Relaxation Technicque for Hemodialysis Patient: A Systematic

Review
Azhar Zulkarnain Alamsyah1, Henny Suzana Mediani2
1
Faculty of Nursing, Padjadjaran University, Bandung, Indonesia;
2
Faculty of Nursing, Padjadjaran University, Bandung, Indonesia
1
azhar19001@mail.unpad.ac.id; 2hennymediani@gmail.com

Abstract
Backgrounds:Relaxation technique is one way of dealing with anxiety in kidney failure patients
undergoing hemodialysis. Purpose: This systematic review aimed to review and appraise the Impact of
relaxation Technique for hemodialysis patients. Research methodology: This study used an RCT
systematic review design. The search strategy was limited to English and Indonesian from 2010 to 2020.
We conducted three databases: PubMed, Science Direct, and Google Scholar. Three independent
reviewers analyzed based on inclusion and exclusion criteria, followed by The Consolidated Standard of
Reporting Trials (CONSORT). The screening citation resulted in nine studies being analyzed. Research
result/contribution: We extracted published studies based on the PRISMA flow chart and found 709. We
filtered the case studies by title and abstract. This study found that relaxation techniques that can reduce
anxiety include Murottal Al-Quran Therapy, Dzikir Therapy, Progressive Muscle Relaxation, Benson
Relaxation Technique, Music Therapy, Hypno EFT (Emotional Freedom Technique), Breathing
Exercises, Acceptance and Commitment Therapy, and Therapy Autogenic.
Keywords: “Relaxation” AND “Anxiety” AND “Chronic Kidney Disease” AND “Haemodialysis”.

I. INTRODUCTION
Chronic Kidney Disease (CKD) is a chronic disease that progressively damages the kidneys so that
it disrupts the body's fluid and electrolyte balance which affects all body systems. CKD is currently one
of the most common diseases and is of concern in the world, including in Indonesia. The number of
sufferers of this disease is very large and tends to increase from year to year (Bayhakki & Hasneli, 2017).
Hemodialysis is a kidney replacement therapy which is often used as an alternative to remove waste
from the body when the kidneys do not perform their function and this action is unable to restore the
organ's function (Lestari. A, 2017). Patients undergoing hemodialysis will undergo this therapy for the
rest of their life (Baradero, Dayrit & Siswadi, 2009, hlm.146). This causes lifestyle changes in the
family because their activities are disrupted by hemodialysis activities, thus affecting limited life
expectancy and ultimately causing psychological problems namely anxiety (Smeltzer & Bare, 2002,
hlm. 1402).
Anxiety is a warning of danger that is threatening someone to overcome the threat. In hemodialysis
patients, of course this will be felt considering that some of their life activities are used for dialysis
therapy for the rest of their life so that they cannot perform activities optimally and feel prolonged
discomfort, it can be called anxiety disorder (Tokala, et al, 2015). Management of anxiety can be done
by providing medical therapy to patients with severe anxiety levels to panic. While relaxation therapy is
given to patients with mild to moderate levels of anxiety (Stuart, 2013).
Anxiety therapy that can be carried out by nurses in dealing with hemodialysis patients is classified
as mild to moderate anxiety, so it can be done by collaborative or independent non-pharmacological
therapy (Holly Crosby & Carol, 2006). Independent action by nurses can be used for patients to overcome
their anxiety in patients undergoing hemodialysis, namely by means of complementary therapies such as
hypnotherapy, relaxation techniques, aromatherapy, and audiovisual music (Mahdavi, Gorji, Yazdani,
& Ardebil, 2013).
Various studies related to the anxiety of patients with chronic kidney failure with hemodialysis have
been carried out, this is an effort to reduce anxiety in patients with hemodialysis and improve medical and
nursing services. Research related to anxiety is very important because hemodialysis can cause anxiety in
patients with chronic kidney disease.
The aim of this systematic review is to gain a broader understanding of anxiety in chronic renal failure
patients undergoing hemodialysis. In addition, this systematic review helps in empirical thesis of studies,
 2 Authors / Mechatronics, Electrical Power, and Vehicular Technology XX (20XX) XX-XX

so as to identify: anxiety of chronic renal failure patients with hemodialysis and the relaxation techniques
used by other researchers in treating anxiety in chronic renal failure patients undergoing hemodialysis.
II. LITERATURE REVIEW
Relaxation technique is a form of therapy in the form of giving instructions to a person in the form
of movements that are systematically arranged to relax the mind and limbs, such as muscles and restore
the condition from a relaxed, normal and controlled state from hand movements to movements feet.
Relaxation techniques are one way to rest physical and mental functions so that they become relaxed,
relaxation is a managed effort to forget and rest the mind by channeling excess energy (psychic) through
fun activities. The purpose of relaxation techniques is to help people relax, thus can improve various
aspects of physical health. To help individuals control themselves and focus their attention so that they
are in a tense situation. (Zainul, 2007).
Relaxation is a technique that involves movement of the limbs and can be done anywhere (Potter & Perry,
2005). This technique is based on the belief that the body responds to anxiety that stimulates pain or
disease conditions. Lowering techniques can reduce physiology (Asmadi, 2008)
III. METHODOLOGY
We use the PRISMA (Prefered Reporting Items For Systematic Reviews and Meta-Analyses)
scheme to describe the step-by-step search strategy, selected articles to be reviewed and analyzed in this
study. See Diagram 1. For a flowchart of the research selection process.
Identification of Research Questions
The research questions were arranged according to the PICO format. The question that guides this
systematic review is "In patients with chronic renal failure in the hemodialysis room, how effective are
relaxation interventions in improving patient anxiety?".
Literature Search
The bilbiography search method used in this paper is a journal-based Systematic Review, with
several stages, namely: determining major topics, screenning journals, coding journals, and determining
the theme of the journal references obtained. Internet database searches used include Google Scholar,
Pubmed and Sciendirect.
Literature studies are carried out by reviewing published research articles related to clinical
questions that have been made. The keywords used in this literature search were "Relaxation" AND
"Anxiety" AND "Chronic Kidney Disease" AND "Hemodialysis". Based on the search results, it was
found that 9 specific RCT articles that met the inclusion criteria and exclusion criteria. Publication period
from 2010 to 2020.
Inclusion and Exclusion Criteria
Inclusion Criteria
The inclusion criteria of this study were : articles that have peer reviews, has a clear enough
intervention, content of articles relevant to the topic of discussion, articles can be download in full
text,that articles using RCT (Randomize Control Trial).
Exclusion Criteria
The exclusion criteria of this study were : articles do not meet the components of a good article
(consisting of abstracts, introducting, method, result, discussion, implications, and references), articles are
review.
Extracted data
We extracted data from each article as follows: the authors, region, sample, Design, and
outcomes. Furthermore. Screening citations resulted in nine studies that were included in the analysis.
The details of the search strategy of articles that meet the requirments are reviewed and analysed
in the PRISMA diagram as follows :
 3 Authors / Mechatronics, Electrical Power, and Vehicular Technology XX (20XX) XX-XX

Diagram 1. Summary of the articles research result process

Article identification through database

search (n= 709)

Identification

Google Scholar PubMed Sciendirect

(n=672) (n=4) (n=33)

Screening
Articles are issued based on title
Articles by title
rating
(n=137)
(n= 106)

Articles by title and abstract

Eigibility (n= 31)

Full text does not meet the eligibility

Full text articles are worth requirements
analyzing (n= 18)
(n= 27)
Included

RCT article in final analysis

(n= 9)

IV. RESULT
Based on search results using three electronic databases, namely Google Scholar, PubMed, and
Sciendirect. Based on the PRISMA flowchart, nine articles were obtained. The results of the analysis of
articles that have been carried out are nine intervention methods that have been shown to significantly
reduce anxiety in patients undergoing hemodialysis effectively by using: Murottal Al-Quran Therapy,
Dhikr Therapy, Progressive Muscle Relaxation, Benson Relaxation Techinique, Music Therapy, Hypno
EFT (Emotional Freedom Technique), Breathing Exercise, Acceptance And Commitment Therapy and
autogenic therapy.

Table 1. General Characteristics of Research Articles

Research Total Gender
Author Year Area Ages
Design Sample (M/F)
Iin Fatimah., et al 2015 RSUD Dr. Slamet, Garut RCT 17 9/8 41 ± 60
Nur E. A, et al 2014 RS. Tegalrejo, Semarang RCT 36 15/21 26 ± 65
Noni A., et al 2020 RS. PKU Aisyiyah, Boyolali RCT 7 4/3 36± 45
Mustofa A., et al 2016 RSUD. Syamsudin,Sukabumi RCT 46 29/17 41 ± 60
RS. PKU Muhammadiyah
Dian N. S., et al 2014 RCT 30 14/16 51 ± 65
Sukoharjo
Siti M., et al 2019 RSUD Moewardi RCT 36 22/14 36 ± 45
Tri Wahyuni., et
2017 RS. Sint Corolus, Jakarta RCT 99 32/67 >45
al
Widiyono., et al 2016 RSUD. Wates, Yogyakarta RCT 30 9/21 >45
Klinik Ginjal dan Hipertensi
Rosdiana S., et al 2019 RCT 104 32/72 36 ± 45
Lestari, Semarang

Tabel 2. Article Extraction

Intervention Differ
Control Group
Autho Group ence
Materials P Value Result
r Tot Tot Between
Mean SD Mean SD
al al Groups
Iin Dzikr 3 2.1 9 4 3.3 8 0.00 Signifikan Kelompok intervensi
Fatimah., et Relaxation Menunjukkan adanya efek
al perubahan kecemasan pada
pasien hemodialisis
Nur E. A, Relaxation 26.31 3.2 15 10.69 10.1 21 0.000 Significant Kelompok intervensi
 4 Authors / Mechatronics, Electrical Power, and Vehicular Technology XX (20XX) XX-XX

Intervention Differ
Control Group
Autho Group ence
Materials P Value Result
r Tot Tot Between
Mean SD Mean SD
al al Groups
et al Progresive Showed a significant
Muscle difference effect on the
level of anxiety in
hemodialysis patients
Noni A., et Benson 34.42 6.37 3 44.28 8.30 4 <0.05 Significant
al Relaxation Significantly, it shows that
Benson intervention is
effective in reducing anxiety
levels in hemodialysis
patients
Relaxation of 47.96 5.29 23 2.13 2.32 23 0.000 Significant The udder music therapy
sundanese intervention group showed a
Mustofa A.,
music “ayun significant effect on
et al
ambing” reducing anxiety in
hemodialysis patients
Dian N. S., Murottal Al- 17.27 21.52 15 33 1.56 15 0.001 Significant The intervention group
et al Quran therapy 2 showed a significant effect
on murottal Al-Quran
therapy on anxiety in
hemodialysis patients
Siti M., et Five Finger 10.69 192.5 22 2.47 3.2 14 0.000 Significant The intervention group
al Relaxation showed a difference in
combining the two
Lemon relaxation techniques in
Aromatheraph patients with anxiety who
y underwent hemodialysis
Tri Acceptance 28.66 19.2 32 49.56 21.4 67 0,000 Significant The intervention group
Wahyuni., And showed a significant effect
et al Commitment on anxiety levels that was
Therapy higher than the control
group
Widiyono., Aroma 40 6 15 12 4,3 15 0.037 Significant The intervention group
et al therapy showed a decrease in
inhalation anxiety levels in
hemodialysis patients
Rosdiana Autogenic 80.78 47.44 52 27 46.44 52 0.000 Significant The intervention group
S., et al Therapy showed an effect of changes
in anxiety in hemodialysis
patients in the intervention
group

In its implementation, relaxation techniques are used to reduce anxiety in hemodialysis patients
by using the dzikir relaxation method. The dzikir relaxation intervention is very relevant to the role of the
nurse. In implementing the role of the nurse in providing nursing care, the nurse should look at all aspects
of the patient, namely: bio, psycho, social and spiritual (Patimah et al, 2015)
Relaxation nursing interventions using progressive muscle relaxation techniques are an effective
way to reduce stress due to psychological problems, where the patient learns to rest the muscles in an
appropriate way, reduces stress levels and can control stress hormones (Cahyo et al, 2019).
This type of relaxation is a type of relaxation that is effective in reducing anxiety, depression and
stress. This type of relaxation does not cause side effects, is cost effective, is affordable and easy to apply.
This physiological reaction of Benson relaxation is caused by alpha brain waves that cause humans to feel
happy and comfortable (Muhammad F, 2018).
Music therapy is widely used by humans to make moods calm, happy and sad. However, this
udder swing music therapy is one of the western Javanese musical instruments whose tones calm the
mind so that it is effectively used in patients with anxiety psychological disorders, especially in patients
with chronic kidney disease who are undergoing hemodialysis. However, this type of music therapy
cannot be accepted by all circles, its dominance can be accepted by the West Javanese themselves
(Alamsah MS et al, 2018).
Murottal Al-Qur'an therapy has proven that just hearing can affect the organs of the body just by
listening to the recitation of the verses of the Al-Qur'an, all Muslims, both those who speak Arabic and
non-Arabic speakers, can feel very large physiological changes, namely; get peace of mind, ward off
prejudice against oneself and God and effectively reduce anxiety in patients with psychological disorders
of anxiety and depression (Zahrofi et al, 2014).
The finger grasping relaxation mechanism by grasping the fingers with a deep breath will reduce
the physical and emotional strain on a person because grasping the fingers can deliver the entry and exit
 5 Authors / Mechatronics, Electrical Power, and Vehicular Technology XX (20XX) XX-XX

points of energy in the meridian channels which will be connected to the organs providing shock waves
or electric currents to the the brain then processes rapidly to the nerves in the affected organ. Supported
by lemon aromatherapy which creates a calm environment and atmosphere because the fragrance can
control patient anxiety (Siwi et al, 2019).
The application of anxiety independent intervention techniques using Acceptance and
Commitment Therapy (ACT) for patients who experience psychological disorders such as anxiety and
Self Efficacy. There are complex interventions that address the four adaptive systems such as:
physiological, self-concept, role and dependence on anxiety and Self Efficacy (Ismoyowati T.M et al,
2018).
Giving inhalation aromatherapy can reduce the level of anxiety in chronic renal failure patients
undergoing hemodialysis, because there are therapeutic elements of essential oils in aromatherapy that
can improve the balance that occurs in the body system. The aroma contained in essential oils can create a
sense of calm in the brain to restore memory, reduce anxiety, depression and stress. Aromatherapy can be
used as an alternative complementary therapy to minimize pharmacological side effects, so nurses are
advised to do this intervention to improve the quality of health services (Nauli. F.A et al, 2015).
The use of autogenic therapy causes depression to decrease in chronic renal failure patients
undergoing hemodialysis, because this therapy uses positive sentence suggestions that will produce
stimuli that will be sent from the axons of ascending sensory fibers to the neurons of the RAS. How to
apply it requires a calm psychological state and a good level of spiritual confidence. The content of the
auto-suggestion carried out can be modified according to beliefs so as to optimize the subconscious
acceptance phase so that it can effectively reduce anxiety (Saputri L. et al, 2019).

V. DISCUSSION
The results of a review of several research journals that were analyzed cited that it needs very
important attention for patients with chronic renal failure with hemodialysis. Over time, patients with
chronic kidney failure with hemodialysis have begun to realize that their current life onwards will be
dependent on an activity that should not be used. break up namely hemodialysis. This turned out to be
very detrimental to the quality of life, welfare, productivity, social skills and self-care. Not only that,
other problems will arise due to his illness, namely biological, psychological, social and spiritual factors.
Then a negative feeling arises that he has been threatened, causing prolonged anxiety.
Almost all research articles taken state that chronic renal failure patients with hemodialysis will
experience anxiety. Assessment of anxiety in patients with chronic renal failure is very necessary in order
to change negative perceptions about all changes in aspects of life. To reduce the anxiety of patients with
chronic kidney failure with hemodialysis, it is very important that the role of nurses in overcoming
anxiety through comprehensive biological, psychological, social and spiritual nursing care is needed
(Astuti. A, 2017).
Anxiety assessment using relaxation techniques is one technique that has a positive impact on
changes in anxiety in patients with renal failure with hemodialysis. This is evidenced by the articles we
take as samples that are relevant to the research. However, from several articles that show its advantages
and disadvantages, especially in progressive muscle relaxation techniques, clients will tire easily if given
interventions by relying on physical assistance, so this needs to be considered considering that kidney
failure patients undergoing hemodialysis are not allowed to undergo hemodialysis. excessive physical
activity, it is necessary. there is strict observation in carrying out this technique.

VI. CONCLUSION
Several methods of relaxation techniques have the same character, namely influencing the mind to
control the patient's psychological back to a healthy state of mind and body. The act of relaxation
basically works by increasing the sympathetic nerves in response to pressure. The sympathetic nervous
system works by activating the adrenal medulla to increase the production of epinephrine,
norepinephrine, cortisol and reduce nitric oxide. This situation will cause changes in the body's response,
such as an increase in heart rate, respiration, blood pressure, increased blood flow to various organs and
an increase in body metabolism.
So far, it is thought that relaxation techniques are less effective because most people need immediate
treatment, namely using pharmacological drugs due to psychological conditions that disturb themselves.
But in fact, the reaction caused by relaxation techniques is almost the same as the use of pharmacological
drugs, it's just that the use of pharmacological therapy is done more instantly. So this relaxation technique
 6 Authors / Mechatronics, Electrical Power, and Vehicular Technology XX (20XX) XX-XX

intervention needs to be done in order to reduce side effects and drug dependence. For this reason, it is
necessary to regularly assess the anxiety of chronic renal failure patients undergoing hemodialysis using
appropriate relaxation techniques.

IMPLICATION
Implications for policy makers of relaxation exercises in kidney failure patients undergoing
hemodialysis can be applied to all hospitals that have hemodialysis rooms.

ACKNOWLEDGEMENT
The researcher would like to thanks Padjadjaran University for facilitating database

REFERENCES
Alam, S., & Hadibroto, I. (2007). Gagal Ginjal Jakarta : Gramedia

Alfiannur. F., 2015. Hubungan Antara Kecerdasa Spiritual Dengan Tingkat Kecemasan
Pasien Gagal Ginjal Kronik yang Menjalani Hemodialisis. JOM Vol 2 No 2,
Oktober 2015.
Alamsah, M. S., Rahayuwati, L., & Purba, C. I. H. (2018). The Effects of Sundanese
Kacapi Suling “Ayun Ambing” Music Therapy to The Level of Anxiety on Chronic
Renal Failure Patient Undergoing Hemodialysis. Jurnal Keperawatan Padjadjaran,
6(1).

Asmadi. 2008. Teknik Prosedural Keperawatan: Konsep dan Aplikasi

Astuti. A, 2017. Effect Of Progressive Muscular RelaxationOn Anxiety Levels In Patients

With Chronic Kidney Disease Undergoing Hemodialysis In The General Hospital Of
Tugurejo Semarang, Indonesia. Belitung Nursing Journal, Volume 3, Issue 4, July-
August 2017.

Baradero, M., Dayrit, M.W., & Siswadi, Y, (2009). Seri Asuhan Keperawatan Klien
Gangguan Ginjal. Jakarta : EGC

Bayhakki, B., & Hasneli, Y. (2017). Hubungan lama menjalani hemodialisis dengan Inter-
Dialytic Weight Gain (IDWG) pada Pasien Hemodialisis. Jurnal Keperawatan
Padjadjaran, 5(3)

Cahyo Pramono., Sri Sat Titi Hamranani., Muhammad Yudha Sanjaya (2019). Pengaruh
Tenkin Relaksasi Otot Progresif Terhadap Tingkat Kecemasan Pasien Hemodialisis
Di RSUD Wonosobo. Jurnal Ilmu Keperawatan Medikal Bedah. ISSN 2621-2986

Chang H.J., Ku, D.Y., Park, Y.S., Kim, S.R., & Ryu, J.W. (2012). Depression and Life
Quality in Chronic Renal Failure Patients with Polyneurophaty on Hemodialysis.
Finnegan, J., Jennifer, T., & Veronica, J. (2013). The psychosocial experience of patients
with end-stage renal disease and its impact on quality of life: findings from a needs
assessment to shape a service. ISRN Nephrology, 308986. doi:10.5402/2013/308986

Gorji, H. M., Davanloo, A., & Heidarigorji, A. (2014). The efficacy of relaxation training
on stress, anxiety, and pain perception in hemodialysis patients. Indian Journal of
Nephrology, 24(6), 356-361. doi:http://dx.doi.org/10.4103/0971-4065.132998
7 Authors / Mechatronics, Electrical Power, and Vehicular Technology XX (20XX) XX-XX

Holly, RN, MS, CCRN; Crosby, Carol, RN, C. (2006). Music Therapy as a Nursing
Intervention. Journal of Psychological Nursing & Mental Health service: Mar; 35, 3
ProQuest pg.34

Iin Patimah, Suryani, Aan Nuraeni. (2015). Pengaruh Relaksasi Dzikir terhadap Tingkat
Kecemasan Pasien Gagal Ginjal Kronis yang Menjalani Hemodialisa. Jurnal
Keperawatan Padjadjaran. Vol 3. Doi : https://doi.org/10.24198/jkp.v3i1.95.g93

Ismoyowati, T. W. (2018). Pengaruh acceptance and commitment therapy terhadap

perubahan kecemasan dan selfefficacy pada pasien dengan hemodialisa di rs sint
carolus jakarta.

Kazdin, A. E. (2001). Behavior Modification in Applied Settings. USA: Wadsworth

Thompson Learning

Kidney Disease Statistic for The Uniter States (2012). The Growing Burden of Kidney
Disease.http://kidney.niddk.nih.gov/KUDiseases/pubs/kustats/KU_Diseases_Stats_5
08.pdf,diperoleh tanggal 4 Juni 2020.

Lestari. A, 2017. Gambaran Tingkat Kecemasan Pasien Gagal Ginjal Kronis Dengan
Tindakan Hemodialisis

Muhammad, f. (2018). Asuhan Keperawatan Pada Pasien Dengan Gagal Ginjal Kronik
dengan Aplikasi Teknik Relaksasi Benson Untuk Penurunan Stres di Ruang Interne
Pria RSUP M. Djamil Padang (doctoral dissertation, universitas andalas).

Musa. L. W. 2015. Hubungan Tindakan Hemodialisis Dengan Tingkat Kecemasan Klien

Gagal Ginjal di Ruangan Dahlia RSUP Dr. R. Kandau, Manado. Ejournal
Keperawatan (3-Kp) Volume 3. Nomor 1. Februari 2015.

Nauli, F. A. (2015). Pengaruh Aromaterapi Inhalasi Lavender terhadap Kecemasan

Pasien Gagal Ginjal Kronik yang Menjalani Hemodialisis (Doctoral dissertation,
Riau University).

Rustina. (2012). Gambaran Tingkat Depresi pada Pasien Gagal Ginjal Kronik yang
Menjalani Hemodialisis di RSUD DR. Soedarsono Pontianak.
http://jurnal.untan.ac.id/index.php/jkf/article/view/1776 diperoleh pada tanggal 5
Juni 2020.

Santoso, D. (2009). 660 Menit Menuju Ginjal Sehat. Surabaya: Jaring Pena

Saputri, R., & Rahayu, D. A. (2019). Terapi Autogenik terhadap Kondisi Psikologis Pasien
CKD yang Menjalani Hemodialisa. Jurnal Ilmu Keperawatan Jiwa, 2(3), 139-148.

Shanty, M. (2011). “Silent Killer Diseases” (Penyakit yang Diam-Diam Mematikan).

Jogjakarta : Javalitera

Siwi, A. S., & Susanti, M. P. I. (2019). Teknik Relaksasi: Genggam Jari Upaya
Menurunkan Kecemasan Pada Pasien Gagal Ginjal Yang Menjalani Haemodialisa Di
RST Wijayakusuma Purwokerto. JURNAL PENGABDIAN MASYARAKAT AL-
IRSYAD (JPMA), 72-81.

Sudoyo, A.W. (2006). Buku Ajar Ilmu Penyakit Dalam. Jilid I. Edisi IV. Jakarta : Balai
Penerbit FKUI
8 Authors / Mechatronics, Electrical Power, and Vehicular Technology XX (20XX) XX-XX

Tokala, et al, 2015. Hubungan Antara Lamanya Menjalani Hemodialisis Dengan Tingkat
Kecemasan Pada Pasien Dengan Penyakit Ginjal Kronik Di RSUP Prof. Dr. R. D.
Kandou Manado, Jurnal e-Clinic (eCI), Volume 3, Nomor 1, Januari-April 2015.

Wahyudi, I.E.D. 2012. Angka Kematian Pasien End Stage Renal Disease Di ICU dan
HCU DR. Kariadi.
http://ejournal-s1.undip.ac.id/index.php/medico/article/download/1752/1750,
diperoleh pada tanggal 5 juni 2020.

Zahrofi, D. N., Maliya, A., & Listyorini, D. (2014). Pengaruh pemberian terapi murottal
Al Quran terhadap tingkat kecemasan pada pasien hemodialisa di RS PKU
Muhammadiyah Surakarta (Doctoral dissertation, Universitas Muhammadiyah
Surakarta).

Zainul, Zen. 2007. Kekuatan Metode Lafidzi. Jakarta : Qultum Media