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THE EFFECTS OF SPIRITUAL COUNSELING ON THE ANXIETY LEVEL OF PATIENT’S FAMILY AT THE INTENSIVE CARE UNIT (ICU) OF dr. DRADJAT PRAWIRANEGARA HOSPITAL IN SERANG, BANTEN PROVINCE, INDONESIA

Background: Critical nursing is a specific service in giving a holistic nursing service to fulfill human response to a lifethreatening problem. A critical nurse can give a social support to patient’s family through assessment, counseling, and supporting group. Counseling is combination between high technology physical caring and emotional caring, which is needed by patients and the family. Spiritual counseling is a complementary medication preferred by the family of patient who is in acute and critical care. Objective: The study intends to identify the effects of spiritual counseling on the anxiety level of patient’s family at the ICU of dr. Dradjat Prawiranegara Hospital in Serang, Banten Province. Methods: The study is a pre-experimental research with one group pre-test and post-test design. The samples are 25 respondents who were selected by using consecutive sampling technique during one month (May to June 2016). The data of anxiety level were collected by using HAR-S (Hamilton Rating Scale for Anxiety) questionnaire. Then the data was analyzed by using parametrical t-test paired sample for the variable of anxiety before and after giving spiritual counseling. Meanwhile, the variable of respondent characteristics to anxiety was analyzed by using independent sample test. Results: The study finds that the mean of respondents’ anxiety level before spiritual counseling is 33.44 and the standard deviation is 5.213. Meanwhile, after conducting spiritual counseling, the mean is 18.60 and the standard deviation (SD) is 2.582. Bivariate analysis result shows a significant difference between anxiety level of patient’s family in ICU (Intensive Care Unit) before and after conducting spiritual counseling in which p value is 0.000, the mean is 14.840, and SD is 5.437. Conclusion: Nurses should be more capable in implementing the intervention of spiritual counseling to patient’s family. Spiritual counseling can give a positive alteration to the family emotional situation. It impacts on the decrease of patient’s family anxiety level. By the decrease of family anxiety level, the possibility of doing mistake in decision-making is expected to be avoided.

ICU is one of most challenging rooms, which can make the patients stressed and have emotional problems relating to anxiety and depression (Rusinova, Kukal, Simek, & Cerny, 2014). Patients in critical condition have not only physiological problem but also psychosocial one. Therefore, the patients and their family need interventions for their development and spiritual process. Nurses who take care of patients at ICU in which the environment is high technology sometimes more focus on technology of maintaining stability of physiological function (P. G. Morton, Fontaine, Hudak, & Gallo, 2013).
Many studies show that critical nurses must be able to give a high quality and skillfully care and to use a proper technology while applying psychosocial and other holistic approach which is suited to time and patient's condition. Chang in his study to 35 patients in Taiwan by interview obtained that adult patients need a multidimensional care including physical, informational, and psychosocial dimension (Chang, Chen, & Su, 2012). This is similar to what has been found in previous study (Lukmanulhakim & Firdaus, 2018) that reaches fulfillment patients and their families, the needed spiritual education facilities so that patients and families can be patient and steadfast in the face of disaster being faced.
The needs are to be relieved from pain and discomfort, to start oral intake as soon as possible, to have continuous sleep, to get information including the development of their illness, prognosis and health progress activity. Psychosocial needs involve nurse caring, flexible visit hour, and good communication from all staffs in ICU. A holistic nursing service needs family approach in family centered context, an approach in which care is intended not only to patients but also their family since every patient is a part of family unit (Duran, Oman, Abel, Koziel, & Szymanski, 2007). Family means two people or more united by bonds of togetherness and emotion and who identify them as part of family. Family will experience a trauma when the member is in critical condition since they are psychologically not ready to face the critical illness (Friedman, 2008).
Complexity of problems that happen to patients in critical condition affects not only on patients, but also on psychological change of their family. It indirectly influences the family members who enter ICU. Patient and family psychosocial need is important in critical and emergency nursing service (Mitchell & Courtney, 2004). Kinrade conducted a study relating to psychosocial need in Australia, taking place in ICU, and using quantitative approach and critical care family needs inventory as the instrument of data collection (Kinrade, Jackson, & Tomnay, 2009). He stated that patient's family needs honest information and hope for healingnurses must know the needs. The study result describes that psychosocial needs are not only for patient but also for their family. It also describes that the main aspects of psychosocial need are comfort and the decrease of stress, which is caused by anxiety due to being in ICU.
Anxiety suffered by family of patient who is taken care in ICU happens because of the threat of helplessness, lose control, the feeling of lose function and dignity, failure to form a defense, isolated feeling, and fear of dying (G. Morton, 2012). The study conducted by Powers shows that anxiety of patients and their family is decreased; and they are satisfied by improvement of patient and family engagement in care plan (Powers, Goldstein, Plank, Thomas, & Conkright, 2000). Some examples of family engagement in care plan are as the following: involving family in decision making, giving adequate information about patient's condition either through health education or through counseling, asking patient's family about their wishes when the patient is close to death, presenting family when the patient dying, and so on. On the other words, anxiety defined as the anxiety level of family's patients who are in ICU.
In initial phase of critical care, patient's family need to decrease anxiety level, guarantee of quality care and information, and support which emerges as the result of stressorfulfilled condition or experience. A clinical nurse can give social support to family members through assessment, counseling, and supporting group. Social support, although not empirically tested, can impact on the ability of family members to support patient and the patient's positive healing from critical illness condition (Halm, 1992). It parallels Stockdale's opinion that counseling is required to combine high-tech physical care and emotional care needed by patients and their family. Counseling which focuses on patient or family is a theoretical model that can be used to achieve balance between the two issues, and counseling throughout to family of patient with spiritual approach well defined as spiritual counseling (Stockdale, 1989).
Patients and their family often feel desperate and helpless when facing critical care environment. Here, the role of religious leader in a health service team to give a holistic service. Providing religious ritual access, praying, and reciting holy books are a very meaningful strategy to decrease stress level of patient. According to Solt-Ashley, supplication and spiritual approach are parts of complementary medication preferred by patients in acute or critical care. They believe there is correlation among body, mind, and soul (Holt-Ashley, 2000). Spiritual support is expected to be able to decrease anxiety level of patient's family. Spiritual and religious engagement contributes to reduce depression symptoms and anxiety (Koenig, 2001). It is strengthened by Young who say that ones who become closer to God will get comfort and solve stress. Proximity to God will give more powers, confidence and comfort (Young & De Abreu, 2010). They are useful for health including reducing depression and solitude, increasing maturity in relationship, and improving social competence and psychosocial assessment in facing stress (Hill & Pargament, 2008).

Study design
The study employed a pre-experimental pretest posttest design (Polit and Beck, 2006) due to the study the limitation of selected group to be a control group. So, this study design intended to examine the effects of the intervention of spiritual counseling on anxiety level by measuring the pretest and posttest. The study aimed to identify the effects of spiritual counseling on patient's family at ICU (Intensive Care Unit).

Setting
The data collection was conducted from May to June 2016 at the ICU (Intensive Care Unit) of dr. Dradjat Prawiranegara Hospital in Serang, Banten Province. The researchers were assisted by several counselor nurses who expert in spiritual counseling. Before conducting spiritual counseling intervention, the researchers explained the research purposes, the benefits, the time, respondent's rights, and the informed consent to patient's family. After achieving an agreement, they did the initial measurement of anxiety level by administering HARS-S anxiety questionnaire to patient's family in the same day. The researchers did accompaniment when the families fulfilled the questionnaire and directly measured the anxiety level. After fulfilling all questionnaire components and doing validation, the counselor nurses applied the intervention of giving spiritual counseling to patient's family at a special room of the ICU. One day after giving counseling, the researchers did the second anxiety level measurement to the same respondents by giving the same treatment.

Sample
The sample were the closest family members who better knowing the patient's condition clearly from before being hospitalized to being admitted at the ICU of dr. Dradjat Prawiranegara Hospital. The sampling technique was non-probability sampling. The respondents were selected by using consecutive sampling. During one-month period between May to June 2016, the researchers obtained 25 samples who have different disease characteristics. The inclusions criteria of the sample are selected are as follows: 1) Members of the patient's core family who were treated at the ICU of dr. Dradjat Prawiranegara Hospital in Serang, Banten Province. 2) The core of patient's family who are able to communicate well and aged ≥ 18 years old. Furthermore, the exclusion criteria of the sample are the core of Patient's family members is mentally disorders and the patient's family members who resigned unexpectedly.

Instrument
Instrument used in this study was HAR-S (Hamilton Anxiety Rating Scale). HAR-S was a questionnaire that consists of 13 questions intending to patient's family to determine the anxiety level. The scale was a list of behavior characteristic levels which classify and assess individuals or symptoms. There were four score choices in HAR-S instrument, namely: < 6 means no anxiety, 7 to 14 means light anxiety, 15 to 27 means moderate anxiety, and > 27 means severe anxiety (Apriady, Yanis, & Yulistini, 2016). The validity and reliability of modified HAR-S anxiety level were examined in Banten Regional Hospital by involving 15 respondents. The score of Cronbach's alpha was 0.912.

Ethical consideration
The study had been approved in the research ethical consideration from ethical committee for research of dr. Dradjat Prawiranegara Hospital. The ethical consideration was to avoid any negative effects relating to ethical issues and to fulfill research ethical principles. The approval research permit letter form dr. Dradjat Prawiranegara Serang Hospital was published on May 6 th , 2016, with letter number 009/TU.1305/V/2016.

Data analysis
Before conducting hypothesis testing, data normality assumption test was firstly done by using Shapiro-wilk test and skewness score, which is divided by error standard score. The sample size is 25 respondents. The normality test by using Shapiro-wilk test for family anxiety data obtains 0.073 p value after comparing the value to 0.05 alpha value. Meanwhile, the normality test by using skewness score and standard error obtain 0.435 for pre-test and 0.430 for post-test. To conclude, both tests identify that the data was distributed normally. Then, the researchers analyzed the data by using paired sample ttest.

RESULTS
The research discussion includes the descriptive analysis and comparative analysis of spiritual counseling effects on the anxiety level of patient's family at the ICU of dr. Dradjat Prawiranegara Hospital in Serang, Banten Province. Based on table 1 above, the data shows that before doing spiritual counseling, family anxiety level was mostly in severe level (92.0%). However, after doing spiritual counseling, family anxiety level is mostly in moderate level (96.0%).
Next, according to table 2, the mean of family anxiety level after giving spiritual counseling to respondents less than 30 years old was 18.47 and the standard deviation was 2.427. Meanwhile, the mean of family anxiety after giving spiritual counseling to respondents who were more than 30 years old was 18.30, the standard deviation was 3.044, and the statistical test result showed p value 0.723 (p > 0.05). In conclusion, age did not affect respondents' anxiety. The mean of anxiety level of female family members was 18.80 and the standard deviation was 2.957. Meanwhile, for the male respondents, the mean of their anxiety was 18.30, the standard deviation was 2.003, and p value was 0.645 (p>0.05) which means gender did not affect the anxiety level.
The p-value of family educational background was 0.116 (p> 0.05). Meanwhile, p value of family occupation was 0.504 (p > 0.05) and the family prior experience of taking care the members in ICU was 0.857 (p > 0.05). In conclusion, there were no influence of age, sex, educational background, occupation, and family experience on anxiety level.  According to table 3 above, the data showed that the mean of respondents' anxiety level before conducting spiritual counseling was 33.44 and the standard deviation was 5.213. Meanwhile, the mean of anxiety level after doing spiritual counseling was 18.60 and the standard deviation was 2.582. While based on table 4, there was a significant difference of anxiety level of patient's family in ICU before and after doing spiritual counseling with the nurses in the emergency room of dr. Dradjat Prawiranegara Hospital in Serang, Banten Province. It showed by 0.000 of p value and 13.648 t value. The mean of family anxiety level before and after doing spiritual counseling was 14.840 and the standard deviation was 5.437.

Depiction of Anxiety Level of Patient's Family at the ICU
The research result shows that the anxiety level of patient's family at the ICU of dr. Dradjat Prawiranegara Hospital in Serang, Banten Province is mostly in severe anxiety level with 68.0% percentage. The result is supported by Rusinova et. al. who explained that critical care unit is the most challenging place in the world and able to cause a stressful condition such as anxiety and depression for family whose member is admitted in a critical care ward (Rusinova et al., 2014). Moreover, Brysiewicz stated that a family whose member has a traumatic injury and is admitted in a critical care unit think that the place is unfamiliar and scary since no one in the family want this to happen. By hospitalization, the family must face a possibility that one of the family members will be disabled or perhaps died (Brysiewicz & Bhengu, 2010).
Patient's family can give response to the patient's critical condition including disadvantageous psychological outcome development such as anxiety, acute stress disorder, posttrauma stress, depression, and complicated grieving (Davidson, Jones, & Bienvenu, 2012). Urden, et.al (2010) argued that possible responses of patients and the family to stressors during suffering from critical illness and being admitted in a critical care unit including death threat, post-injury threat such as disability, pain or discomfort, lack of sleep, and boredom are disappeared just by an instant visit, stimulus, and scary thought (Urden et al., 2010).
Anxiety is a displeased emotional condition signed by unspecific object worry feelings and a displeased and unwanted physical symptom change (Davies & Craig, 2009). One's anxiety in facing family member's illness condition has different level and is influenced by some factors such as age, family relationship, and sex (Lukmanulhakim, Suryani, & Anna, 2016;Syukrowardi, Wichaikull, & von Bormann, 2017).
The research results show in detail that half respondents are less than 30 years old (56.0%) whose anxiety levels are severe (73.2%) and moderate (26.8%). The findings support Krasucki et. al. (2008) who argued that anxiety tends to occur to young mature ages between 21 and 45 years old since in the age range, people are responsible for their deeds. Moreover, they have many problems relating to household, social relationship, and occupation, which are potential to cause an emotional tension. This study finds that among 25 respondents, 17 respondents are female (68.0%) who mostly suffered from severe anxiety (76.5%) and 23.5% of them suffered from moderate anxiety. Being parallel to a theory which states that female tends to be more neurotic or to use her feeling compared to male, female seems to suffer more from anxiety than male. Priest (1990) also explained that female more often suffers from anxiety rather than male since female more often expresses her condition, feelings, and anxiety or tension, compared to male who tends to cover his feelings.

Spiritual Counseling Effects on Anxiety
Level of Patient's Family at the ICU Providing spiritual counseling is an effort of giving objective information, done systematically by nurse counselor who has good communication skills, guidance techniques, and technical knowledge which purpose is to help patient's family identify current condition, current problems, and problem solving.
The research results show a significant difference of anxiety level of patient's family in ICU (Intensive Care Unit) before and after conducting spiritual counseling by nurses of the ICU of dr. Dradjat Prawiranegara Hospital in Serang, Banten Province. It is shown by 0.000 p value, 14.840 mean score, and 5.437 standard deviation. The research findings support what has been identified by Powers in his study in which patient's and family's anxiety are decreased and the satisfaction is increased by improving patient and family engagement in care plan (Powers et al., 2000). Some examples of family engagement in a care plan is as the following: involving family in decision making, providing adequate information about patient condition through health education or counseling, asking family about their wish when patient is close to death, presenting family when patient is dying.
Counseling is a direct care method used to help patient solve problem in identifying and resolving stress and to facilitate interpersonal relationship. The counseling involves emotional, intellectual, spiritual, and psychological support. Although patients and the family need counseling, it does not mean that they are psychologically incapable, but they have difficulty to adapt normally. The counseling given by a counselor nurse supports patients and the family to check some alternatives and to determine useful and proper choice (Potter & Perry, 2005). The effectiveness of counseling has been explained by Urden, et.al who argued that health education and counseling are proven to be able to shorten time of care, lessen rehospitalization possibility, and improve self-care management skills (Urden et al., 2010). The shareable issues in the counseling process are showing principles, procedures, and techniques of proper health care and informing patient's health status. The process includes learning and teaching element, namely interaction between teacher and learner, which has specific learning objectives (Perry & Potter, 2005).
The counseling and health education for patients and the family expect some positive outcomes including: the presence of understanding clarification and patient's perception of the illness and decision of care preference, the improvement of symptom management skills, supporting decision making, decreasing emotional stress relating to unfamiliar environment and prognosis uncertainty, increasing the ability of adaptation in a full stressor situation, the increase of satisfaction of care service, relationship improvement between patient and the family and health workers, and supporting positive self-concept (Urden et al., 2010). Proximity to God will give more power, confidence, and comfort. It is advantageous for health including reducing depression and solitude and improving maturity in a relationship, social competence, and a better psychological assessment to handle stress (Hill & Pargament, 2008). The research results answer to the expectations expressed by previous studies (Koenig, 2001;Lukmanulhakim & Firdaus, 2018;Lukmanulhakim et al., 2016), which states that the increased spiritual support and counseling are expected to reduce patient's family anxiety. The spiritual engagement and religiosity contribute to decrease depression symptoms and anxiety.
Despite the result of this study that found spiritual counseling associated with anxiety level of family's patient in ICU, but some limitations also had identified. The limitations in this study were only involving one group and small sample size.

CONCLUSION
In a critical care, patients will suffer from various stressors which are possible to disturb patient's and the family's psychosocial fulfillment. There are many ways to solve the problem; one of them is by giving counseling to the family. This way is able to decrease family's anxiety so they are abler to participate in the patient's recovery by giving support and to avoid any mistakes in the decision-making.