Effect Of Sleep Hygiene And Deep Breathing Exercise With Spiritual Care On Sleep Quality And Quality Of Life Of Hemodialysis Patient In Ahmad Yani Islamic Hospital Surabaya

Hemodialysis patients experienced sleep disturbance problems that directly affect sleep quality and quality of life of hemodialysis patients. Quality of life is an important part of hemodialysis patients that need attention. The purpose of this study was to analyze the effect of sleep hygiene and deep breathing exercise with spiritual care on sleep quality and quality of life of hemodialysis patients. The research design used a quasy experiment with the pretest posttest approach with control group. Population in this study were all of hemodialysis patients . Sample of this study were 38 respondents divided into 19 ISSN 2354-7642 (Print), ISSN 2503-1856 (Online) Jurnal Ners dan Kebidanan Indonesia Tersedia online pada: http://ejournal.almaata.ac.id/index.php/JNKI INDONESIAN JOURNAL OF NURSING AND MIDWIFERY


INTRODUCTION
The progress of hemodialysis techniques and medical care made the death rate and the high pain of hemodialysis patients experience a marked decrease (1).The quality of life of hemodialysis patients is 63.3% on average and the mortality rate of hemodialysis patients is 33% with a duration of 6-12 months of hemodialysis so that the new goal of medical practitioners is to achieve physical and mental health by satisfying basic human needs fi rst (2) (3).Sleep is a basic human need that is very important for everyone, but many hemodialysis patients experienced sleep disturbances (4).
Sleep disturbances are common in patients who did hemodialysis on end stage renal disease (ESRD) (5).Sleep disturbances are experienced in approximately 50-80% of patients who did hemodialysis (6) (7).According

MATERIALS AND METHODS
This    tension, occurrence of cerebral activity (oxygen consumption, blood fl ow, and neural stimulation), release of epinephrine, and β waves which cause a relaxed and comfortable feeling.Relaxing feeling will be forwarded to the hypothalamus to produce corticotropin releasing factor which further stimulates the pituitary gland to increase proopiomelanocortin production so that the production of encephalin by the adrenal medulla increases.The pituitary gland also produces β endorphins and the limbic system releases neurotransmitters in the form of serotonin, dopamine and norepinephrine which cause the patient to be more relaxed and comfortable in his sleep (27).
Deep breathing exercise which is combined with the belief and gratitude for the blessings of life obtained by saying "Alhamdulillah" will lead to a stronger relaxation response than just relaxation without involving the element of belief.
The sentence that is spoken has an element in the form of God or other words that have a calming meaning (28).Feelings that relax by using this deep breathing exercise technique are obtained by increasing the activity of the beta adrenergic respiratory tract which causes bronchial dilatation and inhibits mucus secretion.The occurrence of dilatation in the bronchi made the entry of large amounts of oxygen that will bind to hemoglobin (oxyhemoglobin) so that increased oxygen saturation, body work and tissue improve.Blood supply (decreased oxygen and glucose levels) to brain tissue has decreased.This situation is then immediately responded by the brain with a yawning refl ex which massively inserts oxygen through the lungs to the brain with a dilation of the diameter of the blood vessels.As a result, the supply of oxygen and glucose into the brain tissue increases rapidly.This condition will revitalize all cellular and microcellular elements which affected the strength and vitality of brain cells.Besides that, the supply of oxygen in large quantities makes mitochondria as the respiratory center of the cell will return to active and work normally.Changes in this state will be seen on the face that is radiant, relaxed, and even asleep (29 , 42).Supported by research that women with breast cancer believe religion is an important factor as emotional support and believe that to feel more comfortable and able to move freely must rely on the power of Allah (33).Combining sleep hygiene and deep breathing exercise with spiritual care can cause a relaxing effect, making the feeling of being close to Allah SWT by relying on the element of surrender and gratitude in it so as to provide peace of mind, mental health, thus making the sleep quality of respondents improve.This is appropriate in the Surah Ar-Ra'd 28 said: "(Those who believe, and whose hearts fi nd satisfaction in the remembrance of Allah for without doubt in the remembrance of Allah do heart find satisfaction".he purpose of the verse above is that anxiety, anxiety and fear are from God that is deliberately created for us.Many people do not understand the meaning of anxiety and anxiety, restlessness, anxiety, fear is actually a blessing and a gift from Allah for those who believe, meaning that unrest that is gnawing at the heart shows evidence of Allah's sadness to his servant to always remember it with Dzikir, reciting the Qur'an and so on then the heart will be calm.The heart will not be able to calm down without remembering and meditating on the greatness and omnipotence of God, always expecting His pleasure (36).The more happily, relaxed by highlighting the value of surrender and gratitude, the better quality of sleep.Quality of life is the extent to which a person can feel and enjoy the occurrence of all important events in his life so that his life becomes prosperous (39).If someone is able to achieve a high quality of life, then the life of the individual leads to a state of prosperity (ill-being) (40).

Sleep Hygiene and Deep Breathing Exercise
When respondents experience tension the system that works in the body is the sympathetic nervous system.Whereas when the body is relaxed and calm, the system that works is the parasympathetic nervous system by suppressing tension so that the feeling of relaxation occurs.Relaxing feeling will be passed The implementation of sleep hygiene and deep breathing exercise will be more optimal if the spiritual values are added in the stages of sleep hygiene and deep breathing exercise in improving sleep quality and quality of life of hemodialysis patients.Interventions used are based on spiritual values with roots in the Quran and as-sunnah from prophet Muhammad SAW and noble leader who is able to be the best intervention for Muslims in critical conditions.Islam cares for spiritual health which comes from the heart of each individual (23).When someone faces prayer diffi culties, recitation of the Quran, grateful and requests for forgiveness from Allah SWT is able to overcome illness and live healthier lives (24).Therefore the researcher was interested in researching about the effect of sleep hygiene therapy and deep breathing exercise with spiritual care on sleep quality and quality of life of hemodialysis patients in Ahmad Yani Islamic Hospital Surabaya.
an effect of sleep hygiene and deep breathing exercise with spiritual care on sleep quality and quality of life of hemodialysis patients with p value = 0,000.There are a strong effects of sleep hygiene and deep breathing exercise with spiritual care on sleep quality with an infl uence of 72.7%.There are a strong influences of sleep hygiene and deep breathing exercise with spiritual care of quality of life with an effect of 66.4%.So sleep hygiene and deep breathing exercise with spiritual care have a greater infl uences on the quality of sleep than the quality of life of hemodialysis patients.The results showed significance which means that there is an effect of sleep hygiene and deep breathing exercise with spiritual care on the sleep quality of hemodialysis patients.In this study sleep hygiene is applied with 5 Islamicbased indicators in which there is a component of submitting to Allah SWT.In addition, sleep hygiene that is applied is combined with deep breathing exercise with spiritual care in which there are 3 indicators with components which are highlighted by gratitude by saying Alhamdulillah.This is consistent explaining in his study that sleep hygiene has a benefi cial effect on the sleep quality of hemodialysis patients and supported by research at 2016 showed that sleep hygiene education has a significant effect on patient sleep quality and this therapy able to be applied to patients with short-term hemodialysis, low cost, practical methods and can be implemented independently by patients (25 , 21) The intervention of sleep hygiene and deep breathing exercise is very easy to do just by changing the habits before going to sleep which should be done as a Muslim who practices the Sunnah and does not require much cost by the respondents in Ahmad Yani Islamic Hospital Surabaya.The main key to the success of the study was volunteerism and coercion from respondents so that the results were satisfactory.This activity is very interesting for intervention respondents and families who evaluated; at this point the support system is needed for the achievement of this research activity.Changes in sleep hygiene towards better affected the quality and quantity of sleep (26).Component of surrender in spiritual care sleep hygiene is psychical activities that is more than passive attitudes.Resignation is an attitude of self-reliance on Allah SWT or called surrender, so that the tension arising from the problems of life can be accepted sincerely by an attitude of surrender.Sleep hygiene is carried out with the aim of achieving REM sleep, loss of muscle The use of phrases are meaningful as in this study by saying Alhamdulillah and being grateful for what Allah has given.It can be used as a focus of faith.Using words or phrases with special meaning will encourage healthy effects.This is because Dzikir and praying contain spiritual, religious elements, which can generate hope and confi dence in the client or sufferer, which in turn increases the body's immune and psychic powers thus accelerating the healing process (30).The stronger a person's confi dence is mixed with the relaxation response, the greater the relaxation effect obtained.The choice of the chosen word should be brief to say in the heart when taking and exhaling the breath normally.Both words are easy to say and easy to remember (31).The focus of relaxation is not on muscle relaxation but on certain phrases that are repeated repeatedly with regular rhythms with an attitude of surrender to the object of transcendence, namely God.The phrases used can be in the form of God's names, or words that have a calming meaning (32).
The stressful situation experienced by the patient will cause the body's reaction to deliver upward stimulation through the brain stem and eventually to the median peak of the hypothalamus.Furthermore the hypothalamus will stimulate the anterior pituitary gland to release Adreno Cortico Tropic Hormone (ACTH) which plays a role in the rapid release of cortisol which causes stimulation of the brain's central nervous system which results in the body becoming alert and having trouble sleeping.Wheather the need for rest and sleep is suffi cient, so the amount of energy expected to restore health status and maintain activities in daily life is fulfi lled (34).In hemodialysis patients in Ahmad Yani IslamicHospital Surabaya, they sleep on average 3-5 days before intervention.The sleep needs of each person vary, in this study most respondents are early and late elderly who need 6-7 hours of sleep a day (35).
with spiritual care has a signifi cant value on the quality of life of hemodialysis patients.There is an improvement in the quality of life of hemodialysis patients after given intervention.The results of this study are in accordance which results in a combination sleep hygiene and aromatherapy has the effect of improving the quality of life and improving the sleep quality of patients with chronic renal failure.Good quality of life is an indicator of the success of hemodialysis therapy routinely performed by patients (37).In the control group the pre-test and post-test values decreased the quality of life of hemodialysis patients.ESRD patients leaded hemodialysis therapy can experience a decrease in quality of life and increase the risk of morbidity and mortality.The risk of morbidity and mortality can be reduced if the patient is in good condition while undergoing hemodialysis therapy (37).To achieve a good quality of life requires fundamental changes in the way of looking at diseases experienced such as chronic kidney failure (38).
on to the hypothalamus to produce Corticotropin Releasing Hormone (CRH) and Corticotropin Releasing Hormone (CRH) activate the anterior pituitary secretion enkephalin and endorphin play a role as neotransmiter which affected the mood to be relaxed and happy.Di beside that, anterior pituitary secretion Adrenocorticotropic hormone (ACTH) decrease, and then Adrenocorticotropic hormone (ACTH) controlled adrenal cortex to control cortisol secretion.Decreased levels Adrenocorticotropic hormone (ACTH ) and kortisol caused stress and decreased tension which can ultimately improve quality of life (40 , 18)When pulling and exhaling slowly, the air entering the body carries oxygen which functions as fuel to activate cells in the body(42).Relaxation is done like Sleep hygiene and deep breathing exercise combined with spiritual care values have the benefi t of using beliefs such as gaining experiences and adding faith in life.CONCLUSION AND RECOMMENDATIONBased on the results of research that has been done about the infl uence sleep hygiene and deep breathing exercise with spiritual care on sleep quality and quality of life in hemodialysis patients in Ahmad Yani Islamic Hospital Surabaya can be conclude that: Sleep hygiene and deep breathing exercise with spiritual care on 30 days 30 minutes of sleep affected sleep quality and the quality of life of hemodialysis patients.Nurses are expected to be able to implement sleep hygiene interventions and deep breathing exercises with spiritual care to enhance sleep quality and quality of life for hemodialysis patients respondents for intervention group and 19 respondents for control group.Sleep hygiene intervention and deep breathing exercise with spiritual care were applied every day for 30 days 30 minutes before going to sleep in the intervention group and in the control group only ran routine or habit before going to bed.Instrument used a PSQI questionnaire (Pittsburgh Sleep Quality Index) and KDQOL SF TM 1.3 (Kidney Disease Quality of Life).Data analysis used MANOVA test with signifi cance value α = 0.05.The results of this study indicated that p value 0,000 with the effect of R squared 72.7% on sleep quality and 66.4% on quality of life, which means that sleep hygiene and deep breathing exercise with spiritual care were signifi cantly infl uence sleep quality and quality of life on hemodialysis patient in Ahmad Yani Islamic Hospital Surabaya.The application of sleep hygiene and deep breathing exercise with spiritual care had a strong infl uence on the quality of sleep and the quality of life of hemodialysis patients.Nurses are expected to be able to implement sleep hygiene interventions and deep breathing exercises with spiritual care to enhance sleep quality and quality of life for hemodialysis patients.
to explained that sleep disturbances that often occur in hemodialysis patients include restless legs syndrome, insomnia, sleep apnea, delayed onset of sleep, frequent awakening during sleep, daytime hanging, Excessive daytime sleepiness are symptoms often experienced by patients end stage renal disease (ESRD) (6) (8).The effects of symptoms on sleep disorders, especially on health, safety, and are included in substantial social and economic burdens (1).According to Hemodialysis clients will generally experience role changes, changes in body shape, loss or decrease in work productivity, uncertainty about the future, economic or fi nancial diffi culties, changes in body image, many changes in lifestyle and self-concept (9). in the legs at night, 1 respondent felt diffi culty breathing (tightness ) at night and 1 respondent said that often could not sleep at night because of all body aches.Of the 9 respondents, 1 said they took sleeping pills.The causes of sleep disorders are due to psychological disorders (depression, anxiety), lifestyle factors (use of coffee, nicotine, alcohol, sleep hygiene), treatment factors (dialysis factors, naps, cytokine production, changes in thermoregulatory, disequilibrium syndrome, disturbances in circadian rhythms due to decreased melatonin products, drug side effects), ESRD specifi c factors (anemia,

Table 1 . Characteristic of respondents
study used a Quasy-Experimental research design with pre post test control group design approach.The populations in this study were all hemodialysis patients at Ahmad Yani Islamic Hospital Surabaya who experienced sleep disturbances as many as 42 people.The sample in this study was 38 hemodialysis patients at Ahmad Yani Islamic Hospital Surabaya.The sampling technique in this study used non probability sampling with total sampling technique.The Samples were obtained by the inclusion and exclusion criteria.Table 5 showed that similarity test of variance-covariance individually for each variable using the Box's Test showed the signifi cance number.The value of the Box's Test was 0.602 which was greater than the 0.05 Alpha.This means that the variances in all of these variables are the same for each group.Assuming the similarity of the variance-covariance matrix has been fulfi lled, the Manova analysis process can

Table 5 .
6showed that in general there is