symptom Symptom Severity Dimension
1 2 3 4 5 ̅ ± SD
𝒙 1 2 3 4 5 ̅ ± SD
𝒙
1) Fatigue 17 7 2 7 1 2.06 ± 1.30
1) Flu-like 1 0 3 1 0 2.80 ± 1.10
Symptoms
2) Flu-like Symptoms 1 1 1 0 0 2.00 ± 1.00 2) Insomnia 10 7 5 2 0 1.96 ± 1.00
3) Muscle Pain 20 8 3 6 0 1.86 ± 1.13 3) Joint Pain 15 5 2 1 3 1.92 ± 1.38
4) Insomnia 13 7 3 3 0 1.85 ± 1.05 4) Fatigue 11 6 4 1 1 1.91 ± 1.13
5) Joint Pain 13 8 3 3 0 1.85 ± 1.03 5) Muscle Pain 4 3 3 1 0 0.91 ± 1.04
Note: Possible range for symptom score was 1 to 5 (1 = very low 2 = low 3 = moderate 4 = high 5 = very high)

Symptom Experiences in the Distress Dimension
The three symptoms that were found to be the most
distressing among males were fatigue, flu-like symptoms,
and muscle pain (𝑥̅ ± SD = 2.06 ± 1.30, 2.00 ± 1.00, and
1.86 ± 1.13, respectively). The top three symptom
experiences among females in the symptom distress
dimension were flu-like symptoms, insomnia, and joint pain
(𝑥̅ ± SD = 2.80 ± 1.10, 1.96 ± 1.00, and 1.92 ± 1.38,
respectively) (see Table 5).

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 Thontham, A., & Polsook, R. (2021)
Symptom Burden Perceived Among the Participants
The range of symptom burden reported by female patients
(Mean= 2.97, SD= 3.48) reached significantly higher than
that of the males (Mean = 1.88, SD = 2.46; t = 3.33; p =
.05) (see Table 6).
Table 6 The burden of symptoms in 4 dimensions (N =394)
The Symptom Burden in Four
Gender Dimensions
Mean SD t p-value
Male (n = 245) 1.88 2.46 3.33 .001
Female (n = 149) 2.97 3.48
Discussion
This study was undertaken to investigate related
differences between genders in symptom experiences of
ADRs among newly diagnosed pulmonary TB patients. In
this study, it was found that more male patients
experienced ADRs than did female patients. A possible
explanation for this is that males usually participate in more
social and work activities than do females, which promotes
the transmission of the disease. Males are more likely to
smoke and also have addictions to alcohol or drugs in
comparison to females. This increases their risk for TB
(Imam et al., 2020).
Additionally, itching was the most common symptom
among males (24.1%) and females (34.9%). This may be
caused by Rifampicin as all study participants receive the
same anti-TB drug regimen, which is widely used for
intrahepatic cholestasis-related itching. Rifampicin is not
only found in medications that cause liver damage, but it
also inhibits the absorption of biliary acid by hepatocytes,
increasing the concentration of biliary acid in plasma.
However, it breaks down the entero-hepatic circulation of
biliary acids on liver metabolic processes (Pongcharoen &
Fleischer Jr, 2016). Previous studies have also commonly
reported this side effect (Fei, Zainal, & Ali, 2018; Nazir,
Farhat, Adil, & Asrafv, 2019; Sinha, Marak, & Singh, 2013).
Vomiting was found to be more severe in males (𝑥̅ ±
SD = 2.73 ± .88). Vomiting may be caused by anti-TB
drugs such as Isoniazid, Ethambutol, and Pyrazinamide
and is common in the early weeks of treatment (Raftery,
Tudor, True, & Navarro, 2018). A possible explanation for
this is that males may be more likely to consume alcohol,
which can induce liver injury, and which also inhibits
absorption irritation that can cause vomiting. So males are
more likely to experience greater severity of vomiting than
females (Iranpour & Nakhaee, 2019; Marçôa, Ribeiro, Zão,
& Duarte, 2018).
Yellowing of the eyes and skin was the most frequent
and severe symptom among females (𝑥̅ ± SD = 3.17 ± .75,
and 3.83 ± 1.47, respectively). These symptoms can be
caused by anti-TB drugs like Isoniazid and Rifampicin,
which induce liver injury. Thus, if the liver is damaged, it
may cause leakage of bilirubin from the liver into the
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
200
bloodstream, and it may also leak into the surrounding
tissues. This is known as hyperbilirubinemia and causes a
yellow color in the skin and eyes (Anita Singh et al., 2011).
One possible explanation for this difference between
genders is that females usually have lower lean mass,
reduced liver clearance, and differences in cytochrome
P450 (CYP) enzyme activity than males. Additionally, the
females may be reporting yellowing of eyes and skin as the
most severe symptom due to the sclera changing from
white to yellow and skin changing from their own skin color
to yellow, which is a clinical symptom of hepatitis. In this
case, these females need to stop anti-TB drugs, change
regimens, or begin a new treatment regimen (Raftery et al.,
2018).
In our study, fatigue was found to be the most severe
and distressing symptom reported by males (𝑥̅ ± SD =
2.50 ± 1.61, and 2.06 ± 1.30, respectively). Fatigue can be
caused by any anti-TB drugs (Raftery et al., 2018). This
difference between genders could be explained by the fact
that males usually have more social and labor-based
activities than females and that associated issues like
unhealthy diets, work duration, and sleep problems with
fatigue are often linked to long-term health problems (Lin
et al., 2015). Flu-like symptoms were the most distressing
symptoms among female patients (𝑥̅ ± SD = 2.80 ± 1.10).
These symptoms can be caused by anti-TB drugs, which
induce hypersensitivity, modified thermoregulation, the
pharmacological action of the drug, idiosyncratic sensitivity
of inherited biochemistry defects, and related
administration. In the narrowest sense, as a sort of
hypersensitivity, drug fever is a febrile reaction specific to
the individual in the treatment process depending on the
drug and the idiosyncrasy of the patient. Clinically, it occurs
when anti-TB drugs become antigens after the formation of
the complex. Therefore, most of the females suffered from
a high fever. In most cases, the temperature reached a
peak on the initial day, whereas body temperature
increases caused by Rifampicin increase day by day and
reach a peak of above 40 degree Celsius within 3 – 6 days
(Fang et al., 2016; Yee et al., 2003).
Based on the symptom burden data, gender was a
significant variable in symptom burden at the p-value of
.05 (t = 3.33) because of identifiable differences between
females and males in terms of pharmacokinetic and
hormonal factors when taking anti-TB drugs. Females
have a slower gastric emptying time, leaner body mass
indices, and differences in total body water compared to
males, resulting in females absorbing more anti-TB drugs.
As a result, females experienced a higher symptom burden
level than males (Zucker & Prendergast, 2020).
This study has several limitations. The results may lack
international generalization due to the setting and cultural
influences in Bangkok, Thailand. Other limitations were
data-based and related to self-reported data, which could
have caused an overestimated or underestimation of
values. The instrument for measuring these variables has
been used only once in a Thai context. Testing of validity
and reliability within a Thai context is needed. Future
 Thontham, A., & Polsook, R. (2021)
studies should be conducted across an entire country's
population to assess the change of symptom experience
for ADRs among newly diagnosed pulmonary TB patients.
Developing intervention programs for females to decrease
ADR symptoms such as itchiness and nausea is needed
to encourage the continuous taking of anti-TB drugs.
This study can contribute to knowledge development
and strengthen nursing science to care for patients with
newly diagnosed pulmonary TB. The findings provide
knowledge that offers direction for the development of
interventions to decrease ADR symptoms regarding the
differences between male and female patients. Such
intervention should incorporate the promotion of strategies
to manage ADR symptoms to enhance adherence to anti-
TB drug regimens in order to reduce transmission and
improve quality of life.
Conclusion
This study found that ADRs were more reported among
male patients, but female patients reported a significantly
higher symptom burden than males. The results of this
study suggest that females receiving anti-TB drugs should
be carefully appropriately monitored for symptoms of
ADRs to deal with ADR symptoms. This would help
patients continue taking anti-TB drugs, which should
decrease the severity of the disease and improve their
quality of life.
Declaration of Conflicting Interest
There are no potential conflicts of interest to declare.
Funding
This study received funding from the Ratchadaphiseksomphot
Endowment Fund, Chulalongkorn University, Bangkok, Thailand
(GCUGR1125633058M).
Acknowledgment
The authors thanked all participants for the time and effort devoted
to this study and the staff of seven hospitals in Bangkok for their
help during the data collection process.
Authors’ Contribution
All the authors participated in the final manuscript. A.T. and R.P.
designed the study, collected data, analyzed the data, wrote, and
revised the manuscript.
Authors’ Biographies
Apichaya Thontham is a Registered Nurse at the Siriraj Hospital,
Bangkok, Thailand. She is also a master's student in the Nursing
Science program at the Faculty of Nursing, Chulalongkorn
University, Bangkok, Thailand.
Rapin Polsook, PhD, RN is an Assistant Professor at the Faculty
of Nursing, Chulalongkorn University. She has published articles
related to cardiovascular disease. She is a reviewer and a
member of the editorial teams of the nursing journals.
Data Availability Statement
Data sets generated and/or analyzed during the current review are
available from the corresponding author upon reasonable
demand.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
201
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Cite this article as: Thontham, A., & Polsook, R. (2021).
Symptom experience of adverse drug reaction among male
and female patients with newly diagnosed pulmonary
tuberculosis in Thailand. Belitung Nursing Journal, 7(3), 195-
202. https://doi.org/10.33546/bnj.1337
Original Research
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Knowledge, attitude, and practice Belitung Nursing Journal
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towards COVID-19 among student https://doi.org/10.33546/bnj.1405

nurses in Manila, Philippines: A

cross-sectional study
Earl Zedrick S. Quisao1, Raven Rose R. Tayaba1, and Gil P. Soriano1,2*

Abstract
Background: Assessing the current understanding of future health care workers about the COVID-19 is very
important in order to identify gaps that affect their perceptions and responses, which they can integrate into the
people in the community.
Objective: This study aimed to investigate the knowledge, attitude, and practice towards COVID-19 of student
nurses in Manila, Philippines.
Methods: This study utilized a descriptive cross-sectional survey of 314 individuals from October 2020 to December
2020 to evaluate the association of different factors to knowledge, attitude, and practice towards COVID-19.
Frequency, percentage, mean, standard deviation, t-test, and one-way ANOVA were used to analyze the data
gathered.
Results: The survey revealed that the respondents have a mean knowledge score of 18.76 (SD = 1.64), a mean
score for attitude of 26.58 (SD = 2.71) and a mean score for practice of 4.26 (SD = 0.93). A significant different
were noted in terms of year level with level 3 having a higher mean score (M = 19.01, F = 2.696, p = 0.046)
compared to other levels and type of school, with public university students having a higher level of knowledge (M
= 18.97, t = 2.070, p = 0.039). In terms of attitude, females have higher mean scores (M = 26.85, t = -2.630, p =
0.009 and students from public university have higher scores (M = 2.81, t = -4.406, p = 0.000) than students from
private university. For practice, a significant difference was noted in terms of year level, with level 3 students having
a higher mean score (M = 4.42, F = 3.180, p = 0.024) compared to other year levels.
Conclusion: Filipino student nurses have a high level of knowledge about COVID-19 and are mainly optimistic
about controlling the pandemic. Nevertheless, having constant reminder from the authorities and health care
professionals are the solution to aid public knowledge and comprehension relating to COVID-19.

Keywords
COVID-19; nursing; students; knowledge; attitude; practice; Philippines

A new strain of flu-causing coronavirus has been spreading
and affecting the lives of many. Reports showed that the
first case was discovered in Wuhan, China, in December
2019, making Wuhan its place of origin (World Health
Organization, 2020a). Formerly known to be 2019-nCoV,
this new strain named Severe Acute Respiratory Syndrome
Coronavirus 2 (SARS-CoV-2) causes the illness coined as
the Coronavirus disease 2019 (COVID-19) having mild
symptoms of fever, dry cough, and tiredness to many
severe symptoms of chest pain, shortness of breath or
difficulty of breathing (World Health Organization, 2020b).
Experts believe that the virus can easily be transmitted
when susceptible hosts inhaled small droplets that contain
the virus, which is expelled from an infected person’s nose
or mouth through coughing, sneezing, or speaking. But as
the experts continue to study more about this pathogen, it

1 College of Nursing, San Beda University, Manila, Philippines Article Info:

2 Graduate Received: 7 March 2021
School, Wesleyan University-Philippines, Nueva Ecija, Revised: 7 April 2021
Philippines Accepted: 15 May 2021

This is an Open Access article distributed under the terms of the Creative
Corresponding author:
Commons Attribution-NonCommercial 4.0 International License, which allows
Gil P. Soriano, MHPEd, RN others to remix, tweak, and build upon the work non-commercially as long as
College of Nursing, San Beda University the original work is properly cited. The new creations are not necessarily
638 Mendiola St., San Miguel, Manila, Philippines licensed under the identical terms.
Email: gil.p.soriano@gmail.com E-ISSN: 2477-4073 | P-ISSN: 2528-181X

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 Quisao, E. Z. S., Tayaba, R. R. R., & Soriano, G. P. (2021)
turns out that there are other ways how this is being
transmitted (World Health Organization, 2020b). The virus
began to spread rapidly, even having cases outside China,
making the World Health Organization’s Director-General
declaring the outbreak a Public Health Emergency of
International Concern. It spreads so fast that it became a
pandemic just more than a month after the previous
declaration (World Health Organization, 2020a).
As the virus continues to spread worldwide, the
Philippines was not able to contain the virus outside its
borders. On 30 January 2020, the Philippine Department
of Health (DOH) recorded the first case of COVID-19 in the
country with a Chinese national. On 7 March 2020, the first
local transmission was reported (World Health
Organization, 2020c). Precisely months have passed since
the primary affirmed COVID-19 case was reported within
the Philippines. The government executed numerous
actions, including adherence to the guidelines and health
protocols released by the WHO, contact tracing to
immediately detect and isolate those who have close
contacts with carriers, and strict community isolation in
Metro Manila extending to Luzon as well as other parts of
the country closing almost all establishments, such as
shopping centers, hoping to contain the rapidly increasing
cases within the bounds of the Philippines (World Health
Organization, 2020d).
But despite these numerous actions, the country’s
situation seems to worsen as time goes by. Ten months
after the first recorded case, the country has reported a
total of 431,630 confirmed cases with total deaths of 8,392
(Elflain, 2020; Philippine Department of Health, 2020;
World Health Organization, 2020e). This makes the
Philippines the 2nd country in Southeast Asia with the
most number of confirmed cases and ranks 27th globally
(Elflain, 2020; Petterson et al., 2020; World Health
Organization, 2020e). According to experts, a significant
factor why COVID-19 cases persist to increase is due to
faulty human behavior (Lee, 2020; Maragakis, 2020) and
Filipinos are no exceptions. On 25 October 2020, Manila
Bulletin released an article announcing that over 100,000
quarantine violators were arrested by the Philippine
National Police (Chavez, 2020).
This shows that the success of the efforts of the
government depends on people’s adherence to preventive
measures, which is affected by their knowledge, attitude,
and practices. A study revealed that public knowledge is
vital in response to outbreaks (University of Surrey, 2018),
which means that public health educators are as crucial as
other front liners, including student nurses.
In the Philippines, the Bachelor of Science in Nursing
(BSN) is a four-year program that includes general and
professional courses. Professional courses are threaded
from the first year through the fourth year, emphasizing the
concepts with corresponding Related Learning Experience
(RLE). The BSN curriculum includes an intensive nursing
practicum designed to improve nursing skills further and
ensure that the BSN program results expected of an entry-
level nurse are met (Commission on Higher Education,
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
204
2017). As early as in their 2nd year in the BSN program,
student nurses are taught how to educate people in the
community. Assessing their current awareness and
knowledge about this virus and its prevention can identify
gaps that affect their perceptions and responses, which
they can integrate into those people in the community.
COVID-19 is a new strain of infectious virus that has
had a catastrophic effect on every individual within the
short time it was first detected. Thus far, only a few
published articles evaluate the knowledge, attitude, and
practice of nursing students towards COVID-19. The
novelty of this virus, together with its precariousness and
serious threats, made it hard for health professionals and
authorities to plan strategic action to stop the spread of the
virus. To the best of our knowledge, this is the first study to
examine COVID-19 knowledge, attitude, and practice
related sociodemographic characteristics among student
nurses in the Philippines. Thus, this study aims to
determine the knowledge, attitude, and practice towards
COVID-19 among student nurses in Manila, Philippines.
Methods
Study Design
This study utilized a descriptive cross-sectional survey to
determine the level of knowledge, attitude, and practice
towards COVID-19.
Participants
An online survey using the Likert scale was used to gather
the necessary data for this study. Total enumeration of
students from two Colleges of Nursing in Manila was
included with a total of 314 student nurses. The inclusion
criteria include: (1) nursing students studying in a college
or a university, either public or private, in Metro Manila; (2)
currently enrolled in the academic year 2020-2021; (3)
have access to internet connection; (4) understands the
English language; (5) and of legal age (18 years old and
above) who can give informed consent.
Measures
This study utilized the questionnaire developed by Al-
Hanawi et al. (2020) in order to measure the knowledge,
attitude, and practice towards COVID-19 among nursing
students. Respondents were asked about their knowledge
using the 22-item Dichotomous questions where the
questions were answered by yes or no with Cronbach’s
alpha coefficient of 0.71. In terms of attitudes, respondents
were asked to answer six attitudinal statements and scored
as 1 = strongly disagree, 2 = disagree, 3 = undecided, 4 =
agree, and 5 = strongly agree. It has a Cronbach’s alpha
coefficient of 0.81. In the section of practice, respondents
five practice statements to be answered by “yes” or “no”
were asked, and a score of one was given for answers that
denote a good practice, and a score of zero was given for
answers that denoted bad practice. The total score ranged
from zero to five, with high scores indicating better
practices. The instrument was administered using the
 Quisao, E. Z. S., Tayaba, R. R. R., & Soriano, G. P. (2021)

English language translation of Al-Hanawi et al. (2020). No 18.76 (SD = 1.64), the mean attitude score of 26.58 (SD =
translation was conducted since English is the medium of 2.71), and the mean practice score of 4.26 (SD = 0.93). Of
instruction in the BSN program in the Philippines. the total individuals, 77 (24.5%) were males and 234
(74.5%) were females, aged between 18 and 31. More than
Data Collection half of them were enrolled in private schools totaling 177
This study involved the use of primary data collection using (56.4%) individuals, and the majority came from Level 1
a self-administered questionnaire. Prior to data gathering, with 122 (38.9%). These participants were also categorized
the researchers got approval from the College Dean according to their family’s monthly income in Philippine
through a letter of request to conduct this study. Permission peso (Php), with 112 (35.7%) in the less than Php 20,000
to utilize the COVID-19 knowledge, attitude, and practice bracket, 59 (18.8%) in the Php 20,000-30,000 bracket, 29
instrument was secured from the developer of the tool. (9.2%) in the Php 30,000-40,000 bracket, 26 (8.3%) in the
Further, with the Dean’s approval and a clearance from the Php 40,000-50,000 bracket, and 88 (28%) in the more than
ethics board, the researchers then collected the data using Php 50,000 bracket. The content of the next tables, Table
Google Forms. Given the physical distancing measures 2-4, shows the participants' responses about knowledge,
and other restrictions implemented, data were collected attitude, and practice towards COVID-19.
online to avoid face-to-face interactions during the course
of the collection from October 2020 to December 2020.
Table 1 Characteristics of the Participants (N = 314)
Data Analysis
This study used frequency, percentage, mean, standard Variable Mean (SD) n (%)
deviation, independent t-test, and one-way ANOVA to Knowledge 18.76 (1.64)
analyzed the data gathered from the respondents. The Attitude 26.58 (2.71)
Practice 4.26 (0.93)
Shapiro Wilk test indicated that the data were normally
Age 19.80 (1.54)
distributed. The alpha level of significance was set at 0.05. Gender
Male 77 (24.5)
Ethical Considerations Female 234 (74.5)
This study was conducted in accordance with the Year Level
established ethical standards of conducting research with 1st year 122 (38.9)
human participants. The researchers obtained ethical 2nd year 86 (27.4)
clearance from San Beda University – Research Ethics 3rd year 75 (23.9)
4th year 31 (9.9)
Board with Protocol Number 2020-040. It was made sure
Type of School
that respondents were informed regarding the study’s Public 137 (43.6)
objectives, associated risks, and benefits of participation Private 177 (56.4)
and encouraged to ask any questions regarding the study. Income
Written consent was also secured when the respondents Less than Php20,000 112 (35.7)
decided to participate. Php20,000 to Php30,000 59 (18.8)
Php30,000 to Php40000 29 (9.2)
Php40,000 to Php50,000 26 (8.3)
Results More than Php50,000 88 (28)

Table 1 shows the socio-demographic characteristics of the

participants, which displays the mean knowledge score of

Table 2 Level of knowledge of the participants about COVID-19

Statements n (%)
Correct Answer Incorrect Answer
SARS-CoV-2 spreads from person to person within close distance of each other (approx. 281 (89.5) 33 (10.5)
six feet)
SARS-CoV-2 spread through respiratory droplets, which occur when infected people 313 (99.7) 1 (0.3)
cough and sneeze
SARS-CoV-2 can be contracted by touching a surface or object on which the virus is 312 (99.4) 2 (0.6)
attached and then touching one’s mouth, nose, or, perhaps, eyes
Close contact or eating wild animals causes COVID-19 145 (46.2) 145 (46.2)
People infected with SARS-CoV-2 cannot transmit the virus to others when a fever is not 282 (89.8) 32 (10.2)
present
The main clinical symptoms of COVID-19 are fever, fatigue, dry cough, myalgia, and 305 (97.1) 9 (2.9)
shortness of breath
Unlike the common cold, congestion, runny nose, and sneezing are less common in people 139 (44.3) 175 (55.7)
infected with SARS-CoV-2

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Table 2 (Cont.)
Antibiotics are an effective treatment for COVID-19 247 (78.7) 67 (21.3)
Currently, there is no effective cure for COVID-19, but early symptomatic and supportive 302 (96.2) 12 (3.8)
treatment can help most patients recover from the diseases
Older adults and those with serious chronic illnesses, such as heart or lung disease and 208 (98.1) 6 (1.9)
diabetes, are at increased risk of developing more serious complications from COVID-19
Not all people with COVID-19 have severe cases. Only older adults with chronic illnesses 234 (74.5) 80 (25.5)
tend to be more severe
Pregnant women are more susceptible to infections than non-pregnant women 231 (73.6) 83 (26.4)
Children do not appear to be at higher risk for COVID-19 than adults 136 (43.3) 178 (56.70)
It is not necessary for children or young people to take precautionary measures to prevent 252 (80.3) 62 (19.7)
SARS-CoV-2 transmission
After being in a public place, after nose-blowing, coughing, or sneezing, people must wash 287 (91.4) 27 (8.6)
their hands with soap and water or use a hand sanitizer containing at least 60% alcohol
for at least 20 seconds
People should avoid touching their eyes, nose, and mouth with unwashed hands 310 (98.7) 4 (1.3)
Ordinary residents can wear general medical masks to prevent the SARS-CoV-2 infection 291 (92.7) 23 (7.3)
People should only wear a mask if they are infected with the virus or if they are caring for 271 (86.3) 43 (13.7)
someone with suspected SARS-CoV-2 infection
Healthy food and drinking water increase the body’s immunity and resistance to COVID- 307 (97.8) 7 (2.2)
19
Isolation and treatment of people infected with the SARS-CoV-2 are effective ways to 313 (99.7) 1 (0.3)
reduce the spread of the virus
People in contact with someone infected with SARS-CoV-2 should be immediately 313 (99.7) 1 (0.3)
quarantined, in an appropriate location, for a general observation period of 14 days
To prevent transmission of SARS-CoV-2, people must avoid going to crowded places and 312 (99.4) 2 (0.6)
avoid taking public transport

Table 3 Level of the attitude of the participants about COVID-19

Statement n (%)
Strongly Disagree Neutral Agree Strongly Agree
Disagree
It is important to keep my distance from others to avoid 0 0 0 11 (3.5) 303 (96.5)
spreading SARS-CoV-2
Washing hands is essential to protect myself from COVID-19 0 0 1 (0.3) 6 (1.9) 307 (97.8)
To protect myself from COVID-19 exposure, I should stay 0 1 (0.3) 8 (2.5) 28 (8.9) 277 (88.2)
home if I am sick unless I am receiving medical care
COVID-19 will eventually be successfully controlled 7 (2.2) 28 (8.9) 88 (28) 76 (24.2) 115 (36.6)
Philippines’ strict measures can help win the battle against 28 (8.9) 33 87 (27.7) 65 (20.7) 101 (32.2)
COVID-19 (10.5)
Compliance with the Department of Health precautions will 3 (1) 11 (3.5) 41 (13.1) 68 (21.7) 191 (60.8)
prevent the spread of COVID-19

Table 4 Practices of the participants about COVID-19

Statements n (%)
Yes No
Have you recently been to a social event involving a large number of people? 58 (18.5) 256 (81.5)
Have you recently been to a crowded place? 105 (33.4) 209 (66.6)
Have you recently avoided cultural behaviors, such as shaking hands? 265 (84.4) 49 (15.6)
Have you been practicing social distancing? 306 (97.5) 8 (2.5)
Recently, have you frequently washed your hands with soap and water, for at least 40 302 (96.2) 12 (3.8)
seconds, especially after going to a public place or after nose-blowing, coughing, or
sneezing?

Table 5 shows the comparison of the characteristics of the
participants with the level of knowledge, attitude, and
practice. In terms of knowledge, a significant difference
noted in terms of year level, with 3rd year having a higher
mean score (M = 19.01, F = 2.696, p = 0.046) compared to
other levels and type of school, with public university
students having a higher level of knowledge (M = 18.97, t
= 2.070, p = 0.039) as compared to private university
students.

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 Quisao, E. Z. S., Tayaba, R. R. R., & Soriano, G. P. (2021)

In terms of attitude, females have higher mean scores a significant difference was noted in terms of year level,
(M = 26.85, t = -2.630, p = 0.009 and students from public with 3rd year students having a higher mean score (M =
university have higher scores (M = 2.81, t = -4.406, p = 4.42, F = 3.180, p = 0.024) compared to other year levels.
0.000) than students from private university. For practice,

Table 5 Comparison of the characteristics of the participants and average of knowledge, attitude, and practice score

Variable Knowledge score Attitude score Practice score

Mean SD F/t p Mean SD F/t p Mean SD F/t p
Gender
Male 18.62 1.97 -0.732 0.406 25.94 3.21 -2.630 0.009* 4.11 1.03 -1.594 0.112
Female 18.80 1.52 26.85 2.44 4.31 0.89
Year Level
1st year 18.62 1.65 2.696 *0.046 26.55 2.66 1.447 0.229 4.22 0.89 3.180 *0.024
2nd year 18.95 1.51 26.92 2.36 4.32 0.96
3rd year 19.01 1.42 26.57 2.75 4.42 0.79
4th year 18.16 2.22 25.74 3.54 3.83 1.21
Type of School
Public 18.97 1.64 2.070 *0.039 25.83 2.81 -4.406 0.000* 4.22 0.94 -0.704 0.482
Private 18.59 1.63 27.15 2.49 4.29 0.93
Income
Less than 20,000 18.74 1.52 0.780 0.539 27 2.52 1.396 0.235 4.33 0.96 1.327 0.260
20,000 to 30,000 18.58 1.91 26.63 2.78 4.25 0.88
30,000 to 40000 18.51 2.31 26.45 3.39 3.89 1.05
40,000 to 50,000 19.11 1.42 26 3.12 4.23 0.91
More than 50,000 18.89 1.38 26.21 2.48 4.31 0.89
*p-value is significant at 0.05

Discussion believe that children are at higher risk for COVID-19

The objective of the study is to determine the significance
of assessing the level of knowledge, attitude, and practice
to be measured can serve as a guide (Azlan et al., 2020).
These circumstances stipulate the necessity of public
adherence to preventive and control measures, which is
influenced by their knowledge, attitudes, and practices (Al-
Hanawi et al., 2020).
The survey on 314 student nurses showed that the
majority of the participants were aware of COVID-19
related knowledge, exhibit a positive attitude and dynamic
practice throughout the outbreak showing the effect of
massive public education campaigns, such as social media
(Peng et al., 2020). Although this study shows that the
participants were very much acquainted with the
precautions, symptoms, and transmission of the virus, it
also manifests that more than half of the participants were
still convinced that having close contact or eating wild
animals causes COVID-19. A total of 169 or 53.8% of the
participants erroneously answered on this item. This
exhibits that these participants still adhere to the claims
that the virus came from bats that were ingested by people
in a marketplace in Wuhan despite the fact that several
reports are claiming that there may have animals that
tested positive for this virus, but there is still no evidence to
suggest that animals are capable of transmitting the
infection to humans (Ohio State University, 2020; Centers
for Disease Control and Prevention, 2021). Another
significant error was 178 (56.7%) of the respondents
compared to adults who may be due to thinking that
children have a weaker immune system, but experts
believe that children are not at higher risk but is equally
susceptible to the virus as adults do (Beusekom, 2020).
Several factors were also incorporated to see if there
would be any differences in the knowledge of participants.
Among the characteristics of the respondents, the year
level and the type of school appear to have a significant
difference. The study revealed that third-year students
have a higher mean score than other levels. This is
different from other studies that show a higher level of
knowledge in fourth and fifth-year students (Noreen et al.,
2020). This reflects the effectiveness of the new nursing
curriculum where the nursing subject for communicable
diseases is now embedded in the third year, giving them
more opportunities to have further information about such
diseases at an earlier time. It also came to light that
students from public schools have a higher mean score
than students from private schools, congruent with other
studies (Peng et al., 2020). This may be rooted in private
schools’ inferiority in terms of numbers, including quantity
and quality of students and teachers, as well as support
from authorities (The World Bank, 2011).
The result for assessment of the participants’ attitude
exhibits notable data. Although almost all of them have a
positive attitude in following measures to address the
spreading of the virus, 39.2% of them think that the current
situation will not be controlled anytime sooner. Nearly half
of them (47.1%) also think that the country’s austere
measures will not be able to control this pandemic. These

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 Quisao, E. Z. S., Tayaba, R. R. R., & Soriano, G. P. (2021)
outcomes show a remarkable number of individuals who
are not assertive in the government’s movement and
immediate response, including austere lockdowns,
suspension of public transports, school classes, leisure
activities, and implementation of a curfew in disparate
cities. However, some of the participants have been
pessimistic regarding this issue owing to the fact that
people tend to experience negative emotions, such as
panic and anxiety, throughout the time of the pandemic that
could influence their attitude. Further, gender and the type
of school were showed to have a significant difference. The
results showed that women tend to be more optimistic and
have a positive attitude towards this crisis which is also
reflected in several studies (Noreen et al., 2020).
Overall, the majority of the participants abides by the
control and preventive measures that the health workers
along with the authorities enacted. This showed beyond
doubt the eagerness of the participants to adjust and
undergo behavioral changes in the face of the COVID-19
pandemic. The participants espoused good and safe
practice for the reason that the government’s palpable
campaign towards the disease influenced the behavioral
change of the individuals.
Based on our knowledge, this is the first study
conducted to analyze the knowledge, attitude, and practice
related to COVID-19 among student nurses in the
Philippines. For that reason, it offers valuable information
about public health education and prevention in Philippine
universities during the COVID-19 pandemic. Our findings
show that most Filipino undergraduate students have a
basic understanding of COVID-19, though their
performance varies by school type and year level. There is
a difference based on gender and type of school based on
the attitude towards COVID-19. These findings indicate
that gender, year level, and type of school can influence
students' responses to the COVID-19 outbreak and
acquisition of public health education, which should be
brought to the attention of educators and health officials.
These factors should also be considered when developing
contingency plans or preparation for students in the event
of potential public health emergencies.
Conclusion
The current study was able to lay out an extensive
exploration concerning the knowledge, attitude, and
practice of the student nurses in the Philippines towards
COVID-19. Knowledge about COVID-19 is pondered to be
the first step in overcoming infectious disease. In addition,
being educated about its basic information, such as its
transmission and causes, increased the possibility of
people being mindful of the spread of communicable
diseases. The outcome proves that Filipino student nurses
have a justifiable level of knowledge in the said disease
and are mainly optimistic in their perspective in controlling
the pandemic. Nevertheless, having constant reminder
from the authorities and health care professionals are the
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
208
solution to aid public knowledge and comprehension
relating to COVID-19.
Declaration of Conflicting Interest
The authors have no conflict of interest to disclose.
Funding
This research did not receive any specific grant from funding
agencies.
Acknowledgment
The authors would like to express their sincerest gratitude to all
the students who participated in the study.
Author Contribution
All the authors have made a substantial contribution from
conception to the finalization of this study. EZQ was involved in
the conception of the study, data collection, and revising the article
for important intellectual content. RRT was involved in the
conception of the study, the collection of data, and editing the
article for important intellectual content. GPS was in charge of the
conception and design of the study, analysis and interpretation of
data, and revising the article for important intellectual content. All
authors approved the final version of the article.
Author Biographies
Earl Zedrick S. Quisao and Raven Rose R. Tayaba are Bachelor
of Science Nursing students at San Beda University, College of
Nursing, Manila, Metro Manila, Philippines.
Gil P. Soriano, MHPEd, RN is an Assistant Professor at San Beda
University, College of Nursing, Manila, Metro Manila, Philippines,
and at Wesleyan University Philippines, Graduate School,
Cabanatuan City, Nueva Ecija, Philippines.
Data Availability Statement
The datasets generated during and/or analyzed during the current
study are available from the corresponding author on reasonable
request.
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Original Research
BNJ
The effect of warm compresses on Belitung Nursing Journal
Volume 7(3), 210-218

perineal tear and pain intensity

© The Author(s) 2021
https://doi.org/10.33546/bnj.1452

during the second stage of labor:

A randomized controlled trial
Soumaya Modoor1,2, Howieda Fouly1,3* , and Hawazen Rawas1

Abstract
Background: Warm compress is believed to reduce perineal tear occurrence and decrease pain intensity during
the second stage of childbirth.
Objective: This study aimed to determine the effect of warm compresses on perineal tear and pain intensity during
the second stage of labor.
Methods: A randomized controlled trial was conducted between 28 September 2018 to 30 October 2018 in King
Khaled Hospital (KKH), affiliated with the Ministry of National Guard Hospital Affairs, King Abdul-Aziz Medical City
Western Region, Saudi Arabia. According to eligibility criteria, the sample randomly recruited through lottery
included 100 primigravida pregnant women, with 50 in each intervention and control group. Data were presented
in the form of frequency and percentages, standard deviation, and mean. Chi-square test was used for data
analysis, with p-value significance at ˂ 0.05.
Results: Sociodemographic data revealed no statistically significant difference in the age, education, occupation,
and residence of both the control and experimental group. The perineum area’s pain intensity after birth showed a
statistically significant difference between the intervention and the control groups (p = 0.001). The perineal tear was
also significantly different between both groups (p = 0.001).
Conclusion: The applied warm compresses on the perineum area positively reduce second and third-degree
perineal tear and pain intensity during the second stage of labor and after childbirth. Therefore, midwives and nurses
are expected to actively provide effective planned in-service training programs regarding warm compresses'
advantages in the second stage of labor and apply this procedure actively.

Keywords
pain; pregnant women; perineum; midwifery; hospitals; laceration; nursing; Saudi Arabia

Before the 1930s, women gave birth to children in home
settings assisted by traditional midwives. During this time,
childbirth was a dangerous affair because many pregnant
women and newborns lost their lives during or following
childbirth (Corretti & Desai, 2018). However, during
intrapartum, different intervention techniques can inhibit the
risk, like the choice of instrument for operative vaginal
delivery, maternal birthing position, perineal massage,
application of warm compresses, episiotomy, and manual
perineal support (MPS) (Gupta et al., 2017).
Labor is the process through which a fetus is delivered
after 24 weeks of gestation. Labor begins when uterine
contractions become consistent and cervical effacement
and distention increase (Wahyuni et al., 2017). The first

1 Article Info:
College of Nursing, King Saud Bin Abdul-Aziz University for Health
Sciences, Kingdom of Saudi Arabia Received: 24 March 2021
2 Revised: 25 April 2021
Maternity and Children Hospital, Makkah, Kingdom of Saudi Arabia Accepted: 26 May 2021
3
Faculty of Nursing, Assiut University, Egypt

Corresponding author:
Assist. Prof. Dr. Howieda Fouly
College of Nursing, King Saud bin Abdul-Aziz University for Health
Sciences, King Abdul-Aziz Medical City, National Guard Health Affairs
Mail Code 6565 | P.O.Box.9515 Jeddah, 21423 Kingdom of Saudi Arabia
Telephone: 966 22246666 Ext. 46243 Phone No: 966538472739
Email: foulyh@Ksau-hs.edu.sa | hoida.elfouly2@aun.edu.eg
This is an Open Access article distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 International License, which allows
others to remix, tweak, and build upon the work non-commercially as long as
the original work is properly cited. The new creations are not necessarily
licensed under the identical terms.
E-ISSN: 2477-4073 | P-ISSN: 2528-181X

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

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 Modoor, S., Fouly, H., & Rawas, H. (2021)
stage of labor occurs in two phases: the latent stage, the
time taken for the cervix to open to 3 centimeters, and the
active phase, which is the time taken from 3 centimeters to
the complete opening of the cervix. During this stage of
labor, the main problem is the failure to progress, which
diagnosed if there is less than 2 centimeters dilatation in 4
hours or decelerating progress in parous women. Labor
that is slow from the beginning is known as dysfunctional
labor, whereas having sudden complications in previously
progressive labor is referred to as arrest (Collins et al.,
2008). Causes of unsatisfactory progress include inefficient
uterine activity, malpresentation, or a large baby.
Our study's primary focus is that the second stage of
labor encompasses the period between the full dilatation of
the cervix and childbirth. The active part begins when the
mother starts pushing using the abdominal muscles to
"bear down." Different positions may be used during this
stage, such as standing, squatting, a supine position, or an
all-fours pose (Pillitteri, 2010). On the other hand, the
perineum may be complicated by the fetal head, expanding
the anus as it comes down. Therefore, to support the
perineum, a pad may be used to hold the perineum and
shield the anus while the other hand conserves flexion,
thereby regulating the head’s rite of passage, reducing
perineal expansion, and minimizing tears (Geranmayeh et
al., 2012). Delivery should occur within three hours of the
second stage of labor in nulliparous women and two hours
for multiparous women (Simkin et al., 2016).
During childbirth in the second stage, women could
have a perineal trauma to the genitalia. The first-degree
tear occurs spontaneously in the perineal skin; the second‐
degree tear consists of the perineal muscles and skin; the
third‐degree tears include the anal sphincter complex, and
the fourth-degree tears include anal sphincter complex and
anal epithelium (Fernando et al., 2015). Moreover, trauma
may also result from prolonged pressure on the perineal
nerve area during more prolonged childbirth labor
(Akbarzadeh et al., 2016). The two classifications of
perineal trauma: spontaneous perineal trauma or tear and
episiotomy (National Institute for Health and Care
Excellence; Essa & Ismail, 2016).
The midwives and nurses should only consider
episiotomies in specific situations, such as complicated
vaginal delivery, breech, forceps, shoulder dystocia, and
ventouse deliveries. A midwife or a nurse may also choose
to perform an episiotomy when there are symptoms of fetal
distress or signs that massive perineal trauma may occur.
The indications of extensive perineal trauma include
numerous perineal tears and perineal buttonholing
(Oladapo et al., 2018). Moreover, perineal tears usually
happen in women following vaginal childbirth that exert
undue pressure on the perineum. It is classified into four
groups depending on the extent of tissue damage. First-
degree tears affect the skin around the perineum only,
whereas second-degree tears damage the perineum and
muscles. An episiotomy is an example of a second-degree
tear. Third-degree perineal tears, on the other hand,
involve damage to the anal sphincter complex. The three
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
211
forms of third-degree tears are 3a, 3b, and 3c. In 3a tears,
less than half of the external anal sphincter is destroyed,
whereas 3b tears involve the destruction of more than half
of the same anatomical area. In 3c tears, the internal anal
sphincter is wrecked. Fourth-degree tears entail the
destruction of the perineum, including the anal sphincter
complex (internal and external) and the anal or rectal
epithelium (Goh et al., 2018).
It appears that there is a relationship between the
extent of perineal trauma and the effect on pain intensity.
The highest reports of complaining due to perineal pain
come from women who have third- or fourth-degree tears
through the anal sphincter and rectal canal. Women with
intact perineum have a low risk for infection, less blood
loss, and less pain after childbirth. Most vaginal births are
associated with tears or trauma in the perineal area
(Aasheim et al., 2017). Midwives and nurses use various
management techniques of the perineum, which play a
significant role in reducing episiotomy and decreasing or
minimizing perineal trauma. One of the most common is
warm compresses (Moore & Moorhead, 2013).
Furthermore, a randomized controlled study by Essa
and Ismail (2016) reported that pain intensity declined after
warm compresses measured by VAS among the study
group, and a strong significant effect was noticed on
decreasing the episiotomy rate. In general, it is due to the
potential treatment effects, including vasodilation,
increased blood flow, tissue extensibility, muscle
relaxation, and pain (Akbarzadeh et al., 2016). Studies in
various parts of the world involving warm compresses
during second-stage labor in nulliparous and primiparous
women reported that it reduces the intensity of perineal
pain. These findings were reported by Ibrahim et al. (2017)
in Egypt, Baba et al. (2016) in Japan, and Ali et al. (2004)
in Pakistan, among other countries.
However, many countries have not implemented
significant beneficial practices. Instead, they uphold
ineffective or deleterious practices. For example, routine
procedures such as shaving of the pubic hair, episiotomy,
seizures, electronic fetal monitoring, and intravenous (IV)
infusion are commonly observed in some Saudi Arabia
areas (Altaweli et al., 2014). The debate still occurs
because some researchers recommended warm
compresses (Essa & Ismail, 2016; Aasheim et al., 2017),
while others found them to have limited or no benefits (Zare
et al., 2014). The use of warm compresses to prevent or
reduce the incidence and degree of perineal tear and pain
is still controversial (Ibrahim et al., 2017). These
contradictory results necessitate several studies to fill the
gap in this respect. Therefore, this study aimed to
determine the effect of warm compresses on perineal tear
and pain intensity during the second stage of labor.
Methods
Study Design
This study applied a randomized controlled trial, post-test
only design. The investigator allocates participants to an
 Modoor, S., Fouly, H., & Rawas, H. (2021)
experimental or control condition on a random basis. So,
this study tested if the independent variable, warm
compresses, affected the dependent variables: perineal
outcome and pain intensity.
Setting
Our study was conducted between 28 September 2018 to
30 October 2018 in King Khaled Hospital (KKH), affiliated
with the Ministry of National Guard Hospital Affairs, King
Abdulaziz Medical City – Western Region, Saudi Arabia. It
is a 600 bedded Joint Commission International (JCI)
accredited Tertiary level Hospital. The setting area for this
experimental study was conducted in the labor and delivery
(L&D) unit, which has six beds for delivery, three beds for
induction of labor, and one room for operation room (OR).
The patient characteristic and information attained from
best care (medical record and patient).
Participants
All the primiparous pregnant women during the second
stage of labor participated randomly in this study. The
inclusion criteria include age from 18-35 years old,
primigravida, healthy pregnancy, singleton pregnancy,
cephalic presentation, full-term, and no contraindication for
vaginal delivery. The exclusion criteria were multiple
pregnant women, complicated labor, the coexistence of
any medical or obstetrical risk factors, and pregnant
women deliver a cesarean section.
Figure 1 Flow chart for the recruitment of the sample
Instruments
The instruments in this study consisted of 1)
Sociodemographic Tool comprising socio-demographic
characteristics including women's age and education level,
occupation, previous admission to the hospital, reproductive
history gestational weeks, number of prenatal care visits.
The information is attained from medical records and
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The number of births in hospitals is estimated at 3000
births every year. The G*power software program (Faul et
al., 2007) was used to calculate the sample size. The
program allows sample size analyses and high-precision
power. Besides, it computes the power values for sample
size, effect size, and alpha levels. The aim was to achieve
the power of 80% with effect size = 0.3, a err prob = 0.05,
power (1-B err prob) = 0.80. The estimation was based on
two tails a = 0.05. After calculation by G*Power, the sample
size was 90 and added 10% for the dropped cases, with a
total sample size of 100 primigravida pregnant women who
met the inclusion criteria.
The investigator applied a simple random technique
(lottery) through the participants' allocation into an
experimental group or control group on a random basis.
Each participant assigned the experiment by letter (A) and
control by letter (B). Then paper folded and mixed inside a
box, and the investigator asked one of the nurses to pick a
number from the box. Then the participant was allocated to
either the experimental group or control group (Figure 1).
To avoid bias, the investigator divided the rooms for the
control or experimental groups based on the women’s
choices of the closed envelope. The experimental group
room was numbered with an odd number, like 1, 3, and the
control group's room was numbered with an even number
like 2, 4,….etc.
patients; 2) Numeric Rating Scale (NRS) For Pain (Hawker
et al., 2011). The investigator got permission to use the NRS
tool for pain assessment. It ranged from zero pain to 10
severest pain in between the two extremity points equal
distances measured 1cm as mild pain (1-2) moderate (3-4),
severe (5-6), very severe (7-8), and severest pain (9-10).
The NRS can be administered verbally or graphically for
 Modoor, S., Fouly, H., & Rawas, H. (2021)
self-completion. The investigator asked the women to reveal
a numeric value on the scale that best describes their pain
degree scoring. The number that the women indicate to rate
their pain intensity was recorded. The scores extend from
0–10; 3) Assessment Tool for Perineal Outcomes. It
includes perineal outcome assessment questions in the
form of an intact perineum, perineal tears degrees “first,
second or third”, and episiotomy guided by the obstetrician
diagnosis and previous studies (Farghaly et al., 2017; Lane
et al., 2017).
All tools were tested for content validity by a jury of four
experts in woman health nursing and one from the
biostatistics field from the College of Nursing, King Saud Bin
Abdul-Aziz University. A previous study also tested the
reliability of the tool (Ibrahim et al., 2017). In addition, the
second stage and perineal outcome assessment
questionnaire were evaluated using Cronbach's Alpha
coefficient test. The instrument contained relatively similar
items, indicated high reliability, with an internal consistency
of 0.81.
Before the primary data collection phase, the tools for
the study were tested at National Guard in King Khaled
Hospital, with ten patients. Those patients were not included
in the main study. It took around one week to accomplish.
The data were collected quickly with the interpretation of
participant outcomes.
Figure 2 Flow chart of the procedure
Data Analysis
SPSS program version 20 was used for statistical analysis.
The variables are presented in the form of frequency and
percentages, standard deviation, and mean. The Chi-
square test was used to compete for categorical variables
and test a significant difference between the study groups'
outcome criteria. P-value was set at <0.05 for statistically
significant criteria.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
213
Intervention
The control group received routine hospital care during the
second stage of labor, such as half-hourly monitoring and
documenting the frequency of contractions, assessing the
vital signs, and checking the frequency of micturition or
catheterization to evacuate the bladder. In addition, a
vaginal examination was done after abdominal palpation
without warm compresses.
The intervention group received routine hospital care
in addition to the application of the warm compresses.
First, the application of warm compresses was made
through applying a sterile perineal pad (gauze) socked in
warm water with a temperature range from 45C-59C
measured by lotion thermometers, and the soaked each
perineal pad was squeezed before being placed in the
perineum area. Then the warm compresses are given
continuously until bulging of the head (Figure 2).
Data Collection
The investigators collected data in the labor room between
23 August 2018 to 30 October 2018. The investigators
directly observed, measured, and recorded the pain and
perineal outcomes for both groups using the validated
instruments. The participants were also asked to enumerate
the severity of pain they have experienced after birth. A
trained health member was assigned to assist the
researcher in obtaining consent and interviewing the
participants.
Ethical Consideration
Ethical approval in this study was obtained from the
research unit committee at the College of Nursing, Jeddah,
and from King Abdullah International Medical Research
Center (KAIMRC) with approval number of IRBC/ 1711/18
on 27 September 2018. Prior to the study, each participant
has signed informed consent. The investigators explained
the nature of the study objectives and a clear explanation
 Modoor, S., Fouly, H., & Rawas, H. (2021)

of data collection. Confidentiality was also ensured by
explaining to the participants that all information was used
only for research purposes and their identities were in the
form of numbers, not names. In addition, the data collected
could only be accessed by the investigators only. All
participants also had the right to withdraw from the study at
any time without penalty.
Results
Table 1 shows that the majority of the participants in this
study aged between 23-26 years, 46% of the control group
and 50% of the experimental group, respectively. The Chi-
square test revealed no statistically significant difference in
age between both groups (p = 0.918). In addition, more
than half of them in both groups respectively graduated
from university (55%), and there was no statistically
significant difference in educational qualification (p =
0.864). The majority of the participants worked as
housewives (75%) and lived in the urban areas (84%), and
most of them had enough income per month (91%). There
were no significant differences in occupation, current
residence, and family income between the control and
experimental groups (p > 0.05). It is noted that gestational
age was similar because of the inclusion criteria of the
participants (37-42) weeks, so it was not included in the
table.

Table 1 Sociodemographic characteristics for control and experimental groups for study participants

Items Control Experiment Total p-value

n (%) n (%) N (%)
Age (year)
18-22 14 (28.0) 14 (28.0) 28 (28.0) 0.918
23-26 23 (46.0) 25 (50.0) 48 (48.0)
27-30 10 (20.0) 5 (10.0) 15 (15.0)
31-35 3 (6.0) 6 (12.0) 9 (9.0)
Educational qualification
Primary school 3 (6.0) 3 (6.0) 6( 6.0) 0.864
High school 19 (38.0) 20 (40.0) 39 (39.0)
Collegiate education 28 (56.0) 27 (54.9) 55 (55.0)
Occupation
Working 10 (20.0) 8 (16.0) 18 (18.0) 0.261
Housewives 38 (76.0) 37 (74.0) 75 (75.0)
Business 2 (4.0) 4 (8.0) 6 (6.0)
Any other specify (online business) 0 1 (2.0) 1 (1.0)
Current residence
Urban 43(86.0) 41 (82.0) 84 (84.0) 0.622
Rural 7(14.0) 9 (18.0) 16 (16.0)
Family income/month
More than enough 0 2 (4.0) 2( 2.0) 0.743
Just enough 47 (94.0) 44 (88.0) 91 (91.0)
Not enough 3 (6.0) 4 (8.0) 7 (7.0)

Table 2 shows that 28% of the total participants' gestational most participants did not attend any antenatal care classes
age was between 38 - 39 weeks. However, 6% of (91%), and more than two-thirds of participants registered
gestational age was 37 weeks. Regarding pelvic training, for seven visits during the pregnancy period (70%).

Table 2 Obstetrical history of study participants

Items Control Experiment Total Mean Std.

n (%) n (%) N (%) Deviation
Week of gestation
37 weeks 2 (2.0) 4 (4.0) 6 (6.0) 39.1 1.136
38 weeks 11 (11.0) 17 (17.0) 28 (28.0)
39 weeks 16( 16.0) 12 (12.0) 28 (28.0)
40 weeks 13 (13.0) 12( 12.0) 25 (25.0)
41 weeks 8 (8.0) 5 (5.0) 13 (13.0)
Did you receive pelvic training
Yes 6 (6.0) 3 (3.0) 9 (9.0) 1.91 0.287
No 44 (44.0) 47 (47.0) 91 (91.0)
Items Median IQR
Number of antenatal care visits 7.00 7.00

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 Modoor, S., Fouly, H., & Rawas, H. (2021)

Table 3 shows that two-fifth of the experimental group
(40%) revealed lesser mild pain than the control group
(52%). There was a statistically significant difference in
mild pain in both groups (p = 0.001). In addition, more than
half of the experimental group (52%) reported moderate
pain than the control group (34%), and there was a
statistically significant difference in moderate pain (p =
0.001). Also, a significant difference was found in severe
pain (p = 0.001), which was higher in the control group
(14%) than the experimental group (8%). There was no one
having very severe or worst pain.

Table 3 Comparing the degree of pain among experimental and control groups immediately after birth (N = 100)

Pain after birth Control Experiment Total df Chi-square p-value

n (%) n (%) N (%)
Mild pain (1,2) 26 (52.0) 20 (40.0) 46 (46.0) 4 54.6 0.001
Moderate pain (3,4) 17 (34.0) 26 (52.0) 43 (43.0) 4 54.8 0.001
Severe pain (5,6) 7 (14.0) 4 (8.0) 11 (11.0) 1 34.1 0.001
Very severe (7,8) 0 (0.0) 0 (0.0) 0 (0.0) 0
Worst pain (9,10) 0 (0.0) 0 (0.0) 0 (0.0) 0

Table 4 shows that there were significant differences in
perineal condition between the experiment and control
groups (p = 0.001), which the percentage of intact
perineum was higher in the experimental group (22%) than
in the control group (10%). In addition, those in the control
group had a higher number of episiotomy (24%) than the
experiment group (18%), and the majority of the control
group (66%) and the experimental group (60%) had a
perineal tear.

Table 4 Effect of warm compresses on the perineal outcome for the experimental and control group (N = 100)

Perineal Condition Control Experiment Total Chi-square p-value

n (%) n (%) N (%)
Intact 5 (10) 11 (22) 16 (16) 50 0.001
Episiotomy 12 (24) 9 (18) 21 (21) 58 0.001
Tear 33 (66) 30 (60) 63 (63) 38 0.001

Table 5 shows a significant difference in the degree of experimental group had lower degrees of perineal tear in
perineal tear in both groups (p = 0.043). However, the the first, second, third degree than the control group.

Table 5 Comparison of degree perineal tear between the experimental versus control group (N = 100)

Degree of Perineal Control Experiment Total Chi-square p-value

Tear n (%) n (%) N (%)
First degree 13 (31.7) 19 (61.3) 32 (44.4) 66.8 0.043
Second degree 24 (58.5) 10 (32.3) 34 (47.2)
Third degree 4 (9.8) 2 (6.5) 6 (8.3)
Fourth degree 0 (0.0) 0 (0.0) 0 (0.0)

Discussion by a study of Dahlen (2012) that examined pain intensity

Perineal injuries during childbirth may affect our goal to
maintain perineal preservation, especially among
primiparous women. Therefore, interventions for reducing
perineal trauma and perineal pain are desirable. Midwives
and nurses widely advocate warm compresses to reduce
perineal trauma and improve comfort during the second
stage of labor (Aasheim et al., 2017).
Our study aimed to assess the effect of warm
compresses on the occurrence of perineal tears and pain
intensity during the second stage of labor. The findings
revealed that the follow-up measurement for pain intensity
after birth in both the control and experimental groups with
no statistically significant differences for pain score
measurement at p = 0.175. These findings are supported
during the second stage of labor after warm packs. In this
study, among women who received warm packs, their pain
intensity score was less than those who received standard
care. As such, women who had warm packs were
significantly less likely to report lousy pain or the worst pain
experienced at birth compared with women who received
routine care without the application of warm packs. Also,
our findings reported mild and moderate degrees of pain in
the intervention group.
Furthermore, Dahlen (2012) examined the concepts of
comfort and pain, including warm compresses' positive
effects on reducing pain, and fewer women reported that
the warm compresses helped to numb their perineum area.
It seems that the warm compresses helped women to deal
with the stinging sensation experienced in the perineum
during the second stage of labor, also described by

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 Modoor, S., Fouly, H., & Rawas, H. (2021)
midwives as the "ring of fire." Being able to get comfortable
is a significant predictor of feeling in control during labor
and birth.
Likewise, a study done by Ahmad and Turky (2010)
found that pain scores were better for the women who used
warm compresses compared to other women during the
second stage at different points of time. This finding may
reflect the benefit of using warm compresses through the
second stage of labor. In addition, Akbarzadeh et al. (2016)
reported that the warm compresses yielded significantly
decreased pain during the second stage of labor by
increasing blood flow to the damaged or inflamed area,
which increased the elasticity of the collagen, which helps
increase tissue flexibility and provide a good feeling and
psychological convenience, which reduces the pain. In the
same vein, warm compresses can relieve pain by
enhancing blood circulation in the perineum (Ozgoli et al.,
2016).
Regarding perineal tears, the results in this study
revealed that the experimental group was better than the
control regarding the intactness of the perineum. However,
the experimental group had fewer perineal tears than the
control group. Interestingly, the experimental group had
fewer participants who received an episiotomy after
childbirth than the control group. Further, the effect of warm
compresses on different degrees of perineal tears reflected
a statistically significant difference between both control
and experimental groups at p < 0.043, with better
outcomes for the experimental group than the control
group in reducing the third degree of laceration and
maintaining perineal integrity
Regarding stitches of the perineum, two previous
randomized studies agreed with the current study indicated
that warm compresses had no effects on the reduction of
stitches in primiparous women, confirming the long-term
effects of warm compresses (Dahlen, 2012). Likewise,
Dahlen et al. (2009) support our findings, as no reduction
was reported in perineal suturing after application of warm
packs, and the trial was underpowered to assess third- and
fourth-degree tear. Meanwhile, a study by Akbarzadeh et
al. (2016) was not in line with our current research,
reporting that a warm compress was effective in reducing
the rate of episiotomy and the mean length of episiotomy
incision, reducing pain intensity after childbirth and
increasing the rate of an intact perineum, which indicates
the significant effects of warm compresses on the
reduction of lacerations and perineal trauma. Another
study by Aasheim et al. (2017) also reported that midwives
applied different techniques to decrease perineal trauma,
genital trauma, episiotomy, pain intensity lubricant
massage, and antenatal pelvic training. However, no
studies declared the most effective method for reducing
the laceration of the perineum during childbirth. Even
though physiology literature has indicated that using a
perineal pack during the second stage of labor leads to
vasodilation, increased blood flow in the perineum area,
increased relaxation, and increased muscle stretch, which
was effective in pain transmission through reduction of
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
216
nociceptive stimulation and improving comfort for pregnant
women (Ozgoli et al., 2016).
Dissimilar to Essa and Ismail (2016), which was not in
line with the present study’s results, revealing a significant
reduction in episiotomy and vaginal/ perineal tear among
the study group (p < 0.000). This finding may reflect the
benefit of applying warm compresses on the perineum
during the second labor stage. In addition, Mohamed et al.
(2011) found that using a warm compress in the perineum
area during the expulsive period reduces the occurrence of
perineal laceration.
A study of Essa and Ismail (2016) has a dissimilarity
with our study related to sample size, as theirs was more
significant than the current study's. Besides, the perineal
pad's material was different, as their study used a towel,
but our study used a perineal pad made of gauze layers.
Additionally, these findings boost the use of perineal warm
compress by trained birth attendants, in line with the meta-
analyses study by Aasheim et al. (2017), which found a
significant effect of using warm compresses on third- and
fourth-degree tears.
In the present study, findings revealed that warm
compresses' application showed a reduction in third- and
fourth-degree tears, reducing second-stage perineal
trauma in primiparous women. In the same vein, Aasheim
et al. (2017) also found that warm compresses and
massage may reduce severe perineal trauma and third- or
fourth-degree tears. Hands‐off techniques may decrease
the number of episiotomies, but it was not clear that they
had a valuable effect on other perineal trauma.
Many advantages occur from applying warm
compresses that produce relaxation by reducing muscle
spasms and reducing pain intensity during childbirth. This
study reflects the benefit of using warm compresses to
decrease the perineal trauma, which is evident by reducing
the second and third-degree tear rate in the experimental
group compared with the control group. Therefore, all
governmental/educational hospitals should provide
effective planned in-service training programs for maternity
nurses regarding warm compresses' advantages during
the second stage of labor. Further research is required to
assess the effect of warm compresses on multiparous
women relating to receiving the same benefit of
comfortable and relief pain degree during the second stage
of labor integrating with assessing woman's satisfaction
regarding the use of warm perineal compresses during the
second stage of labor.
The limitation of the study might include: First, eligible
participant criteria as primiparous women lead to difficulty
collecting data within the determined time of data
collection. Second, most participants showed satisfaction
regarding warm compresses, but the satisfaction variable
was not included in this study.
Conclusion
This study concluded that the application of warm
compresses during the second stage of labor has better
 Modoor, S., Fouly, H., & Rawas, H. (2021)
effects on perineal outcomes. In addition, it showed
evidence of other benefits regarding the positive effect on
reducing the second and third-degree of perineal tear and
pain intensity to lower pain degrees within the experimental
group. Therefore, the practice of applying warm perineal
compresses in the second stage of labor is highly
acceptable by mothers and midwives or nurses in helping
to reduce perineal pain and increase comfort. Furthermore,
the finding reveals that the experimental group that
experienced intact perineum reducing tear and pain is
better than the control group. Interestingly, the
experimental group lesser episiotomies compared to the
control group.
Declaration of Conflicting Interest
The authors declare no conflict of interest in this study.
Funding
None.
Acknowledgment
We acknowledge the maternity nurses at King Abdulaziz Medical
City's labor and delivery department for cooperation during data
collection.
Author Contribution
HF drafted the article and language editing. SM reviewed the
literature and data collection. HF, HR, and SM contributed to study
design and concept, critically reviewed and approved the final
version of the manuscript.
Author Biographies
Soumaya Modoor, RN had a Master of Midwifery Nursing at the
College of Nursing King Saud Bin Abdul-Aziz University for Health
Sciences, Kingdom of Saudi Arabia. Currently, she is a Senior
Midwife Specialist at the Maternity and Children Hospital, Makkah,
Saudi Arabia.
Howieda Fouly, PhD, RN is an Assistant Professor of Maternity
Nursing, College of Nursing King, Saud Bin Abdul-Aziz University
for Health Sciences, Kingdom of Saudi Arabia, and Associate
professor, Faculty of Nursing, Assiut University, Egypt.
Hawazen Rawas, PhD, RN is an Assistant Professor of Medical-
Surgical Nursing, College of Nursing, King Saud Bin Abdul-Aziz
University for Health Sciences, Kingdom of Saudi Arabia.
Data Availability Statement
The datasets generated during and/or analyzed during the current
study are available from the corresponding author on reasonable
request.
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Cite this article as: Modoor, S., Fouly, H., & Rawas, H.
(2021). The effect of warm compresses on perineal tear and
pain intensity during the second stage of labor: A randomized
controlled trial. Belitung Nursing Journal, 7(3), 210-218
https://doi.org/10. 33546/bnj.1452
Original Research
BNJ
DAHAGA: An Islamic spiritual Belitung Nursing Journal
Volume 7(3), 219-226
© The Author(s) 2021
mindfulness-based application to https://doi.org/10.33546/bnj.1494

reduce depression among nursing

students during the COVID-19
pandemic
Meidiana Dwidiyanti1* , Badrul Munif2 , Agus Santoso1, Ashri Maulida Rahmawati3, and
Rikhan Luhur Prasetya3

Abstract
Background: The COVID-19 pandemic significantly impacts students’ mental health. Most of them may experience
depression. Due to restrictions and social distancing during the pandemic, counseling may not be applicable in
detecting the problems. Therefore, an Islamic spiritual mindfulness-based application called DAHAGA is created in
order to detect and reduce depression. It is believed that this innovative app could reduce mental health problems
among students.
Objective: This study aimed to determine the effect of DAHAGA on reducing depression among nursing students
during the COVID-19 pandemic in Indonesia.
Methods: This was a quasi-experimental study with a comparison group pretest/posttest design conducted from
May to June 2020. Seventy students were selected using convenience sampling, of which 35 were assigned in an
experimental group and a comparison group. The validated Indonesian Version-Beck Depression Inventory-II (BDI-
II) was used for data collection. Paired t-test and independent t-test were used for data analysis.
Results: There was a significant effect of DAHAGA on depression (p < 0.001). The level of depression after
intervention (mean 11.49, SD 4.49) was lower than it before the intervention (mean 17.20, SD 4.94). Additionally,
there was a significant difference in depression level between the experimental and comparison groups after the
intervention with a p-value of < 0.001.
Conclusion: The DAHAGA is proven effective in reducing depression. Therefore, this study offers a new and
innovative app that fits with the COVID-19 pandemic to help Muslim students maintain their health status. The
findings also support Islamic spiritual mindfulness as a part of nursing interventions among psychiatric nurses to
deal with mental health problems, especially depression.

Keywords
COVID-19; mindfulness; nursing; students, mental health, depression; Islam; Indonesia

The outbreak of novel coronavirus diseases (COVID-19)
was first reported at the end of 2019 in Wuhan, China
(Manik et al., 2021). The virus has rapidly spread
throughout the world. On 11 March 2020, the World Health
Organization (WHO) declared the pandemic outbreak
(WHO, 2020; Sadang & Palompon, 2021). Due to this
pandemic, many universities in Indonesia are starting to
implement distance teaching and learning activities or
online lectures (Abidah et al., 2020).

1 Article Info:
Department of Nursing, Diponegoro University, Semarang, Indonesia
2
Nursing Program, Institute of Health Sciences Banyuwangi, East Java, Received: 26 April 2021
Revised: 21 May 2021
Indonesia Accepted: 26 June 2021
3
Master Program in Nursing, Diponegoro University, Semarang,
Indonesia This is an Open Access article distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 International License, which allows
others to remix, tweak, and build upon the work non-commercially as long as
Corresponding author:
the original work is properly cited. The new creations are not necessarily
Dr. Meidiana Dwidiyanti, S.Kp., MSc licensed under the identical terms.
Department of Nursing, Diponegoro University (UNDIP)
Jl. Profesor Soedarto, SH, Tembalang, Semarang, Indonesia 50275 E-ISSN: 2477-4073 | P-ISSN: 2528-181X
Phone/Fax: 08164891140. E-mail: meidiana@fk.undip.ac.id

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

219
 Dwidiyanti, M., Munif, B., Santoso, A., Rahmawati, A. M., & Prasetya, R. L. (2021)
Even before the COVID-19 pandemic, research shows
that many nursing students experience depression (Tung
et al., 2018). Similarly, Njim et al. (2020) reported that the
prevalence of depression among nursing students in two
regions in Cameroon reached 69.57%, and 26.40% of
these students experienced severe depression. However,
Asia was the region with the highest prevalence of
depression in nursing students (43.0%) (Tung et al., 2018).
The majority of depression can be increased depending on
stressors and environmental conditions (Acharya et al.,
2018).
There is no doubt that the pandemic exacerbates
depression among students (Graupensperger et al., 2020).
Multiple stressors in a pandemic situation contribute to the
increased levels of depressive thoughts among students. A
previous study found that 72.93% of students in Italian
universities experienced depression during the COVID-19
pandemic (Villani et al., 2021). In Indonesia, 41.5% of
nursing students experienced depression during the
pandemic (Hasanah et al., 2020).
Prolonged depression can affect students’ academic
performance and clinical practice (Chernomas & Shapiro,
2013). Also, research showed that 59 and 87% of suicide
victims suffered from severe depression, and up to 15% of
them eventually die of suicide (Gonda et al., 2007). Hence,
it is necessary to identify an appropriate approach to help
nursing students deal with depression or its symptoms.
Islamic spiritual mindfulness is one of the interventions
that adopt an Islamic spiritual approach to deal with
psychological problems and psychiatric disorders (Asiah et
al., 2019). Mindfulness is practiced with a high level of
awareness, believing that every problem an individual is
facing comes from God (Allah), and it is only God (Allah)
that has the power to overcome (Dwidiyanti et al., 2019;
Munif et al., 2019). Previous studies have investigated the
effect of Islamic spiritual mindfulness. It was found that it is
effective on anxiety and depression among pregnant
mothers in Iran (Aslami et al., 2015), drug adherence on
patients with schizophrenia in Indonesia (Ardinata et al.,
2019; Ardinata et al., 2021), the stress of family of patients
with schizophrenia (Utama et al., 2020), depression level
in older people at nursing homes (Arini et al., 2019), and
depression among patients in a psychiatric hospital in
Indonesia (Asiah et al., 2019). However, these studies only
focused on depression for non-students and were
conducted before the pandemic.
The application of Islamic spiritual mindfulness and the
detection of depression among students may not be
adequate and limited during the COVID-19 pandemic due
to the restriction and social distancing. In fact, most
students are studying from home, and the teachers are
unable to monitor. Therefore, the researchers in this study
developed an innovative application called DAHAGA
(Deteksi Sehat Bahagia/Happy Healthy Detection), an
Islamic spiritual mindfulness app, to prevent or reduce
depression among students. As the application has not yet
been studied, this study aimed to determine the effect of
DAHAGA on reducing depression among nursing students.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
220
This study would benefit mental health nursing services
that aim to maintain optimal health and well-being and
prevent psychological disorders. Inability to perform self-
care or deal with impaired bodily functions related to mental
and emotional distress is vital in mental health prevention
practices, including avoiding depression and suicides
(Videbeck, 2008). Nurses should be able to identify
problems to prevent depression through innovations that
facilitate the detection of disorders as early as possible,
especially during the pandemic. Thus, DAHAGA would be
the best fit to help nurses and nurse educators to develop
an awareness of the problems faced by nursing students
and identify depression levels to increase the ability to
perform self-care.
Overview of Islamic Spiritual Mindfulness
The Islamic spiritual mindfulness is the combination of
three concepts: mindfulness, spiritual, and Islam.
Mindfulness is simply a state of mind, a process of keeping
one’s mind in the present moment, on purpose, non-
judgmentally, fully observe and accept what is experienced
in life from a place of calm objectivity, and detached from
potentially destructive thoughts and feelings (Creswell,
2017; Dwidiyanti et al., 2019; Munif et al., 2019). Spiritual
means believing and connecting beyond the
physical/material world to the soul and spirit state of
existence (Dwidiyanti et al., 2019; Munif et al., 2019).
Meditation and other relaxation techniques connect the two
concepts, in which we pay attention to thoughts, feelings,
and sensations at that moment without being overwhelmed
or overly reactive while connecting to stronger spirits
(Dwidiyanti et al., 2019; Munif et al., 2019).
Mindfulness is found in various forms, in all religious
and secular traditions, from East to West, and has roots in
Buddhism, Hinduism, Judaism, Christianity, and Islam
(Dwidiyanti et al., 2019; Munif et al., 2019). However, in this
study, we focus only on the Islamic perspective. Islamic
spiritual mindfulness refers to a spiritual state of an
individual who is conscious of the awareness of God (Allah)
over their soul, innermost thoughts/feelings, and actions
(Dwidiyanti et al., 2019; Munif et al., 2019). In other words,
it is comprehensive self-knowledge and self-awareness
that Allah is always watching us at all times, which
consequently will change our actions, feelings, thoughts,
and inner states of being to be better. It can also be
described as a mutual awareness, while we are of Allah,
and Allah is aware of us (Mindful Muslim Life, 2021).
Islamic spiritual mindfulness exercise consists of six
steps (Dwidiyanti et al., 2019): (1) intention - generating a
desire in the heart with full awareness according to needs
prayed to Allah accompanied by the belief of
Muroqobahtullah (the belief of feeling supervised by Allah),
(2) self-evaluation - self-introspection by acknowledging
shortcomings and accepting without judgment of oneself
and generating a desire to correct mistakes, (3) body scan
- realizing every mistake made and believing that Allah is
Most Forgiving by fulfilling the conditions of repentance.
The conditions for repentance are to create a sense of
 Dwidiyanti, M., Munif, B., Santoso, A., Rahmawati, A. M., & Prasetya, R. L. (2021)

regret, stop and be determined not to repeat the sins that
have been committed, and fulfill the rights of others who
have been hurt, such as apologizing, (4) repentance -
focusing on feeling the reactions of the heart and body,
such as pounding, heat in the chest, heaviness in the neck,
etc., and accept these reactions with complete acceptance
and relaxation, (5) prayer - praying to God solemnly then
blowing it into the palm and washing it on the organs of the
body that feel hurt or pain, (6) surrender – giving (oneself)
up to Allah with sincerity to get benefit and prevent harm,
and (7) relaxation - holding the body that hurts or pain, take
a deep breath, and then cough (Dwidiyanti et al., 2019).
that focus on Islamic spiritual mindfulness intervention.
This application offers features that make it easier for
individuals to self-detect depression they experienced.
These features are developed based on the experts’
agreement through a series of workshop meetings. A
patent for the DAHAGA app has also been granted by the
Director General of Intellectual Property, Ministry of Law
and Human Rights, Indonesia (Grant Number:
EC00202114477). The following are the features of the
“DAHAGA” application (Figure 1 and Table 1):

Methods

Study Design
This study used a quasi-experimental design with a
comparison group pretest/posttest design. The study was
conducted from May to June 2020.

Participants
The participants in this study are 148 bachelor nursing
students (semesters one to eight) at the Faculty of
Medicine, Diponegoro University, Indonesia. The number
of participants in this study was calculated using G*Power
3.1 (Faul et al., 2009) with type of a priori power analysis
for independent t-test, with Effect Size (ES) value of > 0.80
(Munif et al., 2019), power of 0.95, and error probability
ratio of 0.05. The total samples needed were 70, with 35 Figure 1 Homepage of DAHAGA App
assigned in an experimental group and a comparison
group.
Random sampling could not be used in this study
because the students would be selected if they fit inclusion
criteria, especially the students who experienced mild
depression as indicated using Beck Depression Inventory-
II (BDI-II), held Islamic religion, and agreed to participate.
So, we conveniently examined the students one by one,
and those who had depression were asked to join the study
until the required samples in each group were fulfilled.

Instrument
The Beck Depression Inventory-II (BDI-II) (Beck et al.,
1996) was used for data collection. The inventory consists
of 21 questions. The Indonesian version of the BDI-II was
available (Sorayah, 2018) and considered valid and reliable
using a confirmatory factor analysis (CFA). Each answer is
scored on a scale value of 0 to 3. Higher total scores
indicate more severe depressive symptoms. The
standardized cutoffs used differ from the original: 0–13
(minimal depression), 14–19 (mild depression), 20–28 Figure 2 Features of DAHAGA App
(moderate depression), 29–63 (severe depression)
(Sorayah, 2018). The explanation of each feature is described in the
following.
Intervention 1. The Problem Feature (or Masalah) is a means to
The experimental group in this study was given spiritual make it easier for someone to detect problems that
training using DAHAGA. DAHAGA was an android-based they had with their closest people (family members,
application that contained mental health service packages such as father, mother, brother, sister, husband,

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 Dwidiyanti, M., Munif, B., Santoso, A., Rahmawati, A. M., & Prasetya, R. L. (2021)

wife, and others), other people (e.g., neighbors,
friends at home or work, and others), and the
environment (Dwidiyanti et al., 2019). The problem
databases in this feature were validated by the
participants of the workshops organized three
times, related to the environmental problems that
were too broad and had to be more specific.
2. The Bad Behavior Feature (or Perilaku Buruk) was
developed based on a focus group discussion with
20 participants. They wrote any bad behaviors on
their books which were then collected and
analyzed. This feature contained 13 items of bad
behaviors, which were validated by the participants
of the workshops organized three times. These bad
behaviors were used as a reference for
independent health targets that should be carried
out. The validation was related to the behaviors
concerning ritual implementation, which need to be
simplified and not too detailed.
This feature is to identify how far the users can
remember and admit (in a mindful state) previous
bad behaviors they have done. The 13 items include
(1) rarely have five times of prayer, (2) seldom read
Qur’an, (3) rarely Dua (a prayer of invocation), (4)
think negatively, (5) jealous, (6) arrogant, (7) Riya
(show-off), (8) hurt others, (9) vindictive, (10) lie,
(11) dirty talk, (12) immoral behavior, and (13)
fornication (eye, mind, and physical).
3. Self-Detection Feature (or Deteksi Diri) contains
seven items of feelings currently expressed by
participants, including angry, broken heart,
sadness, cough, headache, and hard to breathe.
These items were validated by the participants of
workshops organized three times. After the data
related to problems, bad behaviors, and self-
detections were identified, the results were then
used to identify factors causing depression.
Validation was carried out using real pictures to
determine the expression of the problems faced.
4. Independent Health Target Feature (or Target
Sehat Mandiri) contains ten items about
independent health targets that participants
planned to change for improvement. These items
were validated by the participants of workshops
organized three times. This feature serves as a
solution that the participants would achieve after
identifying problems, bad behavior, and self-
detection. During the validation, several targets
were removed as they were confusing and did not
relate to the issues that the participants were
experiencing. The ten items include (1) forgiving
everyone who hurts or disappoints, (2) praying on
time and in a congregation, (3) reading Qur’an every
day, (4) drawing closer to Allah and always prays or
participates in Islamic studies, (5) understanding
yourself and others, (6) being more patient and
sincere, (7) learning to smile, at least a day to
twenty people you meet, (8) thinking positively, (9)
always being grateful and realizing Allah’s grace,
and (10) being more open-minded and not quickly
getting angry.
5. Pretest Feature is to detect depression before the
intervention using the Beck Depression Inventory-II
(BDI-II) (Beck et al., 1996; Sorayah, 2018).
6. Pretest Feature is to detect depression after
intervention using the Beck Depression Inventory-II
(BDI-II) (Beck et al., 1996; Sorayah, 2018).
7. Islamic Spiritual Mindfulness (or Latihan
Mindfulness Spiritual Islam) contains a step-by-step
tutorial / Standard Operating Procedure (SOP) on
Islamic spiritual mindfulness that had been
previously identified by the researchers. In the SOP,
the individuals would be invited to consciously
accept the bad behaviors that had been done and
try to correct them through independent health
targets that would be performed. This feature was
packaged in an audio form that could be listened to
by participants. This mindfulness exercise
contained six steps: intention, self-evaluation, body
scan, repentance, prayer, surrender, and
relaxation. The steps are explained in the
background (overview of Islamic spiritual
mindfulness). The procedure can be done between
10 to 15 minutes.
8. Information Feature (or Informasi Aplikasi)
contains information related to the app, developers,
and contents.
The comparison group was given a book of Islamic
spiritual mindfulness only (Dwidiyanti et al., 2019) (see
Figure 3). There was no spiritual training provided; only
after the whole process of study was completed, the
researchers offered them the same treatments as done in
the experimental group.
Figure 3 Islamic spiritual mindfulness book cover

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 Dwidiyanti, M., Munif, B., Santoso, A., Rahmawati, A. M., & Prasetya, R. L. (2021)
Data Collection
The data collection was performed using a website linked
to the “DAHAGA” application for screening. The data were
collected in a nursing college with the help of two research
assistants. The researchers ensured that the research
assistants had been given training for the procedures of the
data collection. Their jobs were to facilitate the participants
in filling out and using the “DAHAGA” application in the
WhatsApp group. Each participant in the experimental
group was asked to do a pretest before applying each
feature of Islamic spiritual mindfulness in the app. The
participants were asked to do the mindfulness exercise six
times and then followed by a posttest. All data were
recorded automatically in the app and could be accessed
by the researchers and admin only.
In the comparison group, the pretest and posttest were
conducted online using Google Forms. The research
assistants also helped them via WhatsApp. After practicing
mindfulness according to the book, the participants were
asked to do a posttest.
Data Analysis
Data were analyzed using descriptive statistics and
bivariate analysis. As data were normally distributed,
Table 1 Difference in the level of depression among students in the intervention and comparison groups (N = 70)
Group
Pretest
Mean±SD
Experiment (n=35) 17.20±4.94
Comparison (n=35) 16.49±4.11
p-value b 0.513 b
aPaired t-test | bIndependent t-test
Based on the results of the paired t-test as shown in Table
1, it could be concluded that there was a significant effect
of DAHAGA on the level of depression in the experimental
group, seen from a significant difference in the depression
level before and after the intervention (p <0.001). In
contrast, there was no significant difference in the level of
depression in the comparison group before and after the
intervention (p = 0.861). This result is also supported by
the statistical result of the independent t-test, which
revealed a significant difference in depression level
between the experimental group and the comparison
group after the intervention with a p-value of <0.001. This
finding indicates that the Islamic spiritual mindfulness
combined with other features in the innovative app
effectively reduces depression levels among students.
Discussion
This study aimed to examine the effect of DAHAGA
application on reducing depression among nursing
students. The results revealed a significant effect of the
app on depression level in the experimental group seen
from the dependent t-test analysis and confirmed by the
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
paired t-test and independent t-test were used to determine
the effect of the intervention on depression in each group
and compare its impact between the experiment and
comparison groups. The significance level is set at 0.05.
Ethical Consideration
This study received ethical clearance from the Health
Research Ethics Committee of the Department of Nursing,
Faculty of Medicine, Diponegoro University, with a
reference number of 99/EC/KEPK/D.Kep/IV/2020. The
researchers also ensured that each student had signed a
written informed consent prior to data collection. Each has
a right to withdraw from the study at any time without
penalty. Confidentiality of the data was also ensured.
Results
Seventy participants were able to join and no one
withdrawn from the study. The majority of them were aged
18-22 years old and included in the category of early
adulthood (Hurlock, 2009). The difference in depression
levels among students can be seen in Table 1.
Depression Mean p-value a
Posttest Difference
Mean ±SD
11.49±4.49 4.28 <0.001a
16.34±4.92 1.80 0.861a
<0.001b
independent t-test analysis, which shows a significant
difference in depression level after interventions between
the experimental and comparison groups. However, the
findings of this study support previous research (Asiah et
al., 2019) that Islamic spiritual mindfulness intervention is
effective not only for patients with depression who are
admitted to a psychiatric hospital but also for nursing
students, as indicated in our study.
An innovative intervention created in this study using
the DAHAGA application helps the students identify
problems that they have or the environment quickly
through the detection feature. However, identifying the
problems is essential for the prevention of mental disorders
(Videbeck, 2008). The app also helps detect the bad
behavior and independent healthy target plans (Dwidiyanti
et al., 2019), which consequently awareness among the
students will be increased, and they could cope with their
problems independently and prevent mental disorders,
especially depression. Additionally, the app allows the
researchers to monitor and help the condition of the
students, which is considered the benefit of the app. In
contrast, the use of the Islamic spiritual mindfulness book
alone was not effective in reducing depression levels
223
 Dwidiyanti, M., Munif, B., Santoso, A., Rahmawati, A. M., & Prasetya, R. L. (2021)
among students compared to app use, as indicated in this
study.
Notably, the DAHAGA application is helpful and
practical, especially during the pandemic. Wei et al. (2020)
said that the provision of integrated internet-based
interventions effectively reduced symptoms of stress and
depression related to COVID-19. In this study, the
DAHAGA application provides eight features: (1) problem,
(2) bad behavior, (3) early detection, (4) independent
health target, (5) pretest, (6) posttest, (7) mindfulness
exercises, and (8) information. The problem feature
contains questions about the problems faced, while the
bad behavior feature contains questions regarding the
user’s experiences of the committed behavior. The early
self-detection element consists of two forms of questions,
namely, current feelings and physical conditions. The
independent health target feature contains target
choices/user expectations for independent health. The
pretest and posttest feature includes questionnaires about
depression that should be completed before and after
mindfulness exercises. The mindfulness training feature
contains mindfulness exercise guidelines that aim to help
users consciously accept the committed bad behavior and
try to correct it through independent health targets that
have been planned earlier (Sadipun et al., 2018; Dwidiyanti
et al., 2019; Munif et al., 2019).
It is noteworthy that Islamic spiritual mindfulness is fully
emphasized in the app. Islamic spiritual mindfulness is an
exercise that aims to help individuals aware of their current
condition or experience by involving the presence of God
(Dwidiyanti et al., 2019). It is also believed that Islamic
spiritual mindfulness is able to change behaviors and build
positive interpersonal skills through intention and self-
evaluation (Dwidiyanti et al., 2019). According to Yapko
(2016), for the healing of depression, a patient should be
taught about (1) the ability to make effective decisions, (2)
effective coping or stress management skills, (3) skills to
build and maintain positive relationships, (4) problem-
solving skills, and (5) building a realistic and motivating
future. Such abilities are taught at each stage of Islamic
spiritual mindfulness. The stages of mindfulness include
the intention and self-evaluation that describe the
decisions made effectively concerning the behavior to be
changed. As for coping, stress management in Islamic
spiritual mindfulness is taught through seven steps:
intention, self-evaluation, repentance, body scan, prayer,
surrender, and relaxation (Dwidiyanti et al., 2019).
Implications of this Study for Nursing Practice
Several implications of this study include: First, the findings
of this study provide evidence to support Islamic spiritual
mindfulness as a part of nursing intervention among
mental health nurses or psychiatric nurses to reduce
depression in their practice; Second, this study offers a
new and innovative app called DAHAGA, which fit with the
COVID-19 condition today where the utilization of the
technology is necessary; Third, the results of the study
provide additional knowledge for nursing science, which
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
224
the concepts of Islam, spiritual, and mindfulness merged in
order to provide holistic nursing care, especially for the
individuals who hold Islamic religion.
Limitation of the Study
We notice two limitations of the study. First, when installing
the “DAHAGA” application, some participants experienced
difficulties due to the device restrictions. As a result, there
was a time difference in starting the mindfulness exercises
using the application. Further study is recommended to
encounter this issue, which the app could be used in any
devices. Second, as the app specifically focuses on
individuals who hold Islam; thus, it cannot be used in
others.
Conclusion
There was a significant effect of using the DAHAGA-
Islamic spiritual mindfulness-based app on reducing the
students’ levels of depression. The app can be used to
detect and treat depression among college students. Also,
it can be utilized as a part of the intervention in nursing
practice. The extended application of the app with non-
students and non-Muslims is a necessity to validate the
findings.
Declaration of Conflicting Interest
The authors declared that they do not have a conflict of interest,
either individuals or institutions.
Funding
This study received funding from the Faculty of Medicine,
Universitas Diponegoro, Semarang, Indonesia.
Acknowledgment
This work was supported by the Faculty of Medicine, Diponegoro
University. We also thank the Department of Nursing, Diponegoro
University, for allowing us to conduct this research.
Authors’ Contribution
All authors contributed equally to the drafting of the manuscript,
revising the manuscript critically for important intellectual content,
conception, and design of the study, acquisition of data, analysis,
and/or interpretation of data. All authors approved the final version
of the article.
Data Availability Statement
The research data could not be shared because they were saved
by Diponegoro University’s server. We strictly followed the
research ethics to ensure the confidentiality of the data.
Authors’ Biographies
Dr. Meidiana Dwidiyanti, S.Kp., MSc is a Lecturer of Mental
Health Nursing in the Faculty of Medicine, Diponegoro University,
Semarang, Indonesia. She is also the Head of the Postgraduate
Nursing Program at the Nursing Department, Faculty of Medicine,
Diponegoro University, Semarang, Indonesia.
Ns. Badrul Munif, S.Kep., M.Kep is a Lecturer of Mental Health
Nursing in Nursing Program, Institute of Health Sciences
Banyuwangi, East Java, Indonesia.
Agus Santoso, S.Kp., M.Kep is a Lecturer of Nursing
Management and Leadership in the Faculty of Medicine,
 Dwidiyanti, M., Munif, B., Santoso, A., Rahmawati, A. M., & Prasetya, R. L. (2021)
Diponegoro University, Semarang, Indonesia. He is also the Head
of Degree Nursing Program at the Nursing Department, Faculty of
Medicine, Diponegoro University, Semarang, Indonesia.
Ns. Ashri Maulida Rahmawati, S.Kep.,M.Kep is a Student of
Master Program in Nursing, Diponegoro University, Semarang,
Indonesia.
Ns. Rikhan Luhur Prasetya, S.Kep is a Student of Master
Program in Nursing, Diponegoro University, Semarang,
Indonesia.
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Cite this article as: Dwidiyanti, M., Munif, B., Santoso, A.,
Rahmawati, A. M., & Prasetya, R. L. (2021). DAHAGA: An
Islamic spiritual mindfulness-based application to reduce
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https://doi.org/10.33546/bnj.1494

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Original Research
BNJ
“Accessibility”: A new narrative of Belitung Nursing Journal
Volume 7(3), 227-234
© The Author(s) 2021
healthcare services for people https://doi.org/10.33546/bnj.1409

living with HIV in the capital city of

Indonesia
Mahathir1* , Wiwin Wiarsih2 , and Henny Permatasari2

Abstract
Background: The progress of the fight against HIV is highlighted by significant change. HIV of the past is different
from HIV of the present. Healthcare services have played an essential role in achieving the optimal goals needed
to end the HIV epidemic. However, people living with HIV and those at risk of catching it (PLWH) often
misunderstand the rapid growth of HIV healthcare service options.
Objective: This study aimed to explore the experiences of PLWH in the healthcare services featured in this study.
Methods: A qualitative phenomenological approach was used. Semi-structured interviews were conducted in 2017
with 12 PLWH who engaged with healthcare services in Jakarta, Indonesia, by using a purposive sampling
technique. Semi-structured questions were asked which related to their experiences of using the services. Stevick
Colaizzi Keen method was used to extract the thematic analysis of the study.
Results: The study developed four essential themes of PLWH healthcare use. They were accessibility, availability
at all healthcare levels, comprehensiveness of service, and affordability.
Conclusion: Providing accessible healthcare services is considered essential by PLWH. It is also pivotal to helping
people feel positive about the community-related healthcare services on offer. Nurse-led HIV services must maintain
this progress by continuously evaluating the quality-of-service outcomes and promoting the accessibility of the
services to the broader population.

Keywords
HIV infections; health services; patient acceptance of healthcare; nursing; Indonesia

United Nations Sustainable Development Goals demand
sufficient progress in ending the epidemic of AIDS and also
achieving universal health coverage by providing qualified
essential healthcare services (United Nations, 2016). It is
vital to establish quality HIV services that offer people-
centered, safe, acceptable, appropriate, effective, and
efficient care for PLWH (World Health Organization,
2019a). PLWH should be engaged in a qualified diagnostic
and treatment of healthcare services (World Health
Organization, 2016) and must be treated with Antiretroviral
Therapy (ART) (World Health Organization, 2020).
In 2019, a total of 37.9 million people around the world
was living with HIV and AIDS (US Department of Health &
Human Services, 2020). Global efforts have been made to
reduce this, although the progress is not sufficient. The
number of people who have tested positive for HIV may be
reducing globally, but this reduction is not significant
enough, and prevention strategies and programs still need
encouragement. There is a significant gap between actual
achievement and the 2020 target. Whereas the target was
to bring the number of deaths down to 500,000, it currently
stands at 770,000. Furthermore, the target for the number
of patients acquiring HIV was 500,000, but in 2018 1.7
million people became infected (World Health
Organization, 2019b). This is why HIV prevention programs
continue to be encouraged.

1 Faculty of Nursing, Universitas Andalas, Indonesia Article Info:

2 Faculty Received: 13 March 2021
of Nursing, Universitas Indonesia, Indonesia Revised: 12 April 2021
Accepted: 22 June 2021
Corresponding author:
Ns. Mahathir, M.Kep., Sp.Kep.Kom This is an Open Access article distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 International License, which allows
Faculty of Nursing, Universitas Andalas others to remix, tweak, and build upon the work non-commercially as long as
Jl. Kampus Unand Limau Manis Fakultas Keperawatan Pauh the original work is properly cited. The new creations are not necessarily
Padang Sumatra Barat, Indonesia licensed under the identical terms.
Phone: +6281364474488 E-ISSN: 2477-4073 | P-ISSN: 2528-181X
Email: mahathirmahat@nrs.unand.ac.id

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 Mahathir., Wiarsih, W., & Permatasari, H. (2021)
Patient experience and satisfaction are important to
achieve better health outcomes (Leon et al., 2019). It is
notably well-known that better healthcare services for
PLWH will improve patients retention with healthcare
services, maintain patients' adherence to ART, and
ultimately reduce the HIV viral load (Dang et al., 2013).
Discontinuation of healthcare engagement and ART
adherence will have adverse HIV consequences and
increase a major public health problem (Pérez-Salgado et
al., 2015; Anh & Thaweesit, 2019). ART non-adherence will
contribute to the failure of the immune systems of PLWH.
It will also lead to an opportunistic infection that threatens
the quality of life, and in the worst-case, lead to mortality
(Johnson et al., 2017). ART is the key to suppressing the
viral load in the bloodstream, which is important to
prevention strategies. It is well known that viral suppression
will reduce the risk of passing the infection to others
(Siedner & Triant, 2019).
The dream of an HIV-free world is facing critical gaps
and barriers, including the optimization of healthcare
services. Healthcare services sometimes have the
limitations of poor performance and unequal treatments
(Keller et al., 2014). Program collaboration and service
integration are now considered vital to health departments
to ensure a comprehensive approach, but this requires
inter-sectional understanding (Bernard et al., 2016).
Stigma also adds challenge to improving the accessibility
of healthcare. Stigma disparaging is the equal access of all
to receive appropriate services at all levels and
circumstances (Moradi et al., 2014).
Within the ecological and policy factors influencing HIV
healthcare engagement, the availability of surveillance,
testing, prevention, medical and supportive services are
crucial. Access within minimal distance, clinic culture,
medical home, and the availability of appointments also
lead to further and better performances and increased
retention of services (Mugavero et al., 2011). Negative
experiences between the healthcare providers and at-risk
population sometimes detriments their relationship. The
feeling of awkward interaction, irrelevant questions,
blaming, pettiness, poor support, and confidentiality
breaches were often experienced by patients during their
treatments (Stutterheim et al., 2014).
In 2018, Indonesia had a total of 640,000 PLWH;
38,000 among them had died from HIV and AIDS-related
illnesses, 46.000 people were newly infected in that year.
Only 51% of the suspected population knew their status,
and 17% of them living with HIV were receiving treatment
(UNAIDS, 2018). Obviously, the number is very far from the
target and needs intensive attention to improve
achievement. Jakarta and parts of West Java, as one of the
megalopolis cities in Indonesia, endure significant numbers
of PLWH. Jakarta and West Java are both included in the
top five most popular provinces that contained people who
live with HIV. In 2017, Jakarta itself had around 6,626
people who tested HIV positive (Ministry of Health of
Indonesia, 2018).
Indonesia’s response to the HIV epidemic is considered
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
228
modest. The escalation of stakeholders’ contribution is
urgent and includes the public health service (Mesquita et
al., 2007). The accessibility of healthcare services has to
overcome a number of barriers. Stigmatization among
healthcare is often high (Risal et al., 2018). It is recognized
as a predictor of discriminatory attitudes towards PLWH
who engage in healthcare facilities (Harapan et al., 2013).
Indonesia also experiences the policy and practice
implementation disjunction that will initiate the
discrimination of treatment and care (Fauk et al., 2019). As
a result, PLWH encounters difficulties in engaging
healthcare access; it is also hard for them to adapt to their
chronic disease (Senyurek et al., 2021).
Nurses play a major role in the eradication of HIV,
providing optimal services starting from preventing
transmission to promoting the health and well-being of
PLWH (Gilks, 2019). Nurses achieve this by implementing
friendly and approachable services within health services.
Nurses make mutual collaborations with the population and
ensure the continuity of care being provided. Nurses
circulate the information about HIV healthcare services
available to the people and seek to improve the quality and
accessibility of these services. Advocating comprehensive
delivery must be empowered by nurse-led HIV services to
bring forth patient-centered care for PLWH (Rouleau et al.,
2019).
Services for the wider population and PLWH are now
broad and advanced. It can be accessed on both a static
basis and a mobile one. The look of healthcare services is
changing hand in hand with the efforts to move forward.
Implementation faces financial obstacles and the
progressive needs of the population. This is regarded as
the key to widening the outreach of healthcare services
(Falkenberry et al., 2018). HIV service delivery is now
shifting from one size fits for all approach. It will
accommodate comprehensive delivery across the
prevention and care continuum through differentiated care
(UNAIDS, 2018). HIV care continuum of HIV has been
recognized as a progression from serotesting, medical and
healthcare engagement, ART treatment and adherence to
the ultimate goal that is viral suppression (Kay et al., 2016).
The rapid shifting and continual efforts shall be followed by
progressive evaluation from all perspectives. This study
aimed to evaluate the experiences of PLWH who engaged
with HIV healthcare services in Jakarta, Indonesia.
Methods
Study Design
This research used a qualitative phenomenological
method. It describes the phenomena of progressive
change within HIV healthcare services. Phenomenology is
a type of qualitative research that focuses on the
individual’s lived experiences within a specific
phenomenon (Creswell, 2013). This method was used to
interpret the experience of the HIV healthcare use from the
service user’s perspective. This study explores the
experiences of PLWH who used healthcare services in
 Mahathir., Wiarsih, W., & Permatasari, H. (2021)
Jakarta, Indonesia. Appropriate conditions help lead
towards the successful achievement of objectives (Smith,
2018).
Participants
Participants in the study were PLWH who used HIV
healthcare services in Jakarta, Indonesia. Purposive
sampling is very commonly used in qualitative research.
Purposive sampling allows the qualitative researcher to
choose the participants and their characteristics for the
study. It is essential for phenomenological study to
accommodate participants who have experienced the topic
of the research question. Furthermore, it will ensure the
quality of the information provided by the research
participants. Therefore, the criteria of participants in this
study were PLWH who have engaged with HIV healthcare
services and willing to share their experiences.
The number of participants was determined by
reviewing available information and data saturation.
Participants were recruited and selected through a
designated HIV non-government organization around the
city. This study evaluates the data collected from twelve
participants. Saturation was achieved when no other bits of
new information or issues emerged. Participants in this
study were PLWH, who used HIV healthcare services,
such as voluntary counseling, mother-to-child transmission
programs, and methadone maintenance therapy clinics
within hospitals, public health services, and prison clinics.
Data Collection
This study was conducted in two non-government
organizations (NGOs) in Jakarta, Indonesia, which provide
social support and engagement for PLWH during their life
with the disease. Jakarta has 38 active NGOs and
foundations in handling HIV/AIDS issues. The two NGOs
provided the list of participants who matched the study
inclusion criteria. The selection of participants for the
research was based on the types of HIV healthcare
services used by the PLWH, as it was expected to enrich
the data collected. The researcher made an appointment
with the participant before the interviews were conducted
to develop emerging environmental situations and build
trust. They then set the appointment to carry out the
interviews. The study was conducted between July 2016 to
January 2017. The study collated the data and information
through semi-structured interviews. Two experts
independently authenticated the interviews. All interviews
were conducted by one person (MH). The other
supervisors (WW and HPS) contributed to data analysis
and validated the trustworthiness of the research. The
interviews were conducted in the Indonesian language and
then translated by MH to the English language after data
analysis.
The interviews were conducted by questioning the
participants through trigger questions and follow-up
questions based on the initial responses. The first question
in the questionnaire was, “Could you please tell me how
has your experience in using HIV healthcare services been
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
229
so far?” Then, based on the participant’s answer, the
interviewer asked a followed-up question such as “Would
you please describe to me what do you mean by easily
accessed?” or “What do you mean by it was different from
what you have ever expected? Could you please elaborate
on what more you expected?”. Other follow-up questions
were asked until the data was confirmed and verified. The
interviews lasted between 45-60 minutes. The oral data
were recorded through secure tape-recording, and any
non-verbal communication data observed were
documented in field notes. Data were stored securely
within a confidential folder on the computer. The recording
results were then written as a transcript in verbatim form
and combined with the results of the field notes.
Data Analysis
The stages of the data analysis process in this study used
the Stevick Colaizzi Keen method (Speziale et al., 2011) by
arranging the information of the interviews and transcribing
the recordings into verbatim form. The data script was
repetitively listened to and read to ensure the accuracy of
significant information. Participant statements were
marked to point out the important information relating to the
objectives of the study. Finally, themes were formulated by
identifying the important information, classifying it into data
groups, and categorizing themes and sub-themes.
Trustworthiness/Rigor
The researchers ensured the trustworthiness of the data
and results by comparing the results with other research
and ensuring the participants provided trustworthy
information. Environment familiarity was also confirmed by
holding pre-interview meetings and advance contact with
all participants. The researcher also discussed the results
with fellow researchers and supervisors (WW and HPS)
with upper-level degrees of education and expertise.
The transferability of the data was conducted by
ensuring that other groups of participants fully understood
the research results. The findings have been read by
PLWH, who were not participants in the study but still fit the
inclusion criteria. This study also surveyed a variety of
participants. The reliability of the data is dependent on the
saturation of the participant’s information by preparing
questions that provide accurate answers based on the
topic or issue of the study. This study also used repeat
questions with an expectation of the same response to
clarify and maintain the trustworthiness of the information
provided by the participants. Data and results were also
presented back to the participants who were involved. The
researchers then showed the principles of the results of the
research documentation and findings to participants who
engaged in the research.
Ethical Considerations
All activities within this research are strictly compliant with
the relevant ethical guidelines and considerations.
Ensuring that no one was at risk of harm or experiencing
negative impacts from the research activities conducted
 Mahathir., Wiarsih, W., & Permatasari, H. (2021)

was crucial. By providing autonomy, beneficence, non-
maleficence, confidentiality, and justice, this study was
committed to protecting the participants involved. This
study was reviewed by the Universitas Indonesia Ethical
Council Committee and declared as ethically feasible to be
conducted with ethical clearance number 0272/UN2.
F12.D/HKP.02.04/2015.
the HIV healthcare facility. His statement is documented
below:
“Actually, there was no obstacle in order to reach out the
facility, and the hospital was really nearby! The only problem I
have is to provide a specific time to go. We didn't have to be
worried; it is no big deal.” (P5)

Results
Characteristics of the Participants
There were 12 participants in this study who were PLWH
that used healthcare services in Jakarta, Indonesia. The 12
participants participated voluntarily in semi-structured
interviews conducted during the research process. All
participants acknowledged their HIV-positive status, were
open to being involved in the study, and cooperatively
answered the questions during the interview. In addition,
participants did not express objection or unwillingness to
provide answers to any of the questions. The quoted text
in this study was originally in Bahasa Indonesia and
translated to English to fulfill journal requirements. The
characteristic of the participants is displayed in Table 1
below.
Table 1 Participants’ Characteristics
The other participant said the same thing; he said that the
healthcare facilities are near his home. He also said that
the facility could be reached while attending another
activity. Along with fitting facial expressions, the participant
stated the following:
“No, the public health center where I ran for regularly
healthcare services was really close by. I can reach the place
while I was going somewhere else. But the waiting was still
taking some time.” (P3)
Participants said that easy access to healthcare facilities
was linked to the availability of transportation that they
could use. There were so many transport choices in order
to reach the services. Following is the relevant participant's
statement:
"... the access was not too difficult for sure, it was easy! Lots
of vehicles and public transportation to use." (P1)

Participant Age Education Year of Risk Theme 2: Available at all healthcare levels
Code Status Population Six participants felt that the healthcare services are now
P1 29 High School 2005 PWID available in all levels of healthcare facilities, from a primary
P2 30 Elementary 2006 PWID level to a tertiary one. Participants recognized that the
P3 2008 Heterosexual facilities are part of government efforts to broaden the
31 Junior High
Male range of available services. Two participants summarized
P4 32 Junior High 2008 PWID
their experience as the following:
P5 34 High School 2008 Prisoner
P6 34 High School 2008 PWID
“It depends on me, where do I want to go, which hospital do I
P7 34 High School 2010 Prisoner
prefer. It’s completely up to me, even though I heard I could
P8 2010 Heterosexual
34 Bachelor choose from the services in public health centers around me.
Female
There are so many facilities that I acknowledged, and I chose
P9 39 High School 2010 PWID
the hospital because I did not want to be recognized.” (P5)
P10 41 Bachelor 2014 PWID
P11 22 High School 2016 MSM
“Surprisingly, at first, I thought it only could be done at the
P12 31 Diploma 2016 MSM
hospital far from my house. But my peer navigator enlightened
Note: PWID= People Who Inject Drugs | MSM=Men Who Have Sex
with Men me it could also be done in the public health center near my
house. It helps me a lot, you know.” (P12)
Themes
Theme 3: Comprehensiveness of service
The study developed four significant themes such as
Participants are fully aware of their risk behaviors. It
accessibility, availability at all healthcare levels,
pushed them to start engaging with the healthcare
comprehensiveness of service, and affordability. Each
services. Participants get sufficient knowledge and
theme is explained in the following.
information from the facility, then complete serostatus
checking and obtain the test results before starting ART
Theme 1: Accessibility
and other behavioral therapy all in one place. Most
Almost all participants stated that they had easy access to
participants admitted that all of the services for HIV care
a healthcare facility. According to the participant's
they experienced were simply done in one place. One
statement, the accessibility of the healthcare facility was
participant stated that he felt relieved because the
determined by the proximity of the HIV healthcare facility
processes were comprehensively all in one place and
and the transportation facilities to help them reach it. One
helped fulfill all needs. Fluently speaking with a heavy tone,
of the participants stated that he had no complaints about
the participant expressed the following:

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 Mahathir., Wiarsih, W., & Permatasari, H. (2021)
“I am fully satisfied with all of the services, which began with
the registration., I can choose whatever name I want to respect
my secrecy. They collected me with the others in a room and
told us information related to HIV before asking us to express
our feelings before getting the test. Some people were crying
at the time, but I felt so comforted by the manner of the
facilitators. I admired that. Then when I tested positive, they
recommended me to start the ART. They looked after me
when I disclosed my status. That was a big moment of my life,
really.” (P11)
The other participant felt the same thing with all the
services provided by the healthcare facility. She
experienced all the procedures she needed to in one place
and only needed to think of her feelings at that time. With a
calm tone and soft smile, she spoke as follows:
“…then they brought me to VCT. I was interviewed by the
nurse, and he told me about HIV. I also ran the test there.
When I came back, the doctor announced the result; I am
positive. They counseled me when I reacted and checked how
I was feeling, and then we planned the ART. They allowed me
to ask as many questions and discuss as many things as I
wanted to.” (P8)
Theme 4: Affordability
Five participants stated that most of the HIV healthcare
services they accessed were free of charge, but some
specific services still cost them. For participants who had
limited financial income, it sometimes increased their
financial challenges. One participant said that the services
cost him little but still caused a burden on his financial
situation:
“Most of the services were free; I don't pay that much, only for
the administration. I guess it might be for doctor service only.
When I don't have any money, sometimes this fee was
uncomfortable and hard to take.” (P1)
The other participant stated that the affordability was
convenient. The funding system did not burden him
because it was just a small amount to cover. Compared to
what he was getting, he felt it was quite cheap. With a
confident tone, he said as follows:
“It was free, I guess, but there were some specific services for
which I should pay, but that was okay; I think that was normal.
At first, I thought it would be expensive, but it was mostly free.
I feel grateful. (P10)
Discussion
The themes indicated that there is a significant growth in
HIV services. Easy access to the facilities mirrors the
success of the healthcare system to provide accessible
and quality healthcare facilities for PLWH. A study of
factors associated with access to HIV healthcare services
stated that HIV-positive patients preferred the nearest
place in order to more easily engage with services (Lubogo
et al., 2015).
Distance to care will determine the ART compliance
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
231
among the PLWH. A study in Malawi found the ART
retention increased, and the possibility of loss during
follow-up decreased. The range of healthcare facilities on
offer influenced PLWH’s decision to maintain engagement
with healthcare. It also improved annual visits in ART
enrollment. Distance to travel was recognized as an
obstacle for PLWH (Bilinski et al., 2017). Further distance
between the healthcare facility and the patient will increase
the cost for PLWH, who had a lower socioeconomic status
(World Health Organization et al., 2013).
The distance to travel for the affected population in rural
areas was also proven to increase transmission probability.
Viral suppression is the key to slow HIV transmission. Viral
load suppression will never be achieved if ART compliance
could not be obtained. ART compliance requires routine
access to reliable and available facilities. The need to travel
farther will reduce the likelihood of ART enrollment (Smith
et al., 2017). The longer the distance to healthcare
facilities, the lower retention in care and viral suppression
(Terzian et al., 2018). The longer distance is also regarded
as a barrier for healthcare service use (Tafuma et al.,
2018).
The availability of healthcare services within all levels
of healthcare facilities is considered an advantage. All-level
facilities will broaden the range of healthcare services
available to the population. Decentralization of HIV
services and facilities will also expand the range that HIV
services can reach. A study of decentralization of HIV
healthcare services experienced by the rural communities
in Canada concluded that the PLWH prefers the services
to expand to all clinics and public health centers. It provides
them with a friendly and well-known environment
(Cunningham et al., 2014). It is also cost-effective and
reduces threats (Kolawole et al., 2017). A study from
Yogyakarta, Indonesia, mentioned that the availability of
services keeps the process simple and is convenient to the
healthcare environments. The transgender women in this
study recognized the positive attitudes of the healthcare
professionals and friendly social relationships on both
sides (Fauk et al., 2019).
Expanding ART services delivery helps to achieve the
desired outcomes of HIV eradication in low and middle-
income countries. The expansion of healthcare facilities
increases the potential of retention and decreases the
mortality rate (Haghighat et al., 2019). The expansion of
primary healthcare facilities for HIV services is also
associated with the reduction of loss in follow-up and fulfills
the gap of incomprehensive healthcare services
(Cunningham et al., 2014). Comprehensive care is not
merely one type of essential service at a time. It covers all
needs and is patient-centered, i.e., the provision of test
results must be followed by emotional support. A primary
setting has much more time to deliver good services, and
this increases patient satisfaction. The satisfaction is also
linked to the attitude from reception, waiting times, HIV
education, and the comfortability of the service from
healthcare professionals. Satisfaction of PLWH also varies
with the extent of the facilities (Odeny et al., 2013).
 Mahathir., Wiarsih, W., & Permatasari, H. (2021)
Delivering comprehensive healthcare services for the
PLWH will optimize the healthcare continuum. It is well
known that comprehensive health services will evidence
the strengths of HIV healthcare services. The
comprehensive services also increase patient enrolment
and retention (Wroe et al., 2018). Comprehensive care also
boosts the reduction of HIV transmission in the community.
Healthcare services focus on prevention and education.
The preventive service scale up the HIV negative and
unknown status to check their serostatus (Subramanian et
al., 2019).
Comprehensive healthcare services for PLWH will
optimize the coordination and communication between
healthcare services. Comprehensive services will unify the
strategies into efficient and effective actions (Watts et al.,
2019). Comprehensive healthcare services lead to
universal access to ART, improving patient-centered care,
and scale up the baseline of HIV testing among the
population at risk and PLWH (Havlir et al., 2019).
The affordable cost of engaging healthcare services is
helping PLWH to deal with their catastrophic life-changing
condition. Low-cost access is believed to be the gateway
to universal access for all of the population affected by HIV.
Providing universal access will increase the impacts of HIV
eradication efforts (Hill & Pozniak, 2016). Providing ART to
all PLWH is mandatory for low and middle-income
countries to achieve clinical prevention and programmatic
benefit for all (Ford et al., 2018). The limitation of the study
found some participants were not able to express the
qualitative narration of their experience. It required the
communication competency of semi-structured interviews.
It was also found that there is no scoring system in
validating the semi-structured questions. The importance
of exploring more about HIV healthcare services literacy
among PLWH is crucial.
The implication of this study can be seen that PLWH
get fairly easy access to HIV healthcare services in urban
and metropolitan settings. In fact, the healthcare services
are now reaching the primary level and easier to access
with good links to public transport. Equitable distribution of
health services in urban and big cities shall be implemented
in suburban areas, especially in concentrated epidemics by
the government and policymakers. This study showed that
the role of nursing is crucial in circulating the information of
the availability of services to those PLWH.
Conclusion
HIV healthcare services are growing stronger and
continuing to progress. The old paradigm of HIV being
nothing but a death sentence is fading away. Precise and
accurate information is increasingly being provided to all
sectors, communities, and individuals. Healthcare
providers and HIV activists are recommended to promote
and campaign about the new perspective of accessibility:
reduced travel to facilities and less financial hardship from
using HIV healthcare services, especially within urban
cities.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
232
Declaration of Conflicting Interest
There is no conflict of interest in this study.
Funding
Self-funding.
Acknowledgment
Gratitude appreciation to Faculty of Nursing Universitas Andalas
and Faculty of Nursing Universitas Indonesia for facilitating and
supporting the research.
Authors’ Contribution
MM contributed to developing the research, collecting and
analyzing data, presenting results, and drafting the manuscript.
WW and HP contributed to the study concept and design, data
analysis, and manuscript development. All authors agreed with the
final version of the article.
Data Availability Statement
All data generated or analyzed during this study are included in
this published article.
Authors’ Biographies
Ns. Mahathir, M.Kep., Sp.Kep.Kom is a Junior Lecturer at the
Faculty of Nursing, Universitas Andalas, Indonesia. He is currently
focusing on community health nursing, HIV and adolescent health
research.
Wiwin Wiarsih, S.Kp., MN is an Assistant Professor at the Faculty
of Nursing, Universitas Indonesia, Indonesia. She is currently
active in community health nursing development in Indonesia.
Dr. Henny Permata Sari, M.Kep., Sp.Kep.Kom is an Associate
Professor at the Faculty of Nursing, Universitas Indonesia,
Indonesia. She is currently making her research dedication in
community health nursing and occupational health.
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33546/bnj.1409
Original Research
BNJ
Psychometric properties of Quality- Belitung Nursing Journal
Volume 7(3), 235-245

of-Life Index for Vietnamese women © The Author(s) 2021

https://doi.org/10.33546/bnj.1332

with breast cancer three weeks

postmastectomy
Ha Thi Nhu Xuan1* and Sureeporn Thanasilp2

Abstract
Background: The patient’s quality of life immediately after mastectomy usually receives less attention than the
quality of life after three months, six months, or a year. It is because the focus is mainly on surgical complications.
Many instruments measure the quality of life from three months onwards. Still, the quality-of-life instruments right
after postmastectomy are not yet verified.
Objective: This paper aimed to test the reliability and validity of the Quality-of-Life Index Vietnamese version (QOLI-
V) in Vietnamese women with breast cancer three weeks postmastectomy.
Methods: The descriptive cross-sectional study was designed to analyze the psychometric properties of a
Vietnamese version of the modified Quality of Life Index. The modified process was conducted after granting
permission from the original authors. The content validity of the modified index was examined by five experts.
Brislin’s model was used for the translation process. The 26-item QOLI-V was tested in 265 patients with breast
cancer stage II three weeks postmastectomy who expected to have a poorer quality of life score. The reliability of
the index was measured using Cronbach's alpha. The construct validity was examined using confirmatory factor
analysis (CFA).
Result: The content validity index results showed that the lowest I-CVI was .80 and the highest was 1.00. S-CVI/Ave
was 0.95, and S-CVI/UA was 0.76. The Cronbach's alpha of QOLI-V was .84, which was considered acceptable.
Most of the 26 items featured the correct item-total correlation of .30 to .60. There were only two items correlated
with the total scale at .18, and the item with the lowest correlation (.06) was deleted from the item set. The CFA of
model 1 with 26 items was not an ideal fit with the data, with Chi-Square/df = 2.15, CFI = .815, GFI = .853, TLI =
.792, RMSEA = .066. After deleted an item #general quality of life, and the CFA of model 2 was conducted on the
25-item index. The final result indicated the improvement of the model fit, with Chi-Square/df =2.26, CFI = .852, GFI
= .814, TLI = .790, RMSEA = .069.
Conclusion: The 25-item QOLI-V version is considered valid and reliable to measure the quality of life of
Vietnamese women with breast cancer three weeks postmastectomy. Nurses and midwives could use this
instrument to measure the quality of life of the patients, and the patients could use it for self-assessment.

Keywords
quality of life; mastectomy; factor analysis; psychometrics; nursing; Vietnam

Patients with breast cancer feel considerable uncertainty these are events they could not foresee and are therefore
when diagnosed with a life-threatening (or terminal) illness. wholly unprepared. From systematic reviews, the stage
Later on, patients facing the treatment process realize from mastectomy one month to initial chemotherapy

1
Faculty of Nursing and Medical Technology, University of Medicine and Article Info:
Pharmacy at Ho Chi Minh City, Vietnam Received: 1 February 2021
2 Revised: 2 March 2021
Faculty of Nursing Chulalongkorn University, Bangkok, Thailand Accepted: 10 May 2021

Corresponding author: This is an Open Access article distributed under the terms of the Creative
Dr. Ha Thi Nhu Xuan, PhD, APN, RN Commons Attribution-NonCommercial 4.0 International License, which allows
others to remix, tweak, and build upon the work non-commercially as long as
Faculty of Nursing and Medical Technology, University of Medicine and the original work is properly cited. The new creations are not necessarily
Pharmacy at Ho Chi Minh City licensed under the identical terms.
217 Hong Bang street, District 5, Ho Chi Minh City, Vietnam
Mobile: +84 356435986 E-ISSN: 2477-4073 | P-ISSN: 2528-181X
Email xuanha@ump.edu.vn

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

235
 Xuan, H . T . N., & Thanasilp, S. (2021)
represented a transition time of poor adjustment and
decreased quality of life (Paraskevi, 2012). However, most
of the studies focus on describing and providing support for
quality of life as much as three months, six months, or over
one year postmastectomy, but ignoring the immediate poor
quality of life for the patients in the hours, days, and weeks
after their mastectomy during the transition from hospital to
home (Razdan et al., 2016). According to previous studies,
it has been shown that decreased quality of life after
surgery may predict early treatment discontinuation in
patients with breast cancer (King et al., 2000; Richardson
et al., 2007). The later poor quality of life will lead to
reoccurrence, metastatic, or even death among this group
(Coates et al., 2000; Mols et al., 2005). Thus, poor quality
of life in patients with breast cancer postmastectomy exists
as an urgent problem and requires effective interventions
to reduce it. In addition to introducing a measure for the
concept of quality-of-life postmastectomy, a reliable and
valid scale must necessarily be established.
Definition of Quality of Life of Patients
Postmastectomy
Quality of life (QOL) is the primary goal that most people
attain during their daily life. Since this concept has been
recognized, QOL is not separate from health because it is
considered as the person’s sense of well-being that stems
from the satisfaction and dissatisfaction with aspects of life
(Ferrans, 1990) or functional capacity, symptoms (physical
and psychological) and perceptions of health (Mccorkle et
al., 1989). The quality of life in the nursing context is related
to a specific illness, and it can be considered similar
meaning with health-related quality of life. A concept
analysis of nursing, based on the guiding theory of
Peplau’s, Rogers’, Leininger’s, King’s, and Parse, is
defined as a contextual, intangible, subjective perception
of one’s lived experience (Plummer & Molzahn, 2009).
Cella (1994) identified four dimensions of quality of life in
the context of cancer that encompasses physical well-
being, functional well-being, emotional well-being, and
social well-being. The concept of Cella (1994) and its four
significant domains of quality of life help investigate the
concept multi-dimensionally. Besides, (Padilla & Grant,
1985) describe the quality of life as five dimensions:
physical well-being, social concerns, body image
concerns, psychological well-being, and
diagnosis/treatment response. In breast cancer, the
concept of QOL describes the impact of breast cancer on
the domains of physical, social, psychological well-being,
and spiritual well-being (Ferrell et al., 1998).
Receiving a mastectomy also raises concerns about
body image, uncertainty in the situation of illness, surgical
symptoms, lacking nursing care or social support, and poor
patient-physician communication impacting the patient’s
quality of life (Denieffe et al., 2014; Mandelblatt et al., 2003;
Wronska et al., 2007). Thus, in patients with breast cancer
postmastectomy, the concept of quality of life should be
more specific, clearly describing the situation, which occurs
among this group. That is why the definition of QOL defined
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
236
by Padilla and Grant (1985) as physical well-being, social
concerns, body image concerns, psychological well-being,
and diagnosis/treatment response remains the most
suitable application for QOL postmastectomy.
Following Padilla and Grant (1985), physical well-being
can be considered a strength, fatigue, ability to work,
current health, and perceived usefulness. Psychological
well-being implies happiness, satisfaction, fun, general
QOL, pleasure in eating and sleep. The body image
concerns mean the ability to look at the changes in one’s
body, the tendency to worry, and the ability to adjust and
live with body changes. The social concerns focus on
social rejection, social contact, or the need for privacy.
Diagnosis/treatment response relates to surgical treatment
symptoms, which are defined as the ability to have
sufficient sexual activity, nutrition, weight, pain, and
severity of pain, nausea, and vomiting (Padilla & Grant,
1985). In postmastectomy patients, the attributes of
physical, psychological, and social concerns of QOL might
be the same as other cancers; however, the defining
attributes of body image and treatment response might
differ. The body image in breast cancer patient
postmastectomy relates to the ability to look at the changes
of the body, worry over scarring, perceived femininity, and
how easy it is to live with anybody changes (Barolia, 2008;
Denford et al., 2011; Fobair et al., 2006; Lindwall &
Bergbom, 2009; Toriy et al., 2013). The treatment
response of mastectomy patients focuses on symptoms
around the hand and shoulder such as the ability to raise
the hand, any swelling of the arm, the sensitivity of the
breast incision, sufficient nutrition, weight, as well as the
severity and frequency of pain (Champion et al., 2014;
Janz et al., 2007; Taghian et al., 2014). Operationally, the
concept of quality of life on postmastectomy patients is
defined as the perception of life experienced based on five
domains: physical well-being, psychological well-being,
body image concerns, social concerns, and treatment
responses. Defining attributes of QOL consist of physical
well-being (strength, fatigue, ability to work, current health
and perceived usefulness), psychological well-being
(happiness, satisfaction, fun/hobbies, eating pleasure and
sleep), body image concern (look at the body, scare of
scarring, perceived femininity, ability to live with losing a
breast, the worry of future living without a breast), social
concerns (family, friends or healthcare giver staff contact,
social rejection, and privacy needs and treatment
responses (ability raising the hand, swelling of the arm,
sensitive of destroying breast, nutrition sufficient, weight,
severity, and frequency of pain)
Existing Instruments
Most of the effective existing instruments measuring the
quality of life for patients with breast cancer are all well-
known instruments that have been used to examine QOL
in many stages of breast cancer (Perry et al., 2007).
Among those, FACT-B and EORTC-BR23 are specific for
patients during chemotherapy treatment. QOL-BR23
focuses on physical function, whereas FACT-B
 Xuan, H . T . N., & Thanasilp, S. (2021)

emphasizes emotional well-being (Nguyen et al., 2015).
EORTC-QLQ30 and SLDS-BC or QOLI are suitable for
QOL in general. Interestingly, the QOLI of Padilla and
Grant (1985) is based on the concept of QOL across a
range of cancers in women, though sharing similar
circumstances to breast cancer patients, such as cervical
cancer, colorectal cancer, and hysteric cancer post-
surgery. The original QOLI of Padilla and Grant (1985)
identifies 14 factors and has been validated in many
studies measuring QOL; hence it has proven validity and
reliability (Rukholm et al., 1998). Over time, the QOLI has
been modified for colostomy patients by adding nine items
focusing on some aspects of symptoms post-surgery. The
dimensions of QOLI would seem to be closest to the
definition of quality-of-life postmastectomy with five
domains of physical well-being, psychological well-being,
social concerns, body image concerns, and
treatment/diagnosis response. The length of 23 items with
self-administer base on the visual line for the most concern
in the past four weeks. Summarily, with the same aspects
of colostomy and mastectomy on colorectal and breast
cancer patients, the QOLI of Padilla and Grant (1985)
covers most aspects of the operational definition of quality
of life postmastectomy. Thus, this instrument will be
selected to test the psychometric properties in the breast
cancer population postmastectomy. The summary of the
comparison of the tools measuring QOL is presented in
Table 1.

Table 1 Summary of existing instruments measuring QOL for patients with breast cancer

Name & Authors Purpose Domains Scale Duration Items Type Reliability Validity
European QOL in the 5 (Therapy side effects; Four-point Past 23 Self-report Reliabilities Discriminant
Organization for breast cancer arm symptoms; breast Likert scale week (10 minutes) ranged from validity of
Research and population at symptoms; body ranging from .70 to .91 mutually
Treatment of various image; sexual 1 (Not at all) exclusive
Cancer QOL Breast stages and functioning) to 4 (Very groups based
Cancer-Specific with patients much) on their initial
Version with differing performance
(EORTC QLQ- modalities status scores
BR23) produced
(Sprangers et al., medium to
1996) large effect
sizes ranging
from .43 to 1.1

European QOL in the 9 (Physical; role, Four-point Past 30 Self- Reliabilities The correlation
Organization for general cognitive; emotional; Likert scale week administere ranged from coefficient
Research and cancer social; fatigue; pain; ranging from d .69 to .90. between the
Treatment of population nausea and vomiting; 1 (Not at all) (Under 10 (Carlsson & QLQ-C30 and
Cancer QOL global health status to 4 (Very minutes) Hamrin, the Profile of
Cancer-Specific and quality of life) much); 1 1996) Mood States
Version (Very poor) (POMS) was
(EORTC QLQ-C30) to 4 Test-retest .56
(Aaronson et al., (Excellent) reliabilities (Mclachlan et
1993) ranged from al., 1998).
.63 to .87
(Hjermstad et
al., 1995)

Functional Specific to 6 (Physical well-being; Five points Past 37 Self-report Internal Spearman
Assessment of breast cancer social/family well-being; Likert scale week or consistency correlations
Cancer Therapy – patients emotional well-being; ranging from interviewer- was .90 between FBSI
Breast Symptom functional well-being; 0 (Not at all) administere and FACT
Index (FACT-B) relationship with to 4 (Very d (estimated ranged from
(Brady et al., 1997) doctors; additional much) 25 minutes) .34 to .84
concerns)
Functional Living Assess the 5(Physical functioning; Answer Past two 22 Self- Reliability Correlation
Index – Cancer effect that mental functioning; questions by weeks; administere ranged from coefficients
(FLIC) cancer social functioning; placing a Past d .64 to .87 between FLIC
(Morrow et al., treatment general health/well- vertical line month; (Under 10 (Morrow et and SF-36
1992) and being; gastrointestinal at the point in Today minutes) al., 1992) ranged from
symptoms on symptoms) the best .50 to .62
functional present point (Wilson et al.,
ability in all 2005).
areas of life

Life Satisfaction Measure 6 (Quality of family Seven points Past 32 Self-report Reliabilities Correlation
Questionnaire one’s general relation; physical Likert scale week (estimated ranged from coefficients
(LSQ) sense of symptoms; ranging from 20 minutes) .62 to .92 between LSQ
(Carlsson & Hamrin, satisfaction socioeconomic 1 (very and EORTC
1996) with life as it situation; quality of much) to 7 QLQ-C30 were
relates to daily activities; (Not at all) -.68 to .54
school, sickness impact; and
relationships, quality of close friend
leisure time, relation)
religious
practices,
and overall
health for
women with
breast cancer

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237
 Xuan, H . T . N., & Thanasilp, S. (2021)

Table 1 (Cont.)
Medical Outcome Developed to 8 (Physical functioning; Scaled using Unspecifi 36 Self- Reliability Correlation
Short Form Health assess role limitations due to various ed administere ranged from coefficients
Survey health- physical health; role scales d .74 to .98 between the
(SF-36) related QOL limitations due to (5 minutes) (Hays et al., SF-36 and the
(Ware et al., 1993) emotional problems; 1995) General Health
energy/fatigue; Questionnaire
emotional well-being; (GHQ-29) were
social functioning; -.35 to =.61
bodily pain; health) (correlations
are negative
because the
two scales run
in opposite
directions)
(Failde &
Ramos, 2000)
Quality of Life Index Assess 5 (Activity; daily living; Three points Past two 5 Interviewer Internal Correlation
(QL-Index) health health; support; Likert Scale weeks administere consistency coefficients
(Spitzer et al., 1981) outcomes of outlook) d or self- of .78 ranged from
those with administere .40 to .63 (32)
cancer and d
other chronic (Under 10
diseases minutes)
Satisfaction with Developed 5 (Social functioning; Seven points Unspecifi Self-report Reliabilities Correlation
Life Domains Scale for appearance; physical Likert-type ed 32 (estimated ranged from coefficient
for Breast Cancer satisfaction functioning; scale ranging 20 minutes) .90 to .93 between SLDS-
(SLDS-BC) with life communication with from 1 (A BC and FACT-
(Spagnola et al., among medical providers; “delighted” B was .59
2003) breast cancer spirituality) face) to 7 (A
patients “very
unhappy”
face
World Health Designed to 4 (Physical health; Five points Past two 26 Self- Reliability Correlation
Organization Quality examine psychological; social Likert scale weeks administere ranged from coefficients
of Life – Brief domain level relationships with varying d .66 to .84. between the
Version profiles environment) anchors (estimated Similar WHOQOL-
(WHOQOL-BREF) assessing 15-20 alphas have BREF and SF-
(Whoqol Group, the quality of minutes) been shown 36 ranged from
1998) life for test-retest .36 to .78
reliability (Da Silva Lima
ranging from et al., 2005)
.66 to .87
Quality of Life Index Examine the 4 (Physical concerns, 10 points Past one 23 Self- Reliability
(Padilla & Grant, quality of life psychological concern, analog scale. month administere Ranged from
1985) of colostomy social concern, body Patients d .65 to .85
patients image concerns, placing a 10 minutes
treatments, and vertical line
responses at the point in
the best
present point

Methods model for CFA in physical health care. A systematic review

Study Design
The descriptive cross-sectional study was designed to
analyze the psychometric properties of a Vietnamese
version of the modified Quality of Life Index (QOLI-V) on
patients three weeks postmastectomy. The modified
process was conducted by researchers after granting
permission, acceptance, and consultation of the original
authors.
Sample and Setting
The population of this study was the patients three weeks
postmastectomy at the Breast Surgical Oncology Ward in
the Oncology Hospital in Ho Chi Minh City, South of
Vietnam. Convenient sampling was used to select the
respondents. The inclusion criteria of the respondents
were aged 30-60, could read and write Vietnamese, no
other diseases, and normal surgical recovery process at
seven days.
The literature suggests the estimated sample size of
CFA should not be less than 200 to avoid violating the
thumb rule of “too few degrees of freedom” (Hair et al.,
2010). Other assumptions requested that the sample was
> 200 for the theoretical model or ≥ 300 for the population
also proposed that the number of subjects should be equal
to the number of items multiplied by 10 in the nursing field
(Watson & Thompson, 2006). It is estimated that 265
patients were included to test the psychometric properties
of QOLI_V, with 26 items modified from QOLI (Padilla &
Grant, 1985) combined with the five domains.
Instrument Validation
The demographic form and the modified quality of life index
Vietnamese version (QOLI-V) were used to collect data in
this study. The demographic form was developed by the
researchers asking about the characteristics of the
respondents, such as age, marital status, occupation,
education, income, and mastectomy type.
The QOLI_V was a 26-item questionnaire composed of
five domains: physical well-being, psychological well-
being, social concerns, body image concerns, and
treatment response. Data were indicated by marking an X
on the visual line equal from 0 to 10 score. Scores were
presented as numeric rating scales. QOL was calculated
by the sum of the scores divided by the sum of items with
a low score indicating a low QOL. The original QOLI with
23 items retained with five domains. In reference to the
concept of QOL in a mastectomy group, four items related

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to the symptoms of patients with breast cancer Hospital. This study was an instrument development part
postmastectomy, including swollen arms, the ability to of the Dissertation project for PhD education in the Faculty
raise hands, the sensitivity of breast incision was added to of Nursing, Chulalongkorn University, Thailand. After IRB
the section on treatment response and perceived approval, the researchers met patients and presented the
femininity was added to the section on body image objectives, procedures to collect data, and approximate
concerns. length of time for data collection at the Surgical Oncological
Then the 27-item QOLI was sent to five experts for Ward. Patients who matched the inclusion criteria and
testing its content validity index following the wished to volunteer signed the consent form to prove that
recommendation of Polit et al. (2007): two surgeons with they agreed to answer the whole questionnaire.
ten years of experience in the mastectomy process, two
Ph.D. nursing lecturers, and one head nurse in the Breast Data Analysis
Surgical Department. The results showed that the lowest The input data were checked for errors before entering the
I-CVI was .80 and the highest was 1.00; S-CVI/Ave was analysis tests. The data were analyzed for the assumption
.95, and S-CVI/UA was .76, which implied good validity for of normal distribution and descriptive demographic data
this instrument (Osanloo & Grant, 2016; Polit et al., 2007). and reliability of the measurement by the SPSS program
The CVI testing of 5 experts confirmed that for 26 items, version 16.0. Then the confirmatory factor analysis was
most of all item was rated from 3 (relevant) to 4 (very conducted by using the AMOS version 20.0. The process
relevant). The sum agreements of each item related to the of conducting the CFA conducted by following
quality-of-life postmastectomy were calculated. The result standardized recommendations: (a) Initial data analysis to
confirmed that most of the items correlated well with the identify any problem of missing data or input errors, (b) Fix
quality-of-life postmastectomy, except the item of sufficient one-factor loading on each sub-construct to a specific
sexual satisfaction (.40). Experts rated this item with a value as equal to 1, (c) Factor loading higher .5 to .7, (d)
lower score of relevancy and recommended researchers Construct reliability .6 was accepted, (e) Standardize
consider the meaning of this item on Vietnamese culture. residual accepted (from 2.5 to 4.0), (f) Not using
modification indices to adjust the model fit (Hair et al.,
Instrument Translation 2010).
The 26 item-modified QOLI was translated into
Vietnamese using Brislin’s model. It was translated from Results
English into Vietnamese and back-translated by two
different bilingual experts at the Language Center, Characteristics of the Respondents
University of Medicine and Pharmacy, Ho Chi Minh City,
Vietnam. Two translated versions were reviewed by a Table 2 Characteristics of participants (N = 265)
Vietnamese nurse responsible for teaching English to
nursing students in the university, identifying ambiguous Characteristic f %
words and confirming the symmetry. The Quality-of-Life Age
Index Vietnamese version (QOLI-V) was then assessed for 30-39 60 22.6
40-49 125 47.2
its intelligibility in the Vietnamese context and culture with
50-59 80 30.2
5 cases of patients in the Surgical Oncology Ward. The
Marital status
piloting of QOLI-V also showed that most patients skipped Married 209 78.9
the question asking about sufficient sexual satisfaction Widowed 29 10.9
after mastectomy. When researchers discussed the Divorced 12 4.6
reason with patients, the answer was that mastectomy Singled 15 5.7
treatment was terrifying and tiring. They and their partner Education
did not want to have sex, or it was of no meaning in the Primary school 75 28.3
postmastectomy period. Based on the Vietnamese culture, Secondary school 84 31.7
High school 63 23.8
women often feel shame and become uncomfortable when
University or higher 43 16.2
asked about sexual activities, or they could not express the Occupation
meaning of sexual satisfaction. In the stage of three weeks Housework 112 42.3
postmastectomy, sufficient sexual satisfaction was felt Small business 52 19.6
completely irrelevant to ask because patients were usually Worker 57 21.5
concerned with other aspects of their life than sexual Officer 31 11.7
satisfaction. Therefore, this item was deleted from the Retire 13 4.9
Monthly income (VND)
questionnaire.
< 3 million 137 51.7
3-5 million 107 40.4
Ethical Consideration 5-10 million 21 8.0
This study was approved by the Board of Ethical in Mastectomy type
Biomedical Research at the University of Medicine and Simple 94 35.5
Pharmacy and the Research Ethical Board of Oncology Radical 171 64.5

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The demographic data of the respondents showed that Square Error of Approximation (RMSEA ≤ .08),
most of them were in middle age (47%). Many of the Standardized Root Mean Square Residual (SRMR ≤ .05),
women were married and living together as a family Comparative Fit Index (CFI ≥ .90) (Hair et al., 2010). The
(78.9%). However, the respondents had low education researchers also used other evidence to concern the
(primary and secondary school, 60.5%), and income from appropriate model fit.
the main family members was still low (<3 million The initial model 1 was drawn up in the AMOS graphic
and/month, 51.7%). The majority of the respondents were program and run CFA with the data set. The first analysis
housewives (42.3%), farmers, or doing small business at showed that with 26 items based on the construct of 5
home (19.6%). Only one-third of them were office workers dimensions, model 1 was not an ideal fit with the data. The
or executives; 64.5% of the respondents received radical findings in detail were reported as Chi-Square/df 623/289
mastectomy (see Table 2). = 2.15, CFI =.815, RMSEA =.066. The model was
presented in (Figure 1).
Reliability of the QOLI-V
The reliability of the revised translation version, 26-item
QOLI-V, was tested for its reliability with 265 Vietnamese
patients three weeks postmastectomy. Cronbach's alpha
of QOLI-V was .84, which was considered acceptable for
the modified instrument (Polit & Beck, 2003). Most of the 26
items featured the correct item-total correlation .3 to .6.
There were only two items correlated with the total scale at
.18. Regarding the last item, "general quality of life," the
total correlation was only .06, and Cronbach's alpha
increased when it was deleted. Thus, it was considered
that this item should be deleted from the item set or not
(see Table 3).

Table 3 Item correlation of Quality-of-Life Index Vietnamese

Version

Items Scale Corrected Cronbach's

Mean if Item-Total Alpha if
Item Correlation Item
Deleted Deleted
Strength 172.82 .525 .832
Tired 171.63 .209 .841
Sleep 172.22 .469 .833
Weight 171.22 .185 .842
Appetite 171.96 .557 .829
Food amount 171.71 .521 .831
Daily work 173.94 .514 .831
Current health 172.82 .603 .827
Fun 173.26 .393 .836
Useful 171.99 .552 .829
Figure 1 CFA Model 1
Happiness 171.36 .556 .830
Worry of future 171.32 .236 .841
Life satisfaction 171.97 .525 .830 Note:
Pain 172.06 .284 .839 PS: Psychological well-being | Phys: Physical well-being | Tr: Treatment
Frequency of pain 171.77 .396 .836 responses| BI: Body image concerns| SO: Social concerns
Arm swollen 170.28 .284 .839
Raise hand 171.82 .165 .842 For most items, the standardized estimation (factor
Breast sensitive 171.53 .291 .839
loading) was from .50 to .66. There is no estimation
Adjust easy 171.66 .374 .836
Scare of scar 171.50 .360 .837 indicated the cross-loading factor. However, there were
Femininity 171.98 .288 .839 three items that the general quality of life, weight, and
Difficult to look body 171.68 .329 .838 breast incision sensitivity were lower than .50, with the
Meeting 172.22 .355 .838
Reject 170.26 .367 .837 standardized regression weight estimated as .045, .48,
Private 171.99 .318 .840 .48, respectively. The residual estimation of 26 items
General quality of life 171.98 .060 .847 ranked from 1.1 to 3.8 was acceptable based on the
standardization rule. However, the residual estimate of e6
Construct Validity - Confirmatory Factors Analysis (general quality of life) exceeded the accepted level with
The construct validity of the instrument was tested using the result at 4.2. The construct reliability of the
the confirmatory factor analysis (CFA). The model validity measurement was high and exceeded the level of .6.
is assessed based on exact test fit, with Chi-Square/df <2.0 As for the modification indices, the general quality of
is considered good and <5.0 is acceptable, Root Mean life item is considered the cross-loading item. The

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regression weight of these items was adjusted for the par
change in every item or latent variable of the model.
Therefore, this item was considered for deletion from the
model.
Following the empirical evidence of the CFA in model
1, the general quality of life was deleted, and the CFA of
model 2 was conducted. The findings showed that the
model fit improved, with the criteria Chi-Square/df =2.269,
CFI=.814, and RMSEA=.069. The construct reliability of
the Psychological dimension was improved after deleted
one item. The model was presented in Figure 2.

Figure 2 CFA Model 2

Note:
PS: Psychological well-being | Phys: Physical well-being | Tr: Treatment responses
BI: Body image concerns| SO: Social concerns

Discussion referenced (Boateng et al., 2018). When we considered

Following Hair et al. (2010) to assess the model validity,
we need the key value of Chi-Square/df, CFI, and RMSEA
and other evidence to concern the appropriate model fit.
Firstly, the confirmed factor analysis showed that the
model of quality of life was acceptable as consistent with
the concept. Although the Chi-square value was .00 (< .05)
implied that the model might not fit. However, the Chi-
square value may be influenced by the number of samples.
In this study, 265 cases were higher than 250, as
the Chi-Square/df in both models, the result was 2.15-2.26,
less than 3 acceptable occasionally (Hair et al., 2010). The
CFI, GFI, TLI of these models was over 8 compared to the
standard of >.9 (Hair et al., 2010). Although it was not a
perfect fit, the model was considered good for measuring
the quality of life. Regarding RMSEA, both models were
acceptable, with RMSEA were .06 (< .08) suggested the
adaptable criteria for model fit.
Secondly, from model 1 to model 2, there was a slight
decrease of CFI, GFI, TLI with increased Chi-Square/df.

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 Xuan, H . T . N., & Thanasilp, S. (2021)
RMSEA increase proved that the deleted item " general
quality of life" was not contributed to the quality of life or
considered redundant. Therefore, this item was deleted
from the model. Thirdly, although model 2 was not also
highly fit with the result of Chi-Square/df =2.269, CFI=.814,
and RMSEA=.069. The researcher did not try to rerun the
model because this model was consistently based on CVI,
Cronbach’s alpha, and experts from a clinical view.
Therefore, deleted more items did not help improve the
model but ruin the construct of the quality of life in patients
with breast cancer.
This study proposed the model for concept quality of
life three weeks postmastectomy. The original model has
been modified with four items and deleted two items
through the process of developing the scale. The final 25-
item QOLI should be tested in another group of patients
with breast cancer in the early stage of treatment to
conclude the validity and reliability of this scale. In addition,
the construct of social concerns needs to be adjusted by
adding the new constraints for increasing the decrease of
freedom set up the tau-equivalent between each construct
in the model following the suggestion of (Hair et al., 2010).
The modification indices also suggested a high correlation
between the appetite and food amount that may imply the
redundancy of the item. This model should be considered
for testing on a larger sample size to satisfy the assumption
of the test and not violate the thumb rule of few degrees of
freedom.
Conclusion
The findings of this study provided good reliability and
validity of the QOLI-V among postmastectomy patients.
The QOLI-V consisted of 25 items with five dimensions:
physical well-being, psychological well-being, social
concerns, body image concerns, and treatment response.
Nurses and midwives can use this instrument to measure
the quality of life of the patients with breast cancer
postmastectomy, and the patients could use it for self-
assessment.
Declaration of Conflicting Interest
There is no conflict of interest in this study.
Funding
This study was funded by the 90th Anniversary of Chulalongkorn
University Scholarship, Chulalongkorn University, Thailand.
Acknowledgments
The first author would like to send the gratefulness to her
supervisor from Chulalongkorn University, who had supported her
in the studying process during the PhD program.
Authors’ Contribution
HTNX designed the study, collected data, analyzed the data,
wrote and revised the manuscript. ST designed the study, wrote
and revised the manuscript. All authors contributed and agreed
with the final version of the manuscript.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
242
Authors’ Biographies
Dr. Ha Thi Nhu Xuan, PhD, ANP, RN is a Vice Head of Nursing
Department, Faculty of Nursing and Medical Technology,
University of Medicine and Pharmacy (UMP) at Ho Chi Minh City,
Vietnam. She manages and contributes to updating the curriculum
training for Bachelor and Master program of Nursing at UMP. She
has experiences doing research in adult nursing care, nursing
education, leadership and management.
Assoc. Prof. Sureeporn Thanasilp, DNP, MSN, RN is A Former
Dean and Lecturer at the Faculty of Nursing, Chulalongkorn
University. She is an expert in cancer nursing caring and
contributes many articles for nursing science.
Data Availability Statement
The datasets of this study are available from the corresponding
author on reasonable request. The final instrument is available in
appendix.
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https://doi.org/10.1093/ptj/85.9.851
Wronska, I., Stepien, R., & Dobrowolska, B. (2007). Satisfaction
of women after mastectomy for nursing care. Advances in
Medical Sciences (De Gruyter Open), 52(Suppl 1), 34-36.

Appendix

The Quality-of-Life Index for patients with breast cancer three weeks postmastectomy
Modified from Quality-of-Life Index of Padilla and Grant (1985)

Instructions:
Please read each question and place an “X” on the line that most closely measures how you feel during the past weeks. The line
level is measured from “Not at all” to “Completely/Extremely”, with the score from 1 to 10. Please answer every question.

1. How much strength do you have?

Not at all A great deal

2. Is the amount of sleeping time sufficient to meet your needs?

Not sufficient Completely sufficient

3. Do you feel tired easily?

Not at all A great deal

4. Do you feel your current weight is a problem?

Not at all A great deal

5. Do you find eating a pleasure?

Not at all A great deal

6. Is the amount of food you eat sufficient to meet your needs?

Not at all Completely sufficient

7. How much can you do your usual tasks (homework, office work, and gardening)?

Not at all A great deal

8. How is your present stage of health?

Extremely poor Excellent

9. How much fun do you have (hobbies, recreation, social activities)?

Not at all A great deal

10. How useful do you feel?

Not at all Extremely useful

11. How much happy do you feel?

Not at all A great deal

12. How satisfying is your life?

Not at all Extremely satisfying

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

244
 Xuan, H . T . N., & Thanasilp, S. (2021)

13. How much pain do you feel in your arm and shoulder?

Not at all Excruciating

14. How often do you feel pain?

None All the time

15. Do you have the arm or hand swollen?

Not at all Extremely

16. Is it difficult to raise your arm or move it sideways?

Not at all Extremely difficult

17. Is your devastated breast over-sensitive like tingling, itching, formication?

Not at all Extremely sensitive

18. How worried are you about your future after mastectomy?

Not at all A great deal

19. How easy is it to live with your devastating breast?

Not at all Extremely fearful

20. How difficult is it for you to look at your body postmastectomy?

Not at all Extremely difficult

21. How fearful are you from the scar of devastating breast?

Not at all Extremely fearful

22. Do you feel less feminine as a result of mastectomy surgery?

Not at all Extremely

23. Is the level of contact with your friends and family sufficient to meet your needs?

Not at all Completely sufficient

24. Do you feel rejected by your family or loved one?

Not at all Extremely

25. Is the amount of privacy you have sufficient to meet your needs?

Not at all Completely sufficient

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

245
Perspective
BNJ
Common ethical dilemmas of family Belitung Nursing Journal
Volume 7(3), 246-250
© The Author(s) 2021
caregivers of palliative patients in https://doi.org/10.33546/bnj.1457

Indonesia
Martina Sinta Kristanti1* , Kusmaryanto2 , and Christantie Effendy3

Abstract
Family caregivers, especially in Asian countries, have a profound role in caring for a sick family member. However,
there are wide variations between the Asian and western world in terms of culture and facilities. Therefore, the
problems and needs of family caregivers between those two regions may also be distinct, and it is important to
explore and elaborate based on our empirical evidence. In Indonesia, motives and values in caregiving and religion
become the wheel-power of the family caregivers in providing care. This affects action and consequences for
caregivers. This paper attempts to elaborate on common ethical dilemmas that usually face by family caregivers in
Indonesia. Unfortunately, family caregivers typically are not prepared to make those challenging decisions.
Therefore, we recommend not only that family caregivers need to be involved in the caring process, but also their
issues and ethical dilemmas should be assessed and addressed by health care professionals, especially nurses,
who have the most frequent contact with patient and family caregiver.

Keywords
Asia; caregivers; religion; health personnel; caring; ethics; nursing; Indonesia

Prolog
Without a good understanding of what it is like to be
overwhelmed by the experience of illness - one’s own or
that of a loved one - how can the doctor or ethicist (or other
health care professionals) appreciate the human situation
the doctor must address?” (Dresser, 2011).
This implies that understanding the lived experiences of
patients and family caregivers is an essential key to take
care of patients with a terminal illness. Accordingly, we
would start this perspective essay by presenting three real
cases.
Case one
Roy, 25 years old, a young man we interviewed in a
chemotherapy clinic in Yogyakarta, Indonesia, was
accompanying his mother, diagnosed with breast cancer.
He took it hard when we asked what his life activity was.
Finally, he said: ‘Well, I was a happy newly graduate
entering my first day of work, but then mom called me
almost every hour that day. She asked what time would I
be home. That night I could not sleep. I thought it should be
fine to postpone my life for 1-2 years to be her caregiver.
My life can wait, but my mother’s treatment cannot. I then
submitted a resignation letter at the end of that week.’
Case two
Celine, 34 years old, who has been married for ten years,
was looking forward to having a child of her own. She used
to live in Singapore, but since last year, she moved back to
Jakarta to take care of her mother, diagnosed with tongue
cancer, and her father, a diagnosed Alzheimer's patient.
Celine has an older sister who lives nearby; however, she
said she was already too busy to take care of her own three
kids. Therefore, it should be Celine who becomes their

1
Department of Basic and Emergency Nursing, Faculty of Medicine, Article Info:
Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Received: 1 April 2021
Revised: 1 May 2021
Indonesia Accepted: 2 June 2021
2
Faculty of Philosophy – Divinity, Sanata Dharma University, Indonesia
3
Department of Medical Surgical Nursing, Faculty of Medicine, Public This is an Open Access article distributed under the terms of the Creative
Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia Commons Attribution-NonCommercial 4.0 International License, which allows
others to remix, tweak, and build upon the work non-commercially as long as
the original work is properly cited. The new creations are not necessarily
Corresponding author: licensed under the identical terms.
Martina Sinta Kristanti, S.Kep, Ns, MN, PhD
Department of Basic and Emergency Nursing, Faculty of Medicine, E-ISSN: 2477-4073 | P-ISSN: 2528-181X
Public Health and Nursing, Universitas Gadjah Mada
Gedung Ismangoen lt.2 Sekip Bulaksumur
Yogyakarta Indonesia 55281
Phone: +6281227811976
Email: sinta@ugm.ac.id

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

246
 Kristanti, M. S., Kusmaryanto., & Effendy, C. (2021)
mom’s caregiver since Celine has no kids. Coming from a
wealthy family, they set up a proper home care plan fully
equipped with nurses and a visiting doctor. However, it has
been three months since she could go anywhere. One time
she went to the gym, but she received a phone call from
her husband asking how she could leave their parents at
home in that condition. She was then stuck at home, bored
and depressed.
Case three
Maria, almost 50 years old, decided to be her sister’s
caregiver, Anna, since five months ago. In doing so, she
needed to leave her family and job in Kalimantan,
Indonesia, which was such a tough decision to make. Anna,
36 years old, was diagnosed with breast cancer around
three years ago. She has fought bravely, and now she
suffered from constant pain and a large malignant wound
on both of her breasts. She also suffered from anemia and
needed to go to the hospital for a transfusion. Nevertheless,
Anna is a cheerful lady with a bright personality. She knew
exactly what is going on with her condition and was ready
for the worst scenario. Her concern was only for her
daughter, Lia (16 years old). Lia never knew who her father
is since she was born. Since Lia goes to school and Anna
was bound to bed rest, Maria’s heart was moved. Actually,
Maria and Anna had such opposite characters; they had
argued in many ways since they were little. Maria decided
to be Anna’s caregiver because she could not be on her
mother’s side during her last moment in life. This guiltiness
haunted her for many years. She was expecting that by
becoming one of Anna’s caregivers, her guiltiness would
fade away. When we asked: “With whom would Lia stay
with when something happens to Anna?” With her soft
voice, she said that this is the most important topic, but she
could not initiate it with Anna. She does not know how and
when to start this discussion.
These cases illustrate that caring for the loved ones
(who are ill) affects the patients and may also change the
family caregivers’ life. Accordingly, the World Health
Organization (2010) defines palliative care as an approach
to enhance not only the quality of life (QOL) of patients but
also their family caregivers. This definition relates to the
Indonesian situation where caring for the family member is
considered part of Asian culture (Funk, Chappell, & Liu,
2013).
This perspective paper aims to elaborate experiences
of family caregivers in Indonesia and to identify some
common ethical dilemmas in their palliative experiences.
Family Caregivers
The family caregiver has various definitions. The most
common meaning refers to people who provide care to their
loved ones with or without blood relations, including in-laws
and neighbors (Kilic & Oz, 2019). This person may or may
not live with the care recipient, but they provide care for at
least 6 hours a day. However, the most common
differentiation with the formal caregiver is that there is no
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
247
financial compensation from the care recipient to this family
caregiver.
Family caregivers’ circumstances are varied between
Western and Asian regions. In the Western world,
independence (or lack of dependency) is highly
appreciated. The government responds by providing
various formal facilities such as long-term, hospice care,
nursing homes, and many other institutions in order to
maintain the individual sense of independence for people
with chronic and terminal illnesses. On the other hand, in
Asian countries, including in Indonesia, taking care of
family members is part of the culture. In this setting, there
are many important lessons that we have learned from
generation to generation—taking care of our family,
especially our parents, may be the only way we know how
to appreciate life and our inheritance. In Javanese culture,
for example, tabon is a term that refers to a child that is
assigned to take care of a parent (Keasberry, 2001).
According to this culture, tabon will be granted ownership
of the house once the parents are passed away
(Keasberry, 2001).
In relation to financial compensation, some developed
countries have various schemes. For example, in the
Netherlands, people are able to self-assign a ‘mantelzorg’
(family caregiver in Dutch). They put this information on
legal government documentation. When something
happens to their health, this mantelzorg will provide direct
care, including taking the patient to the hospital, facilitating
their groceries, and other daily activities. The Dutch
government offers a financial scheme to compensate for
the time spent by the mantelzorg in providing this care.
There is a limited amount of Euros per day that can be
accessed by the mantelzorg and applied as an invoice
(Alice, Inger, & Mirjam, 2019).
Considering the wide variations in the Western and
Asian cultures, this implies that we need be careful about
directly or thoughtlessly adapting ideas or interventions
from the Western countries to Asian ones. Cultures are a
form of intergenerational heritage that actively shapes
people’s lives, including the family caregiving condition.
Since one of the most suitable policy types is supported by
empirical evidence, research on family caregivers in Asia,
including Indonesia, is essentially needed.
Family Caregivers in Indonesia
When one of the authors (MSK) started PhD study in 2015,
funded by the Dutch government, evidence was limited
concerning family caregivers in Indonesia. Fortunately,
research on this topic has been growing progressively in
the past five years. A study revealed that family caregivers
have a profound role in patient care even during
hospitalization (Effendy et al., 2015). This finding implied
that family caregivers must have important tasks at home.
They should be supported. They should be part of the care.
The next question is, how can we provide the support and
care that they need?
 Kristanti, M. S., Kusmaryanto., & Effendy, C. (2021)
This initiated me to start my first study by comparing the
experiences of family caregivers of patients with cancer
and patients with dementia. We found more similarities
than differences in the problems in caregiving, actions of
caregivers, and beliefs in caregiving. Some differences
were also identified (Kristanti, Engels, Effendy, Utarini, &
Vernooij-Dassen, 2018). Family caregivers of people with
dementia revealed that direct contact with health care
professionals was highly appreciated. People with
dementia are usually cared for by either gerontologists or
neurologists, then the communication and coordination can
be much simpler. On the other hand, care for most patients
with cancer is done by multi-disciplines, including
oncologists, internists, surgeons, and many other parties,
depending on their needs. This lack of simple, one-to-one
involvement increases the risk for friction and
miscommunication issues.
However, family caregivers of people with dementia
revealed that they sometimes felt a loss of connection with
the patient even when the patient was still beside them.
“She doesn’t know me anymore; she doesn’t know anyone
anymore” [Husband].
Meanwhile, family caregivers of patients with cancer
often described a stronger family cohesiveness. For
example, one participant said that she (55 years old) had
only talked to her older brother (57 years old), who lived in
a different city once or twice a year since they were busy
with their own life, family, and work. But since she has been
looking after their mother, they keep in touch on a daily
basis, sometimes just to ask how they are doing. As a
result, they found a reconnection during this caregiving
process (Kristanti et al., 2018).
The next study then elaborates on the experiences of
family caregivers of patients with cancer (Kristanti, Effendy,
Utarini, Vernooij-Dassen, & Engels, 2019). Data were
collected from three major cities in Indonesia: Jakarta,
Surabaya, and Yogyakarta. Belief in caregiving is the core
phenomenon (Kristanti et al., 2019). It is the wheel-power
of caregivers. It consists of spiritual and religion, values,
and motives in caregiving. This wheel-power influences the
actions of family caregivers and the consequences they
received. The more constructive their belief in caregiving,
the better the consequences it impacted on them. Those
with this spirit eventually found themselves as a better
person and vice versa.
Common Ethical Dilemmas
These empirical data can help us reflect on ethical
dilemmas that the family caregivers must face in the
caregiving process or their relationships with patients and
other family members. In general terminology, extensive
medical literature used ethics, dilemma, and moral distress
interchangeably (Yildiz, 2019). In the nursing profession, an
ethical dilemma may be alleviated by utilizing a scientific
ethic, that is, by placing people (or the care recipient) at the
center and interacting with family members and their
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
248
network, by considering their values, uniqueness, dignity,
and inherent human rights (Yildiz, 2019).
In the case of the family caregivers’ journey, based on
our empirical data (Kristanti et al., 2019; Kristanti et al.,
2018), one of the most frequent dilemmas was ‘hiding’.
Family caregivers tend to hide their emotions and burdens
in front of the patient. They thought that their feelings were
not relevant and should stay hidden. They would pose a
cheerful, brave, and tough face in front of the patient.
Another hiding is about revealing diagnoses. When the
patient is younger (below 50 years old), the doctor mostly
revealed diagnoses directly. However, when the patient is
older and maybe illiterate (unable to understand), the family
caregiver is the first to receive the diagnosis. The doctor
then would request the family to inform the patient, or in
some cases, the family would ask the doctor and nurses
not to reveal the diagnoses until the patient is ready. When
the patient was not aware of their diagnoses, the condition
became the most problematic situation for the family
caregivers. One of the participants in our study revealed
that once she broke the news of the diagnosis to her
mother, it felt like ‘a mountain had been removed from her
shoulders’ (Kristanti et al., 2019).
The second ethical dilemma was the perception of
voluntary vs. obligatory actions in the caregiving tasks. In
many Western publications, Asian countries are framed
negatively that caregiving is a mandatory action. Our study
in Indonesia showed that we framed ‘this obligation’ in a
positive way so that we see this as a chance to make some
payback to our loved ones. It is described as ‘a chance in
disguise’ or some opportunities and benefits while facing
some challenges (Kristanti et al., 2019).
The third dilemma was that most caregivers were the
so-called ‘first-time players’ with no training (Dresser,
2011), meaning that they are ‘newbies’ (in caregiving role),
and they may need time to grasp information, to have
second or third opinions, to make (some immature)
decisions and/or to change their decision. It is because
nothing is harder than making decisions about treatment
and caring, resulting in life and death consequences.
Family caregivers also felt like living as a shadow. Their
presence was mostly overlooked by healthcare
professionals or other family members. While all the
spotlight is on the patient, the family caregiver is also the
one who needs to be taken care of.
The decision-making process is another dilemma that
we identified. Some caregivers need to decide to continue
or stop treatment when the patient can no longer participate
in this decision. The decision for resuscitation can be a life-
long traumatic memory for them. The guilty feeling to stop
the treatment can also become their burden of guilt for the
rest of their life. In order to reduce unnecessary guilty
feeling, British Medical Association reminds us to apply the
ethical principles of ordinary and extraordinary. The
obligation of healthcare workers is to provide ordinary care,
while extraordinary care is not an obligation (British Medical
Association, 2007). One is not obliged to use all resources
to defend human life. Extraordinary care is a situation in
 Kristanti, M. S., Kusmaryanto., & Effendy, C. (2021)
which we have to say “enough” and not prolonging
treatment or care.
The last dilemma is the appreciation concerning the
formal facilities. Some palliative care experts in Indonesia
are still discussing if hospice care is suitable for our culture.
Would we dare to let our loved ones stay in the hospital at
the end of their life? Can we ignore what people say to us
if we put our loved ones in a nursing home? or do we prefer
to have them stay with peace in their familiar place: at
home? What is the formal facility to support both patients
and caregivers that suits our economic condition, social
status, and culture?
Ethical Considerations in Involving the
Family
As nurses, sometimes we need to decide to involve or not
involve family caregivers as part of our caring team.
Becoming part of the team means that we may have an
equal number of tasks and responsibilities. One of the
important tasks of healthcare workers (including nurses) is
to foster autonomous decision-making of the patients or
their proxy (Beauchamps & James, 2019). As healthcare
workers, nurses have an ethical obligation to give all
necessary information so that patients or their prox may
make autonomous decisions. In many cases, the final
decision is a shared-decision making between family
caregivers and nurses. We may refer to the four prima facie
principles in making the decision: respect for autonomy,
beneficence, non-maleficence, and justice (Beauchamps &
James, 2019).
Principles of beneficence must take positive steps to
help others, not merely refrain from harming them
(nonmaleficence). It is an ethical obligation to do good for
patients and their families, including family caregivers.
Involving family caregivers in patient care will enhance the
collaborative aspect. We then need to identify who is the
daily ‘family caregiver’ and who is the ‘key person to make
a decision for the patient’ because their roles are different.
They can be the same person. But in Indonesia, this is not
always the case. There are cases where the main decision-
maker is living in another part of the world. They can be the
one who is funding the treatment or the eldest ones in the
family. Nurses need to identify this hierarchy so that they
can speak the right topic to the right person.
Non-maleficence relates to the previous principles. The
principle of nonmaleficence obligates us to abstain from
causing harm to others. This principle is identical to the
famous maxim Primum non nocere: “Above all [or first] do
no harm.” Although this principle does not appear in
Hippocratic writings, it is regarded as a fundamental
principle in the Hippocratic tradition. It was found that that
the most dilemmatic problem in family caregivers is their
unbounded tasks (Dresser, 2011). They do everything
every time. In some cases, family caregivers of dementia
passed away when the patient was still alive. Nurses
should assist them in setting up targets and boundaries to
maintain the family caregivers’ own QOL.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
249
The third prima facie is justice. Traditionally justice
means that equals must be treated equally, and unequal
must be treated unequally. This traditional definition is
attributed to Beauchamps and James (2019) added an
important notion, justice means fair, equitable, and
appropriate treatment in light of what is due or owed to
affected individuals and groups. This implies that services
offered by nurses for caregivers should have the same
quality and standard. We should provide the support that is
systematic and structured. Intervention such as providing
basic care training is effective to maintain the QOL of
patients in terminal illness (Kristanti, Setiyarini, & Effendy,
2017). Also, interventions offered should not only be for the
patient’s QOL but also maintain the caregivers’ well-being.
The last principle is respect for autonomy. Respect for
autonomy is to acknowledge patients’ right to hold views,
make choices, and take actions based on their values and
beliefs. It means that nurses or other healthcare workers
have to respect the autonomous decision of patients. The
opposite is true: the decision by a non-autonomous person
should not be respected. Respecting the autonomous
decision of patients means that nurses should obtain
people’s agreement for any decision and any medical
interventions relate to them, keep confidentiality and
promises, and not deceive others (Gillon, 1994). This
principle may relate to the decision-making process in
palliative care. Knowing how challenging the decision-
making process in palliative care could be, advanced care
planning (ACP) should be implemented soon in Indonesia.
ACP is a discussion between the doctor, patient, and family
(and nurses) for planning the treatment and future
decisions. The patient should be in good condition
physically and psychologically following a procedure. The
discussion during ACP may include if the patient accepts or
refuses resuscitation when it is needed. ACP will make the
treatment and next step in the process easier for everybody
and prevent a traumatic event due to the obligation to
provide a decision in a short moment for family caregivers.
Implication for Nursing Practice
Nurses are part of health care professionals who have the
most frequent contact and interaction with patients and
families. Therefore, nurses have an important task to
observe patient's and family’s situations and needs. In
addition, knowing some of the ethical dilemmas that may
be faced by the family caregivers, nurses need to assess
and provide sufficient support for them. Patients and
families are one unit in caregiving. By providing care to the
family caregivers, we support the patients in facing difficult
moments in life due to their illness.
Conclusion
Family caregivers have profound roles in caregiving for
patients with chronic and terminal illnesses. Some ethical
dilemmas along the journey were identified as signposts.
Accordingly, nurses can utilize the four primary ethical
 Kristanti, M. S., Kusmaryanto., & Effendy, C. (2021)

principles of caregiving to provide support for family caregivers' involvement in caring for a hospitalized patient with
caregivers and enhance the family caregivers’ sense of cancer and their quality of life in a country with strong family
well-being. bonds. Psycho‐Oncology, 24(5), 585-591. https://doi.org/10.
1002/pon.3701
Funk, L. M., Chappell, N. L., & Liu, G. (2013). Associations
Declaration of Conflicting Interest
between filial responsibility and caregiver well-being: Are there
None declared.
differences by cultural group? Research on Aging, 35(1), 78-
95. https://doi.org/10.1177/0164027511422450
Funding
Gillon, R. (1994). Medical ethics: Four principles plus attention to
None.
scope. British Medical Journal, 309(6948), 184. https://doi.org/
10.1136/bmj.309.6948.184
Authors’ Contributions
Keasberry, I. N. (2001). Elder care and intergenerational
MSK was responsible for initiating the concept, writing, and
relationships in rural Yogyakarta, Indonesia. Ageing & Society,
drafting and had the ownership of data. K and CE provided
21(5), 641-665. https://doi.org/10.1017/S0144686X01008431
important intellectual content and contributed feedback while
Kilic, S. T., & Oz, F. (2019). Family caregivers’ involvement in
writing a manuscript draft. All authors have provided final approval
caring with cancer and their quality of life. Asian Pacific Journal
and agreement to be accountable for all aspects of the work
of Cancer Prevention: APJCP, 20(6), 1735. https://doi.org/10.
regarding content.
31557/APJCP.2019.20.6.1735
Kristanti, M. S., Effendy, C., Utarini, A., Vernooij-Dassen, M., &
Authors’ Biographies
Engels, Y. (2019). The experience of family caregivers of
Martina Sinta Kristanti, S.Kep, Ns, MN, PhD is an Assistant
patients with cancer in an Asian country: A grounded theory
Professor at the Department of Nursing, Faculty of Medicine,
approach. Palliative Medicine, 33(6), 676-684. https://doi.org/
Public Health and Nursing Universitas Gadjah Mada Yogyakarta.
10.1177/0269216319833260
Her research interest is on family caregiving in palliative care.
Kristanti, M. S., Engels, Y., Effendy, C., Utarini, A., & Vernooij-
Dr. C.B Kusmaryanto is an Assistant Professor at the Faculty of
Dassen, M. (2018). Comparison of the lived experiences of
Philosophy – Divinity, Sanata Dharma University, Indonesia. He
family caregivers of patients with dementia and of patients with
has written several textbooks on Medical Ethics and Bioethics.
cancer in Indonesia. International Psychogeriatrics, 30(6),
Dr. Christantie Effendy, SKp, MKes is an Associate Professor at
903-914. https://doi.org/10.1017/S1041610217001508
the Department of Medical Surgical, Faculty of Medicine, Public
Kristanti, M. S., Setiyarini, S., & Effendy, C. (2017). Enhancing the
Health and Nursing Universitas Gadjah Mada Yogyakarta. Her
quality of life for palliative care cancer patients in Indonesia
areas of interest are adult nursing, oncology, and palliative care.
through family caregivers: A pilot study of basic skills training.
BMC Palliative Care, 16(1), 1-7. https://doi.org/10.1186/s1
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Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

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Case Study
BNJ
Developmental assessment and Belitung Nursing Journal
Volume 7(3), 251-259

early intervention for children with © The Author(s) 2021

https://doi.org/10.33546/bnj.1480

developmental delays: A case study

in South Australia
Mardiyanti1* and Amanda Case2

Abstract
Background: Child development monitoring and screening have been mandated as a national health service
worldwide, including Indonesia; however, a recent study found that Indonesian community health nurses
experienced difficulties detecting and stimulating a child suspected of a developmental delay.
Objective: To explore and provide an example of how Australian community health nurses, along with other
professionals, contribute to a Universal child and family health service (UCFHS), a similar programme name in
Indonesia is child developmental stimulating, detecting monitoring and early intervention programme or SDIDTK.
Case study: This is a case study of a young Australian boy (4 years old) whom the mother reported that her son
has unclear speech and he was not speaking as much as other children at his age. The researcher, as a nurse,
delivered the child developmental assessment and play skills assessment and found that the child has subtle
developmental gaps and was at risk for developmental delay. Several goal setting and programming ideas have
been developed to meet the child developmental milestones. These include goals in fine motor skills,
communication, problem-solving and personal-social skills which have been regarded as early intervention for the
child. Together with the therapy from a Speech Pathologist, these goal settings and programming ideas have been
collaborated with the kindergarten teachers and the family as well as the UCFHS nurses as part of the child
developmental monitoring programme.
Conclusion: Developmental delays can be detected through developmental and play assessments and can be
followed by developmental stimulation and early intervention programme by developing goal settings and
programming ideas around the delays or gaps in play or development.

Keywords
child development; nurses; Indonesia; early intervention; play assessment

Child development monitoring and screening have been
mandated as a national health service worldwide, including
in Indonesia. Examples of the service are Child Find and
Oregon Healthy Start in the US; Universal Child and Family
Health Service (UCFHS) in Australia, and Stimulasi,
Deteksi Intervensi Dini Tumbuh Kembang (SDIDTK, stands
for growth and developmental assessment, stimulation and
early intervention) in Indonesia (Australian Health
Ministers' Advisery Council, 2011; Macy et al., 2014;
Ministry of Health of Indonesia, 2021). Indonesian Ministry
of Health has regulated SDIDTK’s Law number 66 by 2014
(Ministry of Health of Indonesia, 2021). This means that
child developmental screening, stimulation, and early
intervention should be provided regularly in Indonesian
community health centres (Puskesmas). However, a recent
study found that Indonesian community health nurses

1 Article Info:
Department of Pediatric Nursing, School of Nursing, Faculty of Health
Science, Islamic State University UIN Syarif Hidayatullah Jakarta, Received: 14 April 2021
Revised: 12 May 2021
Indonesia Accepted: 10 June 2021
2
College of Nursing and Health Sciences, Flinders University, Adelaide,
Australia This is an Open Access article distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 International License, which allows
others to remix, tweak, and build upon the work non-commercially as long as
Corresponding author:
the original work is properly cited. The new creations are not necessarily
Ns. Mardiyanti, MKep., MDS licensed under the identical terms.
Faculty of Health Science, Islamic State University UIN Syarif
Hidayatullah Jakarta. Jl. Kertamukti no.5 Ciputat, Tangerang Selatan, E-ISSN: 2477-4073 | P-ISSN: 2528-181X
Banten, Indonesia. Phone: +62217401925
Email: mardiyanti@uinjkt.ac.id

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experienced difficulties detecting and implementing early
intervention of a child suspected of a developmental delay
(Mardiyanti et al., 2020). Meanwhile, other countries have
delivered the programme successfully and may become an
example for Indonesian health professionals, especially
nurses. This article provides an example of how a child
suspected of developmental delays has been screened,
assessed, stimulated and intervened earlier so that the
delay can be minimised or corrected before the child enters
the primary school where the delays may become
problems.
Australian Context
The Australian education system provides primary,
secondary and tertiary education. Primary education starts
from the foundation level (kindergarten or preschool from
age 3.5 to 5 years) through year 6 or 7 (Department of
Foreign Affairs and Trade, n.d.). Kindergarten or preschool
are part of early childhood education which responsible for
providing care and supervision for young children,
preparing them for school, and ensuring that the children
are able to effectively participate in subsequent learning
opportunities (Department of Foreign Affairs and Trade,
n.d.). This case study took place in South Australia
kindergarten.
Case Presentation
Evan (not his real name), a 50-month-old male, was born
prematurely on March 2010 at 36-week of gestation, with
his birth weight of 3600 grams. During his first week of life,
he experienced jaundice. He was breast-fed and formula-
fed during the first 6-month of life because of reduced
breast milk supply, then ceased breastfeeding completely
at around 6-months. No feeding difficulties were reported
during the infant period or at his current age. Physically, his
weight and height are appropriate for his age, and he also
looks taller than other children at his age. The only concern
that his mother and teacher reported was his unclear
speech. Dribbling sometimes occurs involuntarily during his
speech. Mom reported a speech delay of 6-months, as
diagnosed and assessed by the speech pathologist.
In March 2013 (aged 3), Evan’s mother had referred
him to a speech pathologist due to unclear speech as he
was not speaking as much as other children at his age.
Evan was assessed using the Diagnostic Evaluation of
Articulation and Phonology (DEAP) (Dodd et al., 2006). It
was found that his speech is relatively clear at the single
word level, but when he tries to sequence sounds to say
longer words and put words together, the clarity of his
speech diminishes and becomes very difficult to
understand. For example, he said: “hou” for a house, “sli”
for slide and “muni” for “monkey”. Dribbling and low oral
muscle tone result in difficulty to precisely make and
sequence the tiny movements necessary for connected
speech (Rosemary & Usha, 2021). The speech pathologist
reported that poor motor control in his mouth and motor
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252
planning component becomes the issue to his imprecise
speech. There were no other issues in developmental skills
at the time, as she found Evan’s play, attention and social
skills, and receptive language were appropriate to age.
Evan will become a successful verbal communicator if he
has regular exercise on speech motor tasks, such as
teaching precise movements for different speech sounds
and sequencing sounds together to form words and
sentences. In addition, she also recommended referring
Evan to Ear, Nose and Throat (ENT) specialist to find out
any structural issue which may impact his oral motor skills.
The Speech Pathologist advised having a hearing test with
an audiologist to find any hearing issues that may be
impacting his processing of speech sounds. She also
advised the mother to include Evan in the Early Entry
Preschool Programme where he attended in July 2013 until
now, in one of the well-known Adelaide Kindergartens.
The kindergarten principal said that she had made a
referral to the Department of Education and Child
Development to get support service, but to date, there has
been no response. The family paid for private therapy as a
result. After following all the recommendations from the
speech pathologist, it concluded that he had not had any
issue with hearing or structure disorder in his mouth.
Currently, one teacher participates regularly in teaching
different speech sounds as suggested by the speech
pathologist. Since February’14, the focus has been on the
speech of words ending with n, ch, f and c/k. Evan shows
many improvements in his speech, as reported by the
teacher and his mother.
During observation in the kindergarten, it was noted the
teachers and his best friend (Nivedh) relatively understand
what Evan’s says, but it is likely difficult for other friends or
adults who are unfamiliar with him. During free play, he
pretended to be a spiderman with Nivedh excitedly. He can
show others something that interested him, imitates others,
join in a group if requested, seek adult assistance, and
respond to questions. He also plays like others either inside
(craft, puzzle, draw, and storytelling) or outside (climb the
rungs, swing and slide). However, his unclear speech
made the play assessment to some point hard for the
assessor. For example, his verbalisation about the play
scenario is hard to understand. In addition, the mother
reported that he does not have any friends at home
because there is no other child his age nearby. He usually
plays with his little sister (Asley, 15-month-old) and his
mother, who was not working at that time. Since starting
Kindergarten, Evan was not attending other settings for
early childhood programme, such as child care.
Methods
Structured observation has been performed two times;
once at the kindergarten class and playground, and
secondly observation at the child home. Informal interviews
were also performed with the mother and the kindergarten
teacher.
 Mardiyanti, & Case A. (2021)

1. Child developmental assessment
Evan’s developmental skills have been assessed using the
Australian Developmental Screening Checklist (ADSC),
Age and Stage Questionnaire (ASQ-3™) and Play skills
checklist (Heidemann & Hewitt, 2010). ADSC is a
professional-completed checklist developed by (Burdon.,
1994), whereas ASQ-3™ is a parent-completed checklist
developed by Squires et al. (2009). The play skills checklist
is adapted from Heidemann and Hewitt (2010) and is an
observational tool. The use of these tools combines both
points of view (parents and professionals), which may differ
in how they judge the child’s ability. ASQ-3™ has been
recommended widely in English-speaking countries
because of its sensitivity and specificity (85% and 86%,
respectively) (Mackrides & Ryherd, 2011). Many studies
recommend ASQ as a standardised screening tool to be
used during well-child visits in any clinical settings either in
urban or rural settings (Hamilton, 2006; Rydz et al., 2006;
Rybski & Wilder, 2008; Burns et al., 2009; King et al., 2010;
Guevara et al., 2013). The ASQ-3™ also utilised by the
Child and Family Health Service (CaFHS) in the Adelaide
region, which will subsequently be used if families or child
health nurses are concerned about the child’s development
(Arrowsmith, May 28, 2014). Evan’s ASQ-3™ results have
been reviewed by Arrowsmith (May 28, 2014) from one
local CaFHS in the Adelaide region. She suggested some
sources and materials for developing Evan’s stimulating
programme.
Play assessments are often taken in screening children,
as play is the central occupation for children (Lynch &
Moore, 2016). Play is complex and may reveal many things
about the child’s development relative to others, including
developmental status and functional skills (Casby, 2003)
and cognitive ability (Fink et al., 2012).
2. Observation
The observation records can be seen in Table 1.

Table 1 Observation records

Date: 12/5/2014 Observer: Yanti

Child’s name & Age: Evan (49 month) Background info: every morning, the one starts with a group
Time: 09.15 session, singing, checking, and greeting each other’s (±20
Setting: Morning session in kindergarten minutes).
Who is present: one group (23 children), one teacher (leader), Other involved: one parent whose daughter was unwell.
and four facilitators
Time Observation
09.15 T/ asking all students to come to the playroom for the group morning session. E/ follow the instruction and sit down at the
front corner closed to his best friend Nivedh. T/ greeting and student too, T/ asked all students to greet all teachers
using other languages such as Spanish, French, Chinese, Vietnamese, and Indonesian. Some students follow the
greetings; some were not. E/ does too. T/ then asked about the weather today, some students answered correctly, and
some were quiet. E/ tried to give his opinion by raising his hand, but the T/ did not look at him as he sat down at the
corner. Finally, he said something, but it was not clear. When another student gave a comment to the T/, Nivedh laughed
and E/ laughed excitedly, T/ reminded them that there was not something funny, and they stopped laughing.
09.35 Small group session (Reading story/storytelling)
One facilitator with four students (two boys and two girls) sat down in the corner. F/ asked which book they wanted to read.
The boys argued as they wanted to read different books, but finally, E/ agreed with his friend and chose to read his book
later. F/ read a book about Charlie and Lola with the title “I like tomato” in front of the students. The boys actively
questioned and answered with the F/, and the other two girls’ students were very quiet. E/ sat beside the F/, which was
not a good position as he needed his head to keep turn right to see the book. While being suggested to move, E/ was
still in the same position. During the conversation, sometimes F/ understood what E/ said, sometimes not. It was noticed
that E/ saliva sometimes splashed while he was talking. E/ looked frequently opened his mouth during storytelling. He
pointed to specific pictures frequently and said some words such as “to..a..too” for “tomato”; “..at..is..nge” for “eat fish
finger” etc. He asked for a specific picture in the book, and F/ explained it and replied with a question and E/ answered
it correctly. It was noticed that his mouth sometimes kept open with the tongue coming out a little bit.
09.50 Fruit time. E/ walked and grabbed his lunch book. Opened the bag’s zipper with his left hand. He took the apple and brought
it to the T/ asked for help to cut it and brought it back to the previous place where he left his bag. Together with Nivedh,
he enjoyed his apple. I noticed again that E/ could not control his saliva while eating.
Date: 13/5/14 Observer: Yanti
Child’s name and age: Evan (49 months) Background info: every Tuesday (once a week), S stimulated E
Time: 09.40 with a words card, asked E to mention the word and arranged it
Setting: Kindy’s office in the same group with other words with the letter ends with Ch,
N, F and C/K. The programme has started on 26 February 2014.
Who is present: One teacher (S) and Evan
The cards consist of a picture of a word and its letters.
Time Observation
09.40 E/ came to the office room in the kindy as the T/ asked him to do so. E/ sat down in a chair, and S/ asked him to sit on the
floor because it was for the observer. E/ asked why the observer came to the office, and S explained it simply, and E/
asked again, but the observer could not understand what he’s talking about. S looked to understand what E/ said, and
she explained and then shifted the focus to the activity. S started the intervention by explaining about talking at the right
speed. She explained using a picture of three types of speed talking: slow (snail), just right and too fast (running people).
She asked E/ to speak at the right speed. E/ looked at the cards and answered every question. S asked E/ to classify

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Table 1 (Cont.)
the card based on its sound. There were four groups for words ending with the sound n—ch—f—c/k. Examples of the word
card are:
▪ Bee-Bean-Beach-Beak
▪ Win-witch-whiff-weck
▪ Lee-lean-leech-leak
▪ Tif-teen-teak-teach
S asked E/ to sound the words correctly, and E/ did it sometimes clear and sometimes unclear. E/ looked excited with these
games, and he tried to sound the words and to put them in the correct group. Sometimes he kept busy on where to put
the cards to the correct group and not follow S instruction; he sometimes asked “where to put this on?” and S kept
remain E/ to sound it correctly and said, “you know where to put don’t you” E/ looked enjoy if S looked a bit disturbed
with his questions. S looked patient and asked E/ to “click them out” every time he finished grouping the cards. There
was one word, “tea”, which did not fit with those four groups, and E/ noticed that correctly.
The second games started. S asked E/ to close his eyes while she hid some words. After finished, S asked E/ to open his
eyes. S asked E/ to find all the words and to pronounce them correctly. E/ could find most of the words, and when he
looked difficult to find, S gave some clue of where the word was. S sometimes reminded E/ to speak just at the right
speed if she could not understand what E/ said.
T/: Teacher S/: teacher responsible for Evan language therapy E/: Evan F/: Facilitator

Results from the developmental assessment

A summary of Evan developmental skills can be seen in Table 2.

Table 2 Summary of Evan developmental skills from ADSC and ASQ-3

No Domain ADSC ASQ-3™

1. Communication Evan is able to name particular
objects, join in songs/nursery
rhymes, identify “same/different”, ask
WH- questions, respond appro-
priately to questions, and understand
or verbalise physical needs.
Apparently, his language skills are
around the age of 44-49 month.
2. Fine motor Evan is able to pincer grasp, holds a
pencil in hand, not a fist, draws
horizontal and vertical lines, turns
doorknob to open the door, cut paper
with scissors, and draw a circle.
Apparently, his fine motor skills are
around the age of 44-49 month.
3. Gross motor Evan is able to jump forwards: feet
together, hops on foot: on the spot,
balances on 1 foot for a few seconds,
can sit on the floor cross-legged,
walks a straight line.
Apparently, his gross motor skills are
around the age of 50-55 months.
4. Problem Evan is able to tell the name of a
solving/cognitive friend or playmate, maintain interest
or involvement for few minutes,
refers to own gender accurately,
understands 2: picks two objects,
tries to count and understands 3:
picks three objects.
Apparently, his cognitive skills are
around the age of 44-49 months
5. Personal-social Evan is able to ask for help if needed,
can tell his own first name, can wash
and dry hands, recognise the gender
of his friend Nivedh and himself, is
able to go to the toilet by himself,
sometimes joins in play with others.
Evan is around 44 months
development in this area.
An overall score is 45, which is above the cut-off (30.72). Evan is
able to answer common questions and act to three commands
without pointing or repeating (give me the pen, open the book and
stand up). Sometimes, he is able to name at least three items for
common questions, such as “tell me the names of some animals”.
Sometimes, he is able to mention the ending of words (-s, -ed, -
ing: such as I see two cats, I kicked the ball, I am playing) and
uses all of the words in a sentence (“a”, “the”, “am”, “is” and “are”).
An overall score is 35, above cut-off (15.81) but close to grey
areas. He is able to draw three shapes and a picture of people
with at least three features (head, eyes, arms, legs). Sometimes
he is able to put together a 5 to 7-pieces puzzle, cut a piece of
paper using a scissor or unbutton one or more buttons of his
clothes. However, he has not yet drawn or colour in within line.
An overall score is 60, which is above the cut-off (32.78). Evan is
able to catch a ball, climb, throw a ball, hop up and down, jump
forward and stand on one foot for 5 seconds, which are
appropriate to his age.
An overall score is 50, which is above the cut-off (31.30). He is
able to repeat three numbers in order without repeating the
request, distinguish items by their size, name five different
colours, and count items. Sometimes he understands the
concept of “under”, “between” and “middle” and does pretend
play.
An overall score is 45, which is above the cut-off (26.60). He is
able to serve himself, wash his hands, and brush all his teeth
without any help. Sometimes he is able to mention the names of
two or more playmates and recognises his identity, such as his
first and last name, age and sex.

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Table 2 (Cont.)
6. Overall Evan has strengths in the area of
Gross Motor and is just under age
appropriate for most other areas.
There are some impacts of
communication difficulties in his
social and communication skills.
There are also some slight delays in
fine motor development.
No problems in hearing, vision, behaviour and medical problems
in the last several months. Evan’s mum worries about two things:
“not talks like other children at his age” and “Others do not
understand most of what your child says”. Since under speech
therapy last year, Evan’s speech now shows many
improvements.

Play assessment checklist
Based on the play checklist, which looked at areas of social
play, communication, pretence and problem solving, Evan
does pretend play by using imaginary objects and uses
verbal declaration approximation (“I am a Spiderman”).
During observation, he enjoys and interacts with Nivedh,
and they play together as they are Spiderman and others
are the bad people. He enjoys playing in a group if an adult
requests it. He is able to show others an interesting object
by pointing, bringing the object or express verbally, and
engaging in the activities for several minutes or until the
activity finishes. He is able to negotiate with a peer about
which book should be read during the storytelling group,
although then he accepted the adult suggestion without
arguing. There are some difficulties in his communication
during a play episode, verbalising about the play scenario
to his play partner, and being understood. He also tends to
play with one (the same) play partner. However, due to
parents’ permission, the observation settings only
happened in the kindergarten. Therefore, there is a need to
observe the child’s play skills in his house, where he
spends most of his time.
Analysis
Overall, Evan’s developmental level is relatively
appropriate for his age. He still has many opportunities to
improve the “sometimes” skills into his “routine” skills to
help him reach his full potential. Evan’s mother and the
teachers are very good sources in shaping his
development. During observation, the mother is very active
in questioning and clarifying Evan’s progress with the
teachers. The teachers also persistently delivered the
activity suggested by the speech therapist. It is believed
that at the end of the kindergarten programme, Evan will be
more than ready for his next primary school.
When looking at each domain in the checklist, more
focus should be taken on the fine motor area,
communication, problem-solving and personal-social. This
means that more activities in these areas should be
supported and created. His dislike to colour in should be
addressed. In addition, given his unclear speech, this may
lessen his motivation to participate in play with others or
lessen his social interaction later when others respond
unexpectedly or when he realises that his speech is
different from other children. This can be seen during
observation in the kindergarten; Evan spent his time mostly
play with Nivedh and not with other children, though he is
an active person and show excellent enthusiasm during
group sessions and story-telling. He tries to participate and
connect with others, but sometimes others do not respond
to him due to his unclear speech. Therefore, we need to
develop strategies not only for building his articulation
speech but also for encouraging him to interact with other
children.
Moreover, support should also be provided to help him
achieve the kindergarten’s learning outcomes so that he
can build a strong sense of identity, feel connected and
contribute to the world, a strong sense of well-being, feel
confident, independent and involved learner as well as an
active communicator (Pasaneda Kindergarten, 2012).
Perhaps providing a positive experience will help him
construct his strong identity, confidence and indepen-
dence.
Goals setting
Goal setting aims to provide assistance for Evan and his
family to optimise his child development. The goals have
been created based on Evan’s developmental level and his
emerging skills that need to be strengthened to achieve his
full potential. Please see Table 3 (Goals for Evan) and
Table 4 (Goals and activities for the families).

Table 3 Goals for Evan

Fine Motor Goals

Goal 1. Evan will colour a picture in a colouring book mostly within the lines minimally three times a week in his time at home by July
30.
Goal 2. Evan will unbutton one or more buttons while undressing his clothes every time he comes back from school or playing with a
cloth buttoning strip by June 30.
Goal 3. Using a child-safe scissor, Evan cuts papers in half on a more or less straight line 3 times a week at home by June 30.
Goal 4. Using a minimum five- to seven-piece interlocking puzzle, Evan puts them together correctly three times a week by June 30.
Communication Goals
Goal 7. (Collaboration with the intervention from Speech therapy). Then requested to sound the words provided, 50 % of Evan’s
speech sounds are correct and clear by July 31.

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Table 3 (Cont.)
Problem-Solving Goals
Goal 8. When requested, Evan pretends to play with one different/new child partner (not Nivedh or his little sister) in the playground or
during kindergarten free play minimally once a week by July 30 (collaboration with the teachers).
Goal 9. When requested to participate in socio-dramatic play, Evan can play with two or three children and interact with each other in
the kindergarten play sessions 50% by July 31. (Collaboration with the teachers).
Personal-Social Goals
Goal 10. When asked by his mum after finish his school session, Evan mentions the names of two or more playmates (not including
his little sister) by July 31.

Table 4 Goals and activities for the families

No Goals Items Activities Description

1. Evan family will look for and use
the services from one of the local
CaFHS in Adelaide by June 30
(e.g., Kid’s health and child
developmental monitoring pro-
gramme).
2. Evan family will look for and use
the services at Forbes children’s
centre for Early Childhood
Development and Parenting by
June 30.
3. Evan’s family will read to Evan
every day.
Explain the CaFHS services in South Australia that family may gain benefits.
Provide the website address (www.cyh.com) or the CaFHS local address and contact
number close to their area (Edwardstown CaFHS; 2 Vurness Avenue 5039, Call number
1300 733 606 between 9 am and 4.30 pm, Monday to Friday to make an appointment).
Explain that Evan needs an-ongoing services from CAFHS to monitor his development
closely (e.g., using ASQ-3™ developmental monitoring until 60-month-old), including the
early childhood intervention programme and parenting support.
Explain the Forbes Children’s Centre services that the family may gain benefits, such as:
• Sessional preschool for children for five sessions a week in the year prior to starting
school.
• Long daycare child care for Evan or Asley. So, the mother will be helped in raising the
children.
• Many programmes will benefit the family, such as Dad engagement, developmental
play sessions, Saturday playgroup, Family service coordinator, Circle of Security,
Premier’s be active challenge, Mums of toddler group).
Offer article to the family about the risk for reading problems in children with speech sound
disorders (Anthony et al., 2011).
The Forbes Children’s Centre also creates a programme, Let’s Read, to support families
reading with their children.
Motivate the family to create a reading programme every twice a week at home.

Programming Ideas
Programming ideas aim to achieve those goals that are
created based on Evan’s emerging skills and the
availability of resources. Play is extremely important for
children’s learning. It is regarded as an activity that helps
develop the child’s cognition, communication, socialisation,
sensory-motor functions, problem solving and self-
awareness (Canadian Association of Occupational
Therapist, 1996 cited in Stagnitti, 2004). The activities
should be integrated into the child’s immediate interests
and ongoing activities, although he might avoid these (e.g.
colour in) (Johnson-Martin et al., 2004). The strategy could
be to rearrange the environment (e.g. remove the materials
the child persists in using for a period during the day and
offer other activities) or to become more directed (e.g. “We
need to spend some time colour in first, and then you can
play with trampoline”). One activity can be used for some
or all domains of development; for example, storytelling in
a group of children may involve cognitive, fine motor, gross
motor, communication and social skills (Table 5).

Table 5 Activities for Evan

Goals Activities Description

Fine motor’s goals Colour in games Provide “Spiderman colouring books” and colour pencils. Ask him to colour in. If he does
not show interest, he will be attracted by modelling first and saying, “I am busy with
Spiderman”. Alternatively, guide his hand and later let him do it independently. Encourage
him by stating, “can you cover all the white?” and “try and stay inside the lines.”
Unbutton games Ask him to unbutton his cloth or another cloth strip from the dressing vest or doll, which
has large, medium and small buttons. If he does not know how to approach this task,
slowly demonstrate for him. Then try to assist him physically. He should hold and lightly
pull the cloth next to the hole with one hand, grasp the button and push it through the hole
with the other hand.
Adapted from “The Carolina Curriculum for Pre-schoolers with Special Needs” (Johnson-
Martin et al., 2004)

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Table 5 (Cont.)
Cut and draw Place a piece of paper and the safety scissors in front of the child. Draw a line from the
games left to the right side of the paper. Ask him to cut the paper in half or to cut all of the ways
across the paper. Give him verbal cues if needed (e.g., “follow the line”). Or use tape by
placing it on either side of the line to encourage the child to stay on the line.
If he is able to do this, expand the games by cutting a circle, square or pictures that he
made and coloured in. It may be helpful to trace around the outline of the picture with a
marker before cutting it out. Encourage the child to stay on the line and not cut into a
picture. Select pictures easily to cut, then stick them into a paper board. Ask him to put his
name and date on it. At the end of June, the families can know how far his progress is.
Adapted from “The Carolina Curriculum for Preschoolers with Special Needs” (Johnson-
Martin et al., 2004)
Puzzles Choose a puzzle that has minimally 5 to 7-pieces. Encourage him to finish the puzzle. If
he cannot do it, try to work together or one-by-one or backchain - do all but the last one
and ask him to add the last piece. Next time do two last pieces, etc.
Communication 3-related items Choose three pictures from common categories (fruit, school items, food), then write the
games name of the picture on a piece of paper, place it close to the picture. Ask him to answer
your question: “things that we eat”, “things in the school”, “things that are yellow”.
Encourage the child to choose three pictures and bring them together with the name. If he
is able to do this, expand the games by only stating the name of the item. Encourage him
to be familiar with the letters. Encourage him to verbalise the name correctly. Model the
correct articulation of the words, then ask him to sound them out.
Identifying the Use the word cards from speech therapy or download the new one from
sound of words www.busybugkits.com.au/freebiesarticulation/. Choose the letter of words that Evan
needs to practice.
Expand the games to “hungry for K’s”. Tell him and other children in a group that they
are on a special diet and can only eat things that start with the /K/ sound. Ask them to put
the things into their lunch box (e.g., carrots, corn, cucumber, ketchup). To make it more
complex, add other objects that start with /k/ but cannot be eaten (e.g., cards, cat, key,
cow). Alternatively, put some words that do not have any /k/ sound. Count to see how
much they can put in their lunch box. Adapted from www.phonologicalawareness.org/
#!phoneme/cr2d
Problem-solving Spiderman Ask Evan to play “Spiderman shopping”. Creates the situation like a shop. Evan becomes
shopping a Spiderman (provide Spiderman costume), and his friend pretends to be a clerk. Provide
pictures as a cue to prompt, and ask Evan to buy things that start with the letter /f/.
Encourage both of them to interact with each other.
Spiderman Sick Ask Evan to play “Spiderman sick” and go to a clinic and meet customer service, doctors,
pharmacists, and other people who need help.

Discussion monitor the child development closely and support the

Evan, who has speech delays, shows much improvement
in his communication since he started the Early Entry
programme in kindergarten and several session therapies
since last year from the Speech Pathologist. Evan will be
more than ready for his next school journey if he and his
family join many community-based programmes and do a
lot of activities, as suggested above.
Some articles show that Subtle Developmental
Problems (SDPs) and Speech sound disorders are at high
risk of academic failure, social-emotional disturbance and
behaviour problems (Glascoe, 1999; Williams & Holmes,
2004; Anthony et al., 2011). These may be due to poor
motor control and motor planning inadequacy that require
much more intensive developmental stimulation. This
stimulation may be hard to do if the family does not have
enough resources and must deal with other demands such
as work and other siblings. Therefore, it is important to
refer all children with high risks of developmental delays to
an early intervention programme, although they have not
yet any diagnosis. It also important as well for CaFHS to
family. Parent’s willingness should also be supported so
that they can participate in the programmes fully.
The case in this report might become a good sample
where the child may show delays in the communication
skills that may not intervene earlier if parents had not
sought help from the speech therapist. Early detection of
the developmental problem may allow an early intervention
programme to reach children’s full potential, academic
success, independence, and confidence.
Nursing Implications
Nurses in the community health centres may be inspired
by this case study and use the information for developing
nursing care for children suspected of a developmental
delay or subtle development. Evan’s goals may also be
used for developing nursing outcomes, and Evan’s and
family activities used for developing nursing interventions.
The developmental screenings (either ADSC or ASQ-
3™) showed Evan’s development was normal, although
the mother’s concerns about Evan’s speech problem,
therefore play skills assessment may be beneficial in
finding which areas of development are specifically at risk

Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021

257
 Mardiyanti, & Case A. (2021)
of delay. Therefore it is recommended to use play skills
assessment, such as the Pretend Play Enjoyment
Developmental Checklist (Stagnitti, 2017) combined with
developmental screening tools such as Kuesioner
Praskrining Perkembangan (KPSP) in the SDIDTK
programme. It is also suggested that policymakers train
community health nurses for developmental assessment
skills and play assessment skills to improve the quality of
child universal health service in Indonesia.
Limitations of this Study
There are several limitations to this study. Firstly, this is a
single case study, and further studies would need to
include more subjects. Secondly, ideally, child
development skills and play skills should be assessed in
three different areas (house, school and other public areas
such as playground); however, this study only conducts
observation in the school and public areas. And thirdly, this
case study did not report on outcomes of the early
intervention for the child, and further studies would do well
to include both quantitative and qualitative outcome data.
Conclusion
Evan’s developmental skills and play are relatively
appropriate for his age based on the tools applied,
although ASQ-3™ picked up parental concerns that need
to be referred into an early intervention programme,
followed by monitoring his development closely. Parents
are strongly recommended to raise any concerns about
their child development and seek help from professionals.
Parents’ concern and willingness should be encouraged
for the success of the early intervention programme and
the well-being of the child.
Declaration of Conflicting Interest
The authors have no conflict of interest to declare.
Funding
This study was part of a major assignment in Master of Disability
Studies. The author (Mardiyanti) had funding support from AAS
(Australian Award Scholarship) and Islamic State University UIN
Syarif Hidayatullah Jakarta, Indonesia.
Acknowledgment
We thank Pasadena Kindergarten South Australia, the Faculty of
Health Science UIN Syarif Hidayatullah Jakarta and Flinders
University for their great supports. Also, special thanks to Evan’s
mother for her openness and kindness.
Authors’ Contribution
All author contributes to the study’s conception and design. MM
and MC conceptualized the study. MM performed data collection,
MM dan MC drafted the original version of the manuscript. All
author accepts the final manuscript.
Authors’ Biographies
Mardiyanti, RN., MKep., MDS is a Lecturer at the Nursing
Programme of the Faculty of Health Science UIN Syarif
Hidayatullah Jakarta, Indonesia. She is also an Alumni of Master
of Disability Studies, Flinders University, Australia.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
258
Amanda (Mandy) Case, MOccTh(GradEntry) is an Associate
Lecturer at the College of Nursing and Health Sciences, Flinders
University, Australia. Her work with children with delays and
disabilities as a Developmental Educator/Occupational Therapist
spans over 30 years. Mandy has taught the Play and Early
Intervention topic at Flinders University for the last ten years. Her
particular interest is play in young children with delays and
disabilities.
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Letter to Editors
Reflections on International Nurses
Day: Current status, issues, and the
future of nursing in Indonesia
Feni Betriana1 , Tetsuya Tanioka2* , Rozzano C. Locsin3,4 , and Nelwati5
Dear Editors,
May 12 is celebrated as International Nurses Day and
as the birthday of Florence Nightingale, the founder of
Modern Nursing (International Council of Nurses, 2021).
For nurses around the world, this is a momentous occasion
reflecting on the state of nursing and how nurses are
advancing the profession. Highlighted by the International
Council of Nurses are three issues; COVID-19 infections
and deaths among nurses and other healthcare workers;
stress and burnout in the nursing profession; and nurse
shortage and retention (International Council of Nurses,
2021). Regarding issues affecting the discipline and
professional practice of nursing, nurses in Indonesia are
austerely experiencing these issues because of the
pandemic; of practicing professional nursing; and
conducting research and enhancing nursing education.
First, with the COVID-19 pandemic, nursing practice
has become more challenging. The invisible disease agent
has caused untimely deaths of many healthcare
professionals, making nursing practice much harder
(Chatterjee & Kagwe, 2020) and less attractive as a
profession. As of March 2021, the Indonesian National
Nurses Association reported that more than 15,000 nurses
were infected with COVID-19 and 274 have passed away
(Guritno, 2021). Improvements in regulations related to
COVID-19 management in hospitals and other healthcare
institutions were imposed, such as increasing supplies of
personal protective equipment (PPE) and prioritizing
benefits for healthcare workers regarding staffing,
including the nurses. This prioritized frontline healthcare
workers, including nurses, to receive vaccinations against
COVID-19 (COVID-19 Handling Acceleration Force,
2021).
Appreciations for nurses’ dedication to their
professional practice during the pandemic were many, but
1 Article Info:
Graduate School of Health Sciences, Tokushima University,
Tokushima, Japan
2
Department of Nursing Outcome Management, Institute of Biomedical
Sciences, Tokushima University, Tokushima, Japan
3
Institute of Biomedical Sciences, Tokushima University, Tokushima,
Japan
4 Commons Attribution-NonCommercial 4.0 International License, which allows
Florida Atlantic University, Boca Raton, FL 33431, USA
5 others to remix, tweak, and build upon the work non-commercially as long as
Faculty of Nursing, Universitas Andalas, Padang, Indonesia
Corresponding author:
Tetsuya Tanioka, RN, PhD, FAAN
Professor, Department of Nursing Outcome Management, Institute of
Biomedical Sciences
Tokushima University, Graduate School, 18–15 Kuramoto-cho 3,
Tokushima, 770–8509, Japan, Phone, and Fax +81-88-633-9021,
E-mail: tanioka.tetsuya@tokushima-u.ac.jp
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
260
BNJ
Belitung Nursing Journal
Volume 7(3), 260-261
© The Author(s) 2021
https://doi.org/10.33546/bnj.1500
still not significant enough, as nurses continue to risk their
lives ― sometimes losing their lives ― in order to save their
patients’ lives and the lives of other co-workers. This
appreciation points to the realization that nurses and their
practice deserve political and social actions for their
valuable work, supporting a deserved salary raise
(Gunawan, 2020). While the risks to nurses’ lives on the
front lines is evident, the global society must finally realize
the professional mandate that frontline nurses are soldiers-
at-war, whose lives are valuable, therefore need protection
by all costs from being uselessly exposed to an invisible
organism and become patients themselves (Chatterjee &
Kagwe, 2020).
Second, in Indonesia, there are various classifications
of nurses based on education. The Indonesian Nursing
Law No. 38 the Year 2014 described categories of nursing
education into vocational education, academic education,
and professional education. Vocational education is a
three-year program, while the academic program prepares
nurses for a baccalaureate degree in nursing, Masters in
Nursing, and Doctor of Nursing. With an academic degree,
professional nursing education qualifies nurses through
internships in the nursing professional (Ners) and nursing
specialty program (Government of Indonesia, 2014).
Despite the variety of educational levels and the limited
number of graduate school programs, nursing education in
Indonesia is steadily improving. With only 11 Professors of
Nursing, there are now two Doctoral Programs in Nursing:
a doctoral program at the University of Indonesia and the
other at the Faculty of Nursing, Universitas Airlangga
(Casman et al., 2020). Nevertheless, transforming the
discipline to advance the professional practice of nursing
requires more interdisciplinary collaboration, especially
with expert nurse researchers from the international arena.
Received: 24 April 2021
Revised: 10 May 2021
Accepted: 11 May 2021
This is an Open Access article distributed under the terms of the Creative
the original work is properly cited. The new creations are not necessarily
licensed under the identical terms.
E-ISSN: 2477-4073 | P-ISSN: 2528-181X
 Betriana, F., Tanioka, T., Locsin, R. C., & Nelwati. (2021)
Third, the regulations from the Indonesian Ministry of
Higher Education require faculty members in academic
positions to publish scholarly articles (Ministry of Research
and Technology of the Republic of Indonesia, 2017), and
for university students to also publish their final projects,
theses, and dissertations in key scientific journals as a
requirement for graduation (Ministry of Education and
Culture, 2012). These requirements are clear evidence
affirming the flourishing of nursing research and knowledge
dissemination in Indonesia. Today, the requirement for
enhancing scholarly articles authored by Indonesian
nurses and nurse educators in international journals has
increased manifold, instigating the establishment of more
rigorous nursing journals. However, even with the
increasing processes for knowledge dissemination as
evidenced by the number of publications, journals indexed
in reputable national and international indices are still few.
As of March 2021, only three nursing journals were
indexed in reputable international databases, such as
Scopus, Web of Science, and EBSCO. These journals are
Belitung Nursing Journal, Nurse Media Journal of Nursing,
and Nursing Journal of Indonesia (Jurnal Keperawatan
Indonesia).
While this letter briefly highlights three current
conditions as the basic informational needs of nursing
practice, education, and research, focused attention on
education, practice, and policies influencing scholarly
nursing endeavors in Indonesia requires more recognition
and appreciation. Editors, researchers, and practitioners of
nursing need to be influential and establish nursing science
journals in order to disseminate ground-breaking and
important nursing work. With the nursing academe, further
progress and recognition of nursing as a discipline of
knowledge and a practice profession will materialize.
Reflecting on the future of Indonesian nurses during
this momentous International Nurses Day leaves us to
realize that, while professional nursing practice in
Indonesia is advancing, more disciplinary and professional
‘homework’ is needed to move nursing as a valuable and
integral health care practice. This consideration is a
significant step towards growing Indonesian nursing to a
level of professional practice that is integral to human
health and well-being.
Keywords
International Nurses Day; COVID-19; professional practice;
delivery of healthcare; nursing; Indonesia
Declaration of Conflicting Interest
None to declare.
Funding
None.
Authors’ Contribution
Initial draft: FB, TT, RL. Writing and editing the manuscript: FB,
TT, RL, N. All authors approved the manuscript before submission
and the final version of the manuscript.
Belitung Nursing Journal, Volume 7, Issue 3, May - June 2021
261
Authors’ Biographies
Feni Betriana, Ns, S. Kep, MNS is a PhD Student, Graduate
School of Health Sciences, Tokushima University, Tokushima,
Japan.
Tetsuya Tanioka, RN, PhD, FAAN is a Professor of Nursing
Outcome Management, Institute of Biomedical Sciences,
Tokushima University, Tokushima, Japan.
Rozzano C. Locsin, RN, PhD, FAAN is a Professor Emeritus in
Institute of Biomedical Sciences, Tokushima University,
Tokushima, Japan, and Professor Emeritus in Florida Atlantic
University, Boca Raton, FL 33431, USA.
Nelwati, S. Kp, MN, PhD is an Associate Professor, Faculty of
Nursing, Universitas Andalas, Padang, Indonesia.
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Cite this article as: Betriana, F., Tanioka, T., Locsin, R. C., &
Nelwati. (2021). Reflections on International Nurses Day:
Current status, issues, and the future of nursing in Indonesia.
Belitung Nursing Journal, 7(3), 260-261. https://doi.org/10.
33546/bnj.1500