CAUSES AND EFFORTS TO REDUCE ANXIETY IN STROKE PATIENTS

I ntroduction: Stroke can cause mild to severe disability, which is the main trigger for anxiety and other effects of stroke. The purpose of this study was to describe some things of the anxiety of stroke patients at RSUD Ibnu Sina Gresik. Methods: This study used a descriptive research design. The population were stroke patients at RSUD Ibnu Sina Gresik in March 2022. The sample in this study was 78 respondents using the purposive sampling technique. The instrument used is a HARS scale questionnaire, analyzed by descriptive method and presented using a distributive table. Results: As many as 87.2% of respondents experienced anxiety. Most of the respondents had a mild level of anxiety (51.3%). It happened because most respondents were outpatients who had entered the recovery period. The most common cause of anxiety among respondents was illness (80.8%) and decreased work productivity (29.5%). The most efforts made by respondents to reduce anxiety were by worshipping and praying (64.1%) and telling stories to trusted people (62.8%). Nurses have an essential role in reducing the anxiety of stroke patients. Conclusions: Most stroke patients at RSUD Ibnu Sina Gresik experienced mild anxiety caused by illness and decreased work productivity. Most efforts are made to reduce anxiety, namely by worshipping and praying and telling stories to trusted people.


INTRODUCTION
Recently, the trend of stroke cases from year to year is increasing increased which resulted in death, physical and mental disorders in both productive age and the elderly (Jahra Alhamid et al., 2018) so it is necessary proper treatment to speed up recovery. In patient care stroke, it cannot only be emphasized on physical recovery but psychological recovery too. According to (Primadi, 2021) based on data from the World Stroke Organization, it was found that every year there are 13.7 million new cases of stroke, and about 5.5 million deaths occur due to stroke. The prevalence of stroke in Indonesia based on the results of Riskesdas in 2018 increased compared to 2013 from 7% to 10.9%. Likewise, the prevalence of stroke in East Java, the results of Riskesdas in 2018 increased compared to 2013 from 9.1% to 12.4%. Stroke is a health problem that causes chronic stressors so that it can cause anxiety disorders which are psychosocial disorders that often occur in every individual (Laela & Wahyuni, 2019).
Symptoms of anxiety occur in 70% of patients who experience physical problems (Laela & Wahyuni, 2019). Anxiety that occurs due to stroke can cause mild to severe disability and decreased quality of life due to disruption of daily activities, needing the help of family or other people, even fulltime daily activities must be assisted by others. Disability can also have an impact on decreasing work productivity and economic capacity, especially the family economy (Sari et al., 2016).
Physical health problems that often occur in a person are also perceived as a threat and will affect the person in dealing with other health problems. So that between physical health problems and anxiety will be interconnected and reciprocal (Zaini, 2019). Anxiety can cause physical, psychological, social, and emotional imbalances. The effects that often arise are indigestion, headaches, difficulty sleeping, reluctance to relate to other people, anxiety, and feelings of insecurity (Zaini, 2019).
Nurses have an important role in reducing anxiety by providing knowledge or descriptions about stroke as well as full motivation and support for stroke sufferers so that the treatment and healing process runs smoothly (PPNI, 2018). Family support is also needed to reduce the level of anxiety experienced by stroke patients. Family support that can be given to stroke patients includes increasing family care for patients, providing motivation so that stroke patients can undergo better treatment in reducing their anxiety levels (Migawati, M. 2021) Based on the description above, the authors are interested in researching the Anxiety of Stroke Patients at Ibnu Sina Hospital Gresik.

MATERIALS AND METHODS
Method used is descriptive method, namely the author wants to describe the incidence of anxiety in stroke patients along with the level, causes, and coping efforts made by the patient. The population of this study were all stroke patients who were treated at RSUD Ibnu Sina Gresik with a total of 354 patients, the study sample size was 78 patients. The sampling technique used is purposive sampling. By fulfilling the research criteria which include: Inclusion criteria; 1. Patients suffering from stroke (Ischemic Stroke and Hemorrhagic Stroke), Patients aged 25-95 years, Patients who are willing to be respondents; The exclusion criteria are patients are difficult to communicate and patients in a state of decreased consciousness. The variables in this study were the anxiety of stroke patients, the factors causing anxiety, efforts to overcome anxiety. The measuring instrument used for anxiety uses the Hars scale. The analysis used is descriptive analysis. This research has obtained a certificate of ethical worth from the faculty of nursing, airlangga university. Based on table 1, the gender of the respondents are mostly male, namely 40 respondents (51.3%), while the age of the respondents are mostly elderly 56 respondents (71.8%) and based on education level, most of them have basic education (53 ,8%). Based on table 2 shows that of the 78 respondents, most of them experienced mild anxiety, namely 40 respondents (51.3%) and a small portion experienced severe anxiety, namely 7 respondents (9%). While a small proportion experienced anxiety caused by a lack of support from family or people around, namely 3 respondents (3.8%). Based on table 4 shows that of the 78 respondents, most of them reduce anxiety by worshiping and praying, namely 50 respondents (64.1%) and telling stories and asking for advice from trusted people as many as 49 respondents (62.8%), while a small proportion provide time for themselves and calm their hearts, namely as many as 17 respondents (21.8%).

Level of anxiety
The results of the study in table 4.5 show that of the 78 respondents who suffered from stroke, as many as 87.2% of respondents experienced anxiety. Most of the respondents experienced mild anxiety, namely 40 respondents (51.3%), almost half experienced moderate anxiety, namely 21 respondents (26.9%) and a small portion experienced severe anxiety, namely 7 respondents (9%). According to Dewandari, (2020) said that the occurrence of physical weakness in a person can trigger anxiety disorders. This is because the body coordinates with the mind. Stroke patients who were respondents experienced mild to severe disability. Symptoms that may occur are a sideways tilt of the face, slurred speech, to muscle weakness in the hands or feet, causing anxiety to varying degrees.
The results of this study contradict the research conducted by Ananda, Z & Darliana, (2017) at RSUD dr, Zainoel Abidin Banda Aceh which showed that most stroke patients experienced severe anxiety. It was found that 60.4% of respondents experienced severe anxiety, 20.4% of respondents experienced moderate anxiety and 15.6% of respondents experienced mild anxiety. Meanwhile, in a study conducted by Rimawati (2017) at Baptist Hospital Kediri, it was found that most stroke patients experienced moderate anxiety. A total of 12.5% of respondents experienced severe anxiety, 75.0% of respondents experienced moderate anxiety and 12.5% of respondents experienced mild anxiety. According to the researcher's analysis, there is a difference between the results of the two studies above and this study regarding the incidence of anxiety caused by the researcher taking respondents, most of whom came from outpatient installations. Patients undergoing treatment in an outpatient installation are patients who have entered a recovery period and have experienced the acceptance phase and can adapt to the things they face.
Based on gender, the results of this study showed that of the 78 respondents who suffered from stroke, 40 of them were male (51.3%) and 38 female (48.7%). It was found that there was a tendency for female respondents to experience mild to moderate anxiety. A total of 19 female respondents experienced mild anxiety (50%) and 14 female respondents experienced moderate anxiety (36.8%). These results are heavier than male respondents who tend not to experience anxiety and only experience mild anxiety, namely 7 male respondents who do not experience anxiety (17.5%) and 21 male respondents who experience mild anxiety (52.5%). This is in line with the theory put forward by Stuart (in Kustiawan and Hasriani, 2014) that women tend to experience anxiety more often than men because women use feelings more, while men use logic more. According to Dewandari, (2020) anxiety disorders attack women more because of human evolution, where initially women only acted as caregivers for children, now they are hard workers who have more burdens than before, such as workload. According to the researcher's analysis, the research results are in accordance with the theory that women tend to use their feelings more than men. This happens because identical women use feelings more sensitive to the anxiety they experience.
Viewed by age, the results of this study indicate that adult respondents tend not to experience anxiety and experience mild anxiety. A total of 5 adult respondents experienced mild anxiety (45.5%) and as many as 3 adult respondents did not experience anxiety (27.3%). Respondents aged and elderly tend to experience mild to moderate anxiety. A total of 29 elderly respondents (51.8%) and 6 elderly respondents experienced mild anxiety (54.6%), 16 elderly respondents (28.6%) and 4 elderly respondents experienced moderate anxiety (46.4%). Meanwhile, 2 adult respondents (18.2%), 4 elderly respondents (7.1%) and 1 elderly respondent (9.1%) experienced severe anxiety. Purba (in Kustiawan and Hasriani, 2014) suggests that physical and psychological problems are often found in the elderly, psychological problems include feelings of anxiety. The results of this study are in accordance with the results of research conducted by Kustiawan and Hasriani (2014) that stroke patients who experience the most anxiety are in the age range of 56-65 years (elderly age), which is 33.3%. In addition, the results of Prabawati & Pitaloka, (2021) at the Muhammadiyah Malang Hospital showed that the most stroke sufferers were aged 56-65 (41.5%). According to the researcher's analysis, in the elderly, many physical and psychological problems are faced. Physical problems such as being prone to disease and health problems, as well as psychological problems such as peers who one by one begin to experience health problems that do not go away and even lead to death affect the feelings of the elderly, so that the elderly often experience fluctuating feelings due to various problems. experienced health so that they are prone to anxiety.
Based on education level, the results of this study indicate that respondents with primary and secondary education tend to experience mild to moderate anxiety. A total of 23 respondents with basic education (54.8%) and 12 respondents with secondary education (54.5%) experienced mild anxiety, 14 respondents with basic education (33.3%) and 6 respondents with secondary education (27.3%) experienced moderate anxiety. More severe than respondents with higher education who tend not to experience anxiety and mild anxiety.
A total of 5 respondents with higher education experienced mild anxiety (35.7%) and 6 respondents with higher education did not experience anxiety (42.9%). The results of this study are in line with the results of research conducted by (Ananda, Z & Darliana, 2017) that anxiety can occur in individuals with low levels of knowledge, this is due to the lack of information obtained and lack of interest in finding information related to the illness. This makes the patient less understanding of the health problems they face. According to the researcher's analysis, the low level of education in stroke patients affects the readiness to receive information about stroke rationally which results in the emergence of anxiety. In addition, the patient's unpreparedness in facing the reality that suddenly appears in front of him also triggers the emergence of anxiety.
In terms of occupation, the results of this study indicate that respondents who do not work, work as farmers/laborers and in the private sector tend to experience mild to moderate anxiety. A total of 20 respondents who did not work (58.8%), 5 respondents as farmers/laborers (38.5%), and 11 respondents as private workers (47.8%) experienced mild anxiety. A total of 11 respondents did not work (32.4%), 4 respondents as farmers/laborers (30.8%), and 6 respondents as private workers (26.1%) experienced moderate anxiety. Meanwhile, respondents who work as civil servants and retirees tend not to experience mild anxiety and anxiety. As many as 2 respondents as civil servants (40%), 2 retired respondents (66.7%) experienced mild anxiety and 3 respondents as civil servants (60%), 1 retired respondent (33.3%) did not experience anxiety. Meanwhile, severe anxiety was only found in respondents who did not work, namely 1 respondent (2.9%), 3 respondents (23.1%) farmers/laborers and 5 respondents (26.1%). In respondents who work as civil servants and retirees, no severe anxiety was found. According to (Sari et al., 2016) in terms of economy, disability due to stroke can have an impact on decreasing work productivity and economic capacity, especially the family economy. According to the researcher's analysis, disability due to stroke causes limitations in physical activity so that many stroke patients who do not have job security in the future such as farmers/laborers and private workers will feel anxiety and even severe anxiety if they cannot work again in the future. Anxiety is also felt by respondents who are no longer working, most of the respondents feel that the family economy has decreased after the respondent has had a stroke and can no longer work. Mild anxiety was more common in respondents because almost all respondents received good support from their families. This can be seen from the respondents who come from inpatient and outpatient services who are always accompanied by their families.

Causes of anxiety
The results showed that from 78 respondents, almost all of them experienced anxiety due to their illness, namely stroke with a total of 63 respondents (80.8%). The second most common cause is the decline in work productivity with a total of 23 respondents (29.5%). The cause of feeling anxious arises because of feeling the danger that lurks. This anxiety is more a feeling of fear that comes from the mind inside (Nugraha, 2020) In stroke sufferers, the thing that is most feared is experiencing a disability that can change an individual who was previously strong to become weak and dependent on others (Laela & Wahyuni, 2019). According to the analysis of researchers, changes that occur due to stroke will have an impact on daily life so that the main cause of anxiety in stroke patients is stroke itself. Decreased productivity caused by physical health problems also causes anxiety in stroke patients because it will then affect the economy.

Efforts to Reduce Anxiety
The results showed that out of 78 respondents, most of them did worship and pray (64.1%) and told stories to trusted people (62.8%) to reduce the anxiety they felt. According to (Hawari, 2016) the religious approach will give a sense of comfort to the mind, while closeness to Allah, dhikr, and prayer will give positive hope. Praying is a nonpharmacological therapy (distraction). Distraction is a method by diverting attention to other things so that patients forget the anxiety they are experiencing (Mardiani & Hermawan, 2019). Telling stories to trusted people or self-disclosure is when someone discloses personal information about himself to others, one of the benefits is to get help or support (Gamayanti et al., 2018).effects of selfdisclosure , namely the first to vent negative feelings can evoke feelings of relief (Gamayanti et al., 2018), the second to make the mind become calm and undisturbed by events that arise, allowing individuals to evaluate and understand the problems that are being or have been experienced and improve the abilities that exist in the individual (Gamayanti et al., 2018). According to the researcher's analysis, by praying and praying, respondents can divert their minds to the anxiety they feel by getting closer to God and being more sincere and patient with the trials they experience. Talking to a trusted person will make the respondent feel relieved so that the patient will feel better than before.

CONCLUSIONS
The most common causes of anxiety in stroke patients at RSUD Ibnu Sina Gresik are due to illness and decreased work productivity; Efforts made by stroke patients at RSUD Ibnu Sina Gresik to reduce anxiety are to worship and pray and tell stories to trusted people.