MATA KULIAH

ASUHAN KEPERAWATAN GAWAT DARURAT 1

REVIEW JURNAL
“ INITIAL ASSESSMENT “

DI SUSUN OLEH :

SUCI MUSLIKA ANGGITARI

20176523104

POLTEKKES KEMENKES PONTIANAK

D-IV KEPERAWATAN PONTIANAK
TAHUN AKADEMIK 2020/2021
 REVIEW JURNAL PENELITIAN

Judul Nurse’s Knowledge On The Initial Assessment For Primary Survey Of

Emergency Patient At Emergency Department.

Penulis Mesalina Sukardi Massa

Master Student at Department of Health Administration and Policy ,
Faculty of Public Health.
Airlangga, University, Indonesia.

Pendahuluan Departmen darurat (IGD) adalah instalasi untuk menangani kasus-

kasus darurat, seperti keracunan, kecelakaan, korban bencana
alam,muntah-muntah, diare yang parah yang membutuhkan
perawatan segera untuk menyelamatkan nyawa dan menghindari
kelumpuhan. Seseorang yang mengalami gangguan pernafasan atau
serangan jantung belum tentu kematian, masih dapat dibantu
(Wicaksana 2011)
Pemeriksaan awal dengan initial assessment (penilaian awal) adalah
dimulai dari persiapan dalam mengidentifikasi pasien. Setelah itu
melakukan triage menurut klasifikasi penyakit dan diikuti dengan
melakukan survei primer yaitu ABCD airway, pernafasan, sirkulasi
ketidakmampuan) dalam melakukan tindakan pertolongan pertama
yang kemudian melanjutkan dengan bentuk tindakan resusitasi
cardiopulmonary (CPR). Dengan demikian, ada hubungan antara
tingkat pengetahuan tingkat pemahaman perawat tentang penilaian
awal pasien gawat darurat dengan survei dasar di department gawat
darurat (IGD) (asosiasi jantung amerika, 2015)
Penanganan dalam keadaan daruat hendaknya dilakukan dengan
cepat dan tepat sehingga ancaman kehidupan dapat ditangani dengan
efektif. Penilaian awal adalah proses penilaian cepat dalam pasien
darurat yang langsung diikuti dengan resusitasi (Suryono,2010).
Penilaian awal dibagi dalam 2 fase, yaitu survei primer dan survei
sekunder, tujuan survei utama adalah untuk manangani 1 akut.
Masalah yang harus dengan cepat diidentifikasi melalui penilaian
ABCD (jalur udara, pernafasan, sirkulasi, dan kelumpuhan)
sementara tujuan survei sekunder adalah untuk mengidentifikasi
semua penyakit dan cedera atau masalah yang berkaitan dengan
keluhan pasien FGHI (kondisi penuh tanda-tanda vital, memberikan
langkah-langkah penghiburan, sejarah, dan penilaian dari kepala ke
kaki, memeriksa permukaan posterior).
Manajemen awal dari survei pertama dihampiri melalui (ABCD):
1) Menjaga saluran udara dengan mengontrol tulang belakang leher
Rahim, manajemen jalur udara adalah yang terpenting dalam
melakukan pernafasan dan membutuhkan keterampilan khusus
dalam menangani keadaan darurat, karena itu hal pertama yang
harus dinilai adalah kelicinan jalur udara, yang mncakup
pemeriksaan jalur udara yang dapat disebabkan oleh benda asing,
patah tulang laringgeal atau trakea. Gangguan saluran udara
dapat muncul tiba-tiba dan secara total, secara bertahap sebagian
dan secara progresif atau berulang kali (Dewi, 2013)
2) Tetap bernafas dengan ventilasi oksigen sangat penting bagi
kehidupan. Sel tubuh memerlukan pasokan oksigen yang
digunakan untuk mendukung reaksi kimia yang menghasilkan
energy, yang menghasilkan Co2 yang harus dilepaskan terus
menerus (Dewi, 2013)
3) Lakukan pengendalian perdarahan (Kontrol Hemoragik), karena
perdarahan adalah penyebab kematian setelah trauma
(Krisanty,2012)
4) Status neurologis didekat akhir survei utama mengevaluasi
keadaan neurologis yang cepat. Hal ini dinilai sebagai tingkat
kesadaran, ukuran dan reaksi . cara cepat untuk mengevaluasi
status neurologis adalh menggunakan AVPU (siaga, suara, rasa
sakit, kesadaran), sementara GCS (Skala koma Glasgow) adalah
metode evaluasi neuro-logika, dan dapat dilakukan pada saat
 survei sekunder (Krisanty,2012)
Berdasarkan penjelasan diatas, tujuan penelitian ini adalah untuk
menjelaskan hubungan antara tingkat pengetahuan perawat pada
penilaian awal pasien gawat darurat dengan implementasi survei
dasar di department darurat rumah sakit daerah Toto kabila.
Metode Penelitian ini dilakukan dengan desain studi lintas alam. Responden yang
menggunakan penelitian ini adalah perawat yang bekerja di department
darurat rumah sakit regional Toto Kabila, Regency Bolango Bone,
Gorontalo. Teknik menentukan sampel adalah menggunakan kriteria
termasuk dan pengecualian. Pertimbangan dalam kriteria penyertaan
adalah perawat.
Variable yang digunakan dalam penelitian ini, terdiri dari dua jenis
variable yaitu variable independen dan variable bergantungan. Variable
independen yang digunakan dalam penelitian ini adalah pengetahuan
tingkat perawat tentang penilaian awal pada pasien darurat. Kemudian
variable yang digunakan adalah tindakan implementasi dari survei utama.
Hasil Berdasarkan hasil penelitian yang telah digambarkan dalam bagian
sebelumnya diketahui bahwa pengetahuan penilaian awal dimiliki oleh
perawat dengan aplikasi survei primer yang dilakukan oleh perawat bagian
gawat darurat department rumah sakit daerah Toto Kabila memiliki
hubungan yang kuat hasilnya menjelaskan bahwa ketika penerapan survei
primer oleh perawat department darurat rumah sakit Toto Kabila mampu
melakukannya denga baik, hal ini dapat dijelaskan bahwa perawat
memiliki pengetahuan tentang penilaian awal adalah baik. Sebaliknya, jika
perawat memiliki pengetahuan penilaian awal yang buruk, kecuali
kemungkinan perawat tidak dapat melakukan survei utama dengan baik.
Penilaian awal itu sendiri adalah proses penilaian cepat pasien gawat
darurat di rumah sakit.
Dalam hasil penelitian yang telah dilakukan untuk menjelaskan bahwa
tingkat pengetahuan perawat tentang implementasi penilaian awal
memiliki hubungan dengan implementasi survei primer yang dilakukan
oleh perawat. Hasilnya mendukung hasil riset yang telah dilakukan, tempat
survei utama dapat dilakukan dengan benar dan cepat jika perawat
memiliki pemahaman dan pengetahuan yang baik tentang penilaian awal.
 Kemudian berdasarkan hasil analisis deskriptif yang telah dilakukan oleh
perawat yang bekerja di department darurat rumah sakit regional toto
kabila lebih dari 70% dilakukan dengan cukup baik.

Reference 1. Wicaksana, (2011). Buku Dasar- Dasar Keperawatan Darurat,

Jakarta: Trans Info Media.
Jurnal :
2. American Heart Association (AHA), 2015, Adult Basic Life
Support: Guidelines for cardiopulmonary Resuscitation and
Emergency Cardiovascular Care, diakses 16 oktober 2016,
http://circ.ahajournals.org/content/122/16suppl 2/S298.

3. Niels. K., Obendorfer, D., White, L. F., Rebholz, C., Magauran, B.,
Baker, W., & Olshaker, J. (2012). Time series analysis of
emergency department length of stay per 8hour shift. Western
Journal of Emergency Medicine, 13(2), 163.

4. Suryono, B. (2010). Materi Pelatihan Penanggulangan Penderita

Gawat Darurat (PPGD) dan Basic Life Support Plus (BLS).
Yogyakarta: Tim Pusbankes 118 BakerPgdm Persi Dij.

5. Steinmann, (2010). Buku Proses Kegawatdaruratan. Jakarta: Trans

Info Media.

6. Dewi, K. (2013). Buku Ajar Dasar – Dasar Keperawatan Gawat

Darurat. Jakarta: Salemba Medika Jakarta.

7. Krisanty, P. (2009). Asuhan Keperawatan Gawat Darurat. Jakarta:

Trans Info Media.

8. Advanced Trauma Life Support. (2015). Advanced trauma life

support course for physicians. 8th Edition. The Committee.

9. National Highway Traffic Safety Administration. (1997).

Emergency Medical Technician-Basic: National Standard
Curriculum. USA: Department of Transportation.

10. Fathoni, A. & Ariyani, W. (2012). Hubungan Tingkat Pengetahuan

Perawat Tentang Basic Life Support (BLS) Dengan Perilaku
Perawat Dalam Pelaksanaan Primary Survey Di RSUD DR.
Soediran Mangun Sumarso Kabupaten Wonogiri. Skripsi. Program
Studi STIKES Kusuma Husada Surakarta.

11. Sutawijaya, R. B. (2010). Gawat Darurat. Yogyakarta : Publishing

 Aulia.

12. Nursalam, (2013). Metodologi Penelitian Ilmu Keperwatan:

Pendekatan Praktis, Edisi 3, Jakarta Salemba Medika.
 KESIMPULAN

Kesimpulan penelitian ini adalah bahwa ada hubungan yang signifikan antara tingkat
pengetahuan yang dimiliki tentang penilaian awal oleh perawat department perawat darurat
rumah sakit Toto Kabila, Regency Bolanga, Gorontalo dengan penerapan survei primer oleh
perawat. Hasil ini menjelaskan bahwa para perawat dapat melaksanakan survei dasar dengan
baik sewaktu memperoleh pengetahuan tentang penilaian awal juga. Akan tetapi, apabila si
perawat tidak memiliki pengetahuan awal yang baik tentang penilaian itu, kemungkinan besar
si perawat akan disebut tidak dapat melaksanakan survei utama dengan sepatutnya.
 NURSE'S KNOWLEDGE ON THE INITIAL ASSESSMENT
FOR PRIMARY SURVEY OF EMERGENCY PATIENT AT
EMERGENCY DEPARTMENT
Mesalina Sukardi Massa*

Master Student at Department of Health Administration and Policy, Faculty of Public Health,
Airlangga University, Indonesia

*Corresponding author: Mesalina Sukardi Massa, Surabaya,

Email: mesalinavivi90@gmail.com

https://doi.org/10.32827/ijphcs.5.6.124
ABSTRACT

Background: A person who has experienced an interruption of breathing or cardiac arrest is

not necessarily dead, he can still be helped. The early examination with initial assessment
which is starting from the preparation in identifying the patient, after that do the triaging
according to disease classification and followed by doing primary survey in doing first aid
action, then proceed with action cardiopulmonary resuscitation (CPR).

Materials and Methods: The method used in this study is quantitative research with the type
of correlational design. The population was taken is emergency installation nurse at
Emergency Department of Regional Hospital Toto Kabila, Bone Bolango Regency, Gorontalo
with total of 23 respondens, which is analyzed by rank spearmen correlation technique.

Results: The results show a positive correlation value of correlation test results that have been
done, it is known that the significance value shown is equal to 0.000 or <0.05 with a
coefficient of 0.743.

Conclusion: The higher the nurse's knowledge about the initial assessment the better in the
implementation of the primary survey. These results may serve as a reference to improve the
performance of nurse emergency installation in dealing with emergency patients.

Keywords: Initial Assessment, Primary Survey, Emergency Department.

1.0 Introduction

Emergency Department (IGD) is an installation to handle emergency cases, such as accidents,

poisoning, natural disaster victims, heat, vomiting, severe diarrhea requiring immediate
treatment to save lives and avoid disability. A person experiencing an interruption of
breathing or cardiac arrest is not necessarily a death, can still be helped (Wicaksana 2011).

Preliminary examination with initial assessment that is, starting from the preparation in
identifying the patient, after that do triage according to the classification of disease and
followed by doing primary survey that is ABCD (Airway, Breathing, Circulation, Disability)
in performing first aid measures which then proceed with the form of action Cardiopulmonary
resuscitation (CPR). Thus there is a relationship between the nurse's knowledge level of the
emergency patient's initial assessment with the primary survey at the Emergency Department
(IGD) (American Heart Association, 2015).

The 2014 the data of patient visits to Emergency Department (IGD) throughout Indonesia
reached 4,402,205 (13.3% of total visits in hospitals) with 12% are from Emergency
Department visits. This significant amount requires considerable attention with emergency
patient services. This is particularly influential in total Emergency Department such as
waiting time, wasting time, patient mortality and patient satisfaction, used to assess the
density and clinical performance of each patient arrival at the Emergency Department used as
an indicator of efficiency assessment of operational and clinical performance improvement
(Niels, et.al, 2012).

Through observation results in the report of Emergency Department of Regional Hospital

Toto Kabila in December 2016 showed the top 10 cases of ISPA (upper respiratory infection),
GE (gastro intestinal), febrile/Fever, HT (hypertension), DM (diabetes mellitus), Colic
Abdomen, DHF (dengue hemorrhage fever), CVA (cerebrovascular accident), typhoid fever
and traffic accident.

Based on preliminary study conducted by the author on December 19, 2016 in Emergency
Department of Regional Hospital Toto Kabila with interview method to 2 nurses stated that in
the initial assessment of the first thing to do inspection of his consciousness and then perform
airway, breathing and circulation checks quickly and done resuscitation action if necessary.
Handling in emergency patients should be done quickly and appropriately so that life threats
can be effectively tackled. Based on the observation of 5 nurses, 3 nurses can conduct initial
assessment according to procedure while 2 other nurses perform the initial assessment not
according to procedure.

Initial assessment is a rapid assessment process in emergency patients directly followed by

resuscitation (Suryono, 2010). Initial assessment is divided into 2 phases, namely primary
survey and secondary survey, the purpose of the primary survey is to deal with lifethreatening
issues that must be quickly identified through the assessment of ABCD (Airway, Breathing,
Circulation, and Disability), while the purpose of the secondary survey is to identify all
illnesses and injuries or problems related to the patient's complaints FGHI (fulset of vitals,
give comfort measure, history, and head to toe assessment, inspect posterior surfaces)
(Steinmann, 2010).
The initial management of the primary survey is approached through (ABCD):

(1) Maintaining airways with cervical spine control, airway management is paramount in
resuscitation and requires special skills in the management of emergency situations, therefore
the first thing to be assessed is the smoothness of the airway, which includes airway checks
that can be caused by a foreign object, a laryngeal or tracheal fracture. Airway disturbances
can arise suddenly and totally, gradually partially and progressively or repeatedly (Dewi,
2013),

(2) Keeping breathing with oxygen ventilation is very important for life. The body's cells
require the supply of oxygen used to support the energy-producing chemical reaction, which
produces CO2 that must be released continuously (Dewi, 2013),

(3) Perform bleeding control (hemorrhagic control), because bleeding is the cause of death
after trauma (Krisanty, 2012),

(4) Neurological status near the end of the primary survey evaluated rapid neurologic
state. It is assessed is the level of awareness, size and reaction of the pupil (Advanced Trauma
Life Support, 2015). A quick way to evaluate neurological status is to use AVPU (Alert,
Voice, Pain, Unconscious), while the GCS (Glasgow Coma Scale) is a more detailed method
of evaluating neuro- logical status, and can be done at the time of the secondary survey
(Krisanty, 2012).

Based on the description above, the purpose of this study is to explain the relationship
between the level of knowledge of nurses on the initial assessment of emergency patients with
the implementation of primary survey at Emergency Department of Regional Hospital Toto
Kabila.

2.0 Materials and Methods

This research is conducted with cross-sectional study design. The respondent that use in this
study is a nurse who works at the Emergency Department of Regional Hospital Toto Kabila,
Bone Bolango Regency, Gorontalo. The technique of determining the sample is to use
inclusion and exclusion criteria. Considerations in the inclusion criteria are nurses who are
still directly involved in dealing with the patient, the letter of registration is still valid, and the
emergency first aid certificate is still valid. Then, on the exclusion criteria the considerations
include: (1) There are circumstances or diseases that interfere with the measurement or
interpretation of results,
(2) There are circumstances that interfere with the ability of implementation

(3) Ethical barriers,

(4) The subject refuses to participate. Based on the criteria used, the number of nurses used as
samples in this study is a number of 23 nurses.
Variables used in this study, consists of two types of variables, namely independent variables
and dependent variables. Independent variable used in this research is nurse knowledge level
about initial assessment in emergency patient. Then the dependent variable used is the action
of the implementation of the primary survey.

The indicators used to explain the nurse's knowledge level on initial assessment in emergency
patients consist of five things:

(1) Preparation,

(2) Triage,

(3) Primary survey,

(4) Fluid resuscitation, and

(5) Cardiopulmonary resuscitation.

Then on the action of the implementation of the primary survey, the indicators used are
through the ABCD assessment, which consists of:

(1) Airway,

(2) Breathing,

(3) Circulation, and

(4) Disability.

Data collection techniques in this study were conducted by using questionnaires. In the
primary survey, the questionnaire used in this study is based on Emergency Medical
Technician-Basic: National Standard Curriculum (National Highway Traffic Safety
Administration, 1997), consisting of 36 statements. The questionnaire used to explain the
nurse's knowledge level on initial assessment is based on the questionnaire that has been used
in the Nursalam (2013). The questionnaire consisted of 30 statements about nurse knowledge
on initial assessment.
On validity test and reliability of research instrument, done by using spearman correlation test.
The result of validity and reliability test shows that every statement used in this research can
be used for further analysis, that is Rank Spearman Correlation analysis. Before Rank
Spearman Correlation analysis, first coding is done with the aim to simplify the respondent's
answer so that it can be processed.

3.0 Results

The results of this study were discussed below:

Table 1: Nurse's Knowledge About Initial Assessment at Emergency Department of Regional

Hospital Toto Kabila, Bone Bolango Regency, Gorontalo

Nurse's Knowledge About Initial

No N %
Assessment
1 Good 17 73.91%
2 Good Enough 6 26.09%
Total 23 100

Based on the results shown in Table 1, it is known that of the 23 nurses working in the
Emergency Department of Regional Hospital Toto Kabila that the knowledge of the initial
assessment has been at a good level, ie there are 17 nurses. Then there are 6 nurses who have
knowledge of initial assessment which is in enough category. These results explain that the
nurses are working in the Emergency Department of Regional Hospital Toto Kabila has good
knowledge of initial assessment.
Table 2: Implementation of Primary Survey at Emergency Department of Regional Hospital
Toto Kabila

Implementation of Primary
No N %
Survey
1 Good 1 4.35%
2 Good Enough 18 78.26%
3 Not good 4 17.39%
Total 23 100

Based on the results shown in Table 2, it is known that the implementation of the primary
survey conducted by the nurses working at Emergency Department of Regional Hospital Toto
Kabila most have been pretty good. This is indicated by there are 18 nurses who fall into
category good enough in carrying out primary survey. Then the rest there are 4 nurses who are
still less good in implementing the primary survey, and there is 1 nurse who entered in the
category both in implementing the primary survey in Emergency Department of Regional
Hospital Toto Kabila.

Tabel 3: Spearman Rank Correlation Test Result between Nurses' Knowledge About Initial
Assessment with Implementation of Primary Survey in Emergency Department of
Regional Hospital Toto Kabila

Correlation Coefficient Sig (2-tailed)

0.743 0.000

Referring to the results shown in Table 3, it is known that the significance value shown is
0.000. The value of significance explains that there is a significant relationship between the
knowledge possessed by the nurses about the initial assessment with the implementation of
the primary survey by the nurse in Emergency Department of Regional Hospital Toto Kabila.
When considering the value of the coefficient shown, that is equal to 0.743, it can be
explained that the relationship exists between the knowledge possessed by the nurse about the
initial assessment with the implementation of the primary survey by the nurse in Emergency
Department of Regional Hospital Toto Kabila is in the high category.
4.0 Discussion

Based on the results of research that has been described in the previous section known that the
knowledge of initial assessment owned by nurses with the implementation of primary survey
conducted by the nurses section Emergency Department of Regional Hospital Toto Kabila
have a significant relationship and have a strong relationship This result explains that when
the implementation the primary survey by the nurse of the Emergency Department of
Regional Hospital Toto Kabila is able to do well, it can be explained that the nurse has
knowledge of the initial assessment is good. On the contrary, when the nurse has a poor initial
assessment knowledge, it is unlikely that the nurse is unable to perform the primary survey
well.

Initial assessment itself is a process of rapid assessment of emergency patients in a hospital.

Assessment conducted can be physical and psychosocial assessment to be able to know the
problems or illness experienced by patients quickly and accurately (Suryono, 2010). In
emergency patients most are patients who need rapid treatment; therefore knowledge of initial
assessment becomes an obligation to be able to provide quick and precise action to the patient.
The action in question is the action of primary survey and secondary survey. According to
Steinmann (2010) primary survey is an action taken to deal with life-threatening issues that
must be identified quickly.

Fathoni and Ariayani (2012) in the results of research that has been done to explain that the
level of nurse knowledge about the implementation of initial assessment has a relationship
with the implementation of primary survey conducted by nurses. These results support the
results of the research that has been done, where the primary survey can be done correctly and
quickly when the nurse has a good understanding and knowledge of the initial assessment.

Based on the results of descriptive analysis that has been done in the previous section, it can
be explained that more than 70 percent of nurses working at the Emergency Department of
Regional Hospital Toto Kabila have knowledge of the initial assessment is good. This result
explains that nurses working at Emergency Department of Regional Hospital Toto Kabila
were able to conduct a quick preliminary assessment when receiving emergency patients.
Then based on the results of descriptive analysis that has been done, it is also known that the
implementation of primary survey conducted by nurses who work in Emergency Department
of Regional Hospital Toto Kabila more than 70% done pretty well.

Therefore, knowledge of initial assessment has an important role for a nurse, especially nurses
who work at Emergency Department of Regional Hospital Toto Kabila to be able to support
the implementation of primary survey quickly, precisely and efficiently. As explained by
Sutawijaya (2010) that in emergency response time is the main concern, the speed and
handling of emergency patients is critical to saving emergency patients, through good initial
assessment knowledge so as to support the implementation of a good primary survey,
especially at Emergency Department of Regional Hospital Toto Kabila.
5.0 Conclusion

Based on the results of research and discussion that has been described in the previous
section, the conclusion of this study is that there is a significant relationship between the level
of knowledge possessed about the initial assessment by the nurses of the emergency
department Emergency Department of Regional Hospital Toto Kabila, Bone Bolango
Regency, Gorontalo with the implementation of primary survey by nurses. This result
explains that the nurse can carry out the primary survey well when having knowledge of the
initial assessment as well. However, when the nurse does not have a good initial knowledge of
the assessment, it is likely that the nurse concerned can not properly carry out the primary
survey.
References

1. Wicaksana, (2011). Buku Dasar- Dasar Keperawatan Darurat, Jakarta: Trans Info
Media.

2. American Heart Association (AHA), 2015, Adult Basic Life Support: Guidelines for
cardiopulmonary Resuscitation and Emergency Cardiovascular Care, diakses 16 oktober
2016, http://circ.ahajournals.org/content/122/16suppl 2/S298.

3. Niels. K., Obendorfer, D., White, L. F., Rebholz, C., Magauran, B., Baker, W., &
Olshaker, J. (2012). Time series analysis of emergency department length of stay per
8hour shift. Western Journal of Emergency Medicine, 13(2), 163.

4. Suryono, B. (2010). Materi Pelatihan Penanggulangan Penderita Gawat Darurat

(PPGD) dan Basic Life Support Plus (BLS). Yogyakarta: Tim Pusbankes 118 BakerPgdm
Persi Dij.

5. Steinmann, (2010). Buku Proses Kegawatdaruratan. Jakarta: Trans Info Media.

6. Dewi, K. (2013). Buku Ajar Dasar – Dasar Keperawatan Gawat Darurat. Jakarta:
Salemba Medika Jakarta.

7. Krisanty, P. (2009). Asuhan Keperawatan Gawat Darurat. Jakarta: Trans Info Media.

8. Advanced Trauma Life Support. (2015). Advanced trauma life support course for
physicians. 8th Edition. The Committee.

9. National Highway Traffic Safety Administration. (1997). Emergency Medical

Technician-Basic: National Standard Curriculum. USA: Department of Transportation.

10. Fathoni, A. & Ariyani, W. (2012). Hubungan Tingkat Pengetahuan Perawat Tentang
Basic Life Support (BLS) Dengan Perilaku Perawat Dalam Pelaksanaan Primary Survey
Di RSUD DR. Soediran Mangun Sumarso Kabupaten Wonogiri. Skripsi. Program Studi
STIKES Kusuma Husada Surakarta.

11. Sutawijaya, R. B. (2010). Gawat Darurat. Yogyakarta : Publishing Aulia.

12. Nursalam, (2013). Metodologi Penelitian Ilmu Keperwatan: Pendekatan Praktis, Edisi 3,
Jakarta Salemba Medika.