Workload stress management in the implementation of nursing discharge planning

Work stress is a stress that comes from excessive workload. Nurse profession is a job that has a high workload, the task of nurses who must provide comprehensive nursing care up to the implementation of discharge planning or planning for the patient's return requires proper time and work management. Stress caused by workload can affect the quality of nursing care services, such as the implementation of Discharge Planning. One of the stress management that can be done with stress management. This study aims to determine the effect of stress management workload using Progressive Muscle Relaxation on the implementation of Nursing Discharge Planning at Mitra Husada Hospital with a sample of 15 nurses. This type of research uses the quasi-experiment method by using a pre and post without control design; it is carried out pre-test and then given intervention and post-test. Intervention gave twice. Statistical tests using the dependent t-test showed differences in the average adherence score before and after the intervention of 41.13 and 19.00 and the value of t 14.992 with a p-value of 0.001. There is a difference between the average work stress score before and after the intervention, which is 47.00 and 97.00, and t-value 15.585 with a p value 0.001. The result show that workload stress management using the PMR method is useful in implementing Discharge Planning. Progressive Muscle Relaxation is recommended to be done to reduce nurse's work stress. This open access article is under the CC–BY-SA license.


Workload stress management in the implementation of nursing A B S T R A C T
Work stress is a stress that comes from excessive workload. Nurse profession is a job that has a high workload, the task of nurses who must provide comprehensive nursing care up to the implementation of discharge planning or planning for the patient's return requires proper time and work management. Stress caused by workload can affect the quality of nursing care services, such as the implementation of Discharge Planning. One of the stress management that can be done with stress management. This study aims to determine the effect of stress management workload using Progressive Muscle Relaxation on the implementation of Nursing Discharge Planning at Mitra Husada Hospital with a sample of 15 nurses. This type of research uses the quasi-experiment method by using a pre and post without control design; it is carried out pre-test and then given intervention and post-test. Intervention gave twice. Statistical tests using the dependent t-test showed differences in the average adherence score before and after the intervention of 41.13 and 19.00 and the value of t 14.992 with a p-value of 0.001. There is a difference between the average work stress score before and after the intervention, which is 47.00 and 97.00, and t-value 15.585 with a p value 0.001. The result show that workload stress management using the PMR method is useful in implementing Discharge Planning. Progressive Muscle Relaxation is recommended to be done to reduce nurse's work stress.
This open access article is under the CC-BY-SA license.
Manajemen stres beban kerja pada pelaksanaan discharge planning keperawatan A B S T R A K Stress kerja adalah stress yang berasal dari beban kerja yang berlebihan. Profesi perawat merupakan pekerjaan yang memiliki beban kerja tinggi, tugas perawat yang harus memberikan asuhan keperawatan komprehensif hingga pelaksanaan Discharge planning atau perencanaan kepulangan pasien membutuhkan manajemen waktu dan pekerjaan yang baik. Stress yang disebabkan oleh beban kerja dapat mempengaruhi kualitas pelayanan asuhan keperawatan, seperti pelaksanaan Discharge Planning. Salah satu penanganan stress yang dapat dilakukan adalah dengan manajemen stress. Penelitian ini bertujuan untuk mengetahui pengaruh manajemen stress beban kerja menggunakan Progresive Muscle Relaxation pada pelaksanaan Discharge Planning keperawatan di RS Mitra Husada dengan jumlah sampel 15 perawat. Jenis penelitian menggunakan metode quasy eksperiment dengan menggunakan desain pre and post test without control, dilakukan pre test kemudian diberikan intervensi dan post test. Intervensi yang diberikan sebanyak 2 kali. Uji statistik me dependent t-test menunjukkan perbedaan rata-rata skor kepatuhan sebelum dan sesudah intervensi yaitu 41,13 dan 19,00 dan nilai t 14,992 Workload stress management in the implementation of nursing Work stress is a stress that comes from excessive workload. Nurse profession is a job that has a high workload, the task of nurses who must provide comprehensive nursing care up to the implementation of discharge planning or planning for the patient's return requires proper time and work management. Stress caused by workload can affect the quality of nursing tation of Discharge Planning. One of the stress management that can be done with stress management. This study aims to determine the effect of stress management workload using Progressive Muscle Relaxation on the implementation of Nursing Discharge g at Mitra Husada Hospital with a sample of 15 nurses. This type of experiment method by using a pre and post-test test and then given . Statistical tests using test showed differences in the average adherence score before and after the intervention of 41.13 and 19.00 and the value of t . There is a difference between the average core before and after the intervention, which is 47.00 and . The result show that workload stress management using the PMR method is useful in implementing Discharge Planning. Progressive Muscle Relaxation is ecommended to be done to reduce nurse's work stress. license.

Introduction
Nurses are occupational professions that specialize in efforts to handle nursing care for patients with work demands that depend on certain characteristics in carrying out their work, namely, task and material characteristics such as (equipment, speed, preparedness), organizational characteristics namely work hours / work shifts and characteristics of the work environment such as friends, tasks, temperature, noise, lighting, socio-culture, and pollutants. Besides the role of nurses is very important because it is the spearhead of health services in hospitals and is the longest contact with patients carrying out nursing care for 24 hours (Nursalam, 2012). Discharge Planning or nursing planning is part of the health services performed by nurses. Discharge Planning must be done systematically and completely, so that it can become one of the workloads for nurses.
Fluctuations in excessive workload are an improper condition, a tendency to leave work and can cause anxiety and generating work stress (Nursalam, 2012) consistent with the results of research conducted by Trifena LM Thio, et al. (2016) describing the existence of work stress on nurses, which is found that working conditions as much as 52.3% showed the greatest contribution to the occurrence of work stress then work climate 67.7% and workload of 46.2%. So many things related to the workload of nurses in hospitals that can trigger the emergence of work stress.
Prolonged stress can have an impact on aspects and systems of a person's body. Emotional impacts include anxiety, depression, physical and psychological stress, cognitive impacts resulting in decreased concentration and psychological effects on the digestive system, and the impact on behavior results in increased absence of work and quality of work (Potter and Perry, 2010). One of the nurses 'tasks that can be influenced by nurses' stress status is patient nursing Discharge Planning. Discharge planning mechanism of nursing care that is given continuously, information about ongoing nursing care needs after returning home, an evaluation agreement and self instruction (Swanburg, C., R. 2000). Stress that can not be anticipated properly and correctly will result in the inability of a person to interact positively with their environment, both in the work environment and outside the work environment. In addition, the most potentially stressful environment is a work environment where the workload of the work in question can really interfere with employees or workers. Job stress is an interaction between a person and an environmental situation or stressor that threatens or challenges to cause a physiological or psychological reaction to the worker (Swanburg, C., R.2000). As with previous This open access article is under the CC-BY-SA license.
Nurses are occupational professions that specialize in efforts to handle nursing care for patients with work demands that depend on certain characteristics in carrying out their work, namely, task and material characteristics paredness), organizational characteristics namely work hours / work shifts and characteristics of the work environment such as friends, culture, and pollutants. Besides the role of nurses is very important it is the spearhead of health services in hospitals and is the longest contact with patients carrying out nursing care or nursing planning is part of the health services performed by nurses. must be done systematically and completely, so that it can become one of the workloads for Fluctuations in excessive workload are an improper condition, a tendency to leave work and can cause anxiety and generating work stress (Nursalam, 2012). This is consistent with the results of research conducted by Trifena LM Thio, et al. (2016) describing the existence of work stress on nurses, which is found that working conditions as much as 52.3% showed the greatest contribution to the occurrence ork stress then work climate 67.7% and workload of 46.2%. So many things related to the workload of nurses in hospitals that can trigger the emergence of work stress.
Prolonged stress can have an impact on aspects and impacts include anxiety, depression, physical and psychological stress, cognitive impacts resulting in decreased concentration and psychological effects on the digestive system, and the impact on behavior results in increased absence of work and quality work (Potter and Perry, 2010). One of the nurses 'tasks that can be influenced by nurses' stress status is patient Discharge planning is a mechanism of nursing care that is given continuously, care needs after returning home, an evaluation agreement and self-care instruction (Swanburg, C., R. 2000). Stress that can not be anticipated properly and correctly will result in the inability of a person to interact positively with their environment, th in the work environment and outside the work environment. In addition, the most potentially stressful environment is a work environment where the workload of the work in question can really interfere with employees or on between a person and an environmental situation or stressor that threatens or challenges to cause a physiological or psychological reaction to the worker (Swanburg, C., R.2000). As with previous related studies as far as researchers have not read much t provides a solution to the handling of stress caused by workload, therefore this research is important to do. This study aims to improve the quality of nursing care Planning services for patients in hospitals through the management of work stress in the inpatient operating room.
Stress of the workload of nurses is a condition that requires follow up and special handling. So far, Mitra Husada Hospital of Pringsewu has never taken action on nurses' work stress status, but there are some data tha need for management of nurses work stress on nurses in the hospital, which is 64% incomplete Discharge Planning process, and an increase in BOR chart by 13% until 2017(Mitra Husada, 2017. This condition is the reason for the need to handle nurses work stress that can be one of the factors that affect the quality of nurse performance by looking at the nursing Discharge Planning process.

Method
This study was carried out through 4 stages, in the first stage carried out was to identify specifically the source of workload of nurses both quantitative and qualitative through case studies, the second stage of work stress analysis data was then linked to the implementation of Nursing Planning. Phase 3 of stress management implementation. In stage 4 a work stress analysis is carried out again and the Discharge Planning is carried out to see the effectiveness of stress management using Progressive Muscle Relaxation PMR. The research instrument used was the PMR Module sourced from Vargogli, L & christina, D (2011) and Job analysis sourced from Susan M. Heathfield (2011), as well as work stress measurement using the Workload Stress instrument sourced from Nursalam in 2014. The PMR intervention consisted of 12 movement sessions or methods in PMR that started from the facial muscles, shoulders, chest, stomach, arms, thighs and legs. Whereas for job analysis using the role play method describes nurse w assignments in one service shift. This research was conducted at Mitra Husada Hospital in Aster Room with a sample of 15 nurses with a total sampling technique. This type of research uses the quasy experiment method a pre and post test without control design, then the pre test is then given an intervention and post test. Interventions given 2 times, this aims to ensure the accuracy of the application of Progressive Muscle Relaxation The research data was collected in July -Augu related studies as far as researchers have not read much that provides a solution to the handling of stress caused by workload, therefore this research is important to do. This study aims to improve the quality of nursing care Discharge services for patients in hospitals through the ress in the inpatient operating room. Stress of the workload of nurses is a condition that requires follow up and special handling. So far, Mitra Husada Hospital of Pringsewu has never taken action on nurses' work stress status, but there are some data that show the need for management of nurses work stress on nurses in the hospital, which is 64% incomplete Discharge Planning process, and an increase in BOR chart by 13% until 2017(Mitra Husada, 2017. This condition is the reason for the ses work stress that can be one of the factors that affect the quality of nurse performance by looking at the nursing Discharge Planning process. This study was carried out through 4 stages, in the first stage carried out was to identify specifically the source of workload of nurses both quantitative and qualitative through case studies, the second stage of work stress analysis data to the implementation of Nursing Discharge . Phase 3 of stress management implementation. In stage 4 a work stress analysis is carried out again and the is carried out to see the effectiveness of ve Muscle Relaxation PMR. The research instrument used was the PMR Module sourced from Vargogli, L & christina, D (2011) and Job analysis sourced from Susan M. Heathfield (2011), as well as work stress measurement using the Workload Stress ed from Nursalam in 2014. The PMR intervention consisted of 12 movement sessions or methods in PMR that started from the facial muscles, shoulders, chest, stomach, arms, thighs and legs. Whereas for job analysis using the role play method describes nurse w ork assignments in one service shift. This research was conducted at Mitra Husada Hospital in Aster Room with a sample of 15 nurses with a total sampling technique. This quasy experiment method by using , then the pre test is then given an intervention and post test. Interventions given 2 times, this aims to ensure the accuracy of the Progressive Muscle Relaxation by respondents. August 2019. The frequency distribution of respondents' characteristics showed the results that the age of nurses who served in the Aster room mostly consisted of ages ranging from 24 -35 years, namely 86.6%. According to Simbolon & Ria Hot Juanita (2010) states that the productive age of workers is at intervals of 25 -35 years. This means that respondents in this study 86.6% were productive workers. The condition of productivity based on age illustrates the percentage of opportunities in Aster Room at Mitra Husada Hospital producing good nursing care products. Whereas for workload analysis 66.6% of nurses had a heavy workload category and only 5 respondents in the light category.
Nurse health personnel of workload analysis can be seen based on aspects of the tasks performed according to their main function. Some aspects related to the workload are the number of patients who must be treated, work capacity according to education, shifts that are used to carry out their duties in accordance with the hours of work that take place every day i.e 7 hour morning shifts, 7 hour afternoon shifts and night shifts 10 hours, in addition to the complete facilities that can help nurses complete their work properly according to Setiyana, (2013).
According to Hurrel (in Manuaba, 2010) workload is one of the factors causing stress. Work factors that can cause stress are categories of intrinsic factors in work, such as physical and tasks, duties include workload, night work and exposure to risks and dangers. Meanwhile, from several analyzes conducted by Hawari in 2011, one of the main sources of work stress includes; Excessive workloads, for example, caring for too many patients, experiencing difficulties in maintaining high standards, feeling unable to provide the support needed by coworkers and facing the problem of limited nurse staff. In accordance with the conditions in the Aster room that the high BOR rate reached 86% in August with AVLOS 3-4 days. Aster nurses number only 15 nurses. This condition requires attention of HR management in the provision of nurses in accordance with the calculation of the number of nurse needs based on the number of patients and the level of dependency of patients, which is 81% is partial care.
This research is in line with research that proves this theory was also carried out by Dewi Yana (2014), namely the nurse's workload was high in 93.1% of respondents with a moderate stress level of 82.8% and there was a relationship between workload and nurses' work stress in the District Hospital Semarang with a p value of 0,000. The high workload on nurses in the study could reach 93.1%. The results of the analysis in table 2 show that there are differences in the average adherence score from 41.13 to 19.00 and t value 14.992 with a p-value of 0.000 and there is a difference between the average work stress score before the intervention and after the intervention that is 47, 00 and 97.00 and the value of t -15,585 with a p-value of 0,000.
The results of the above study indicate that there is a significant difference between discharge planning compliance and work stress before and after the intervention. It can be concluded that there is an Effectiveness of Stress Management Workload in the Implementation of Nursing Discharge Planning at Mitra Husada Hospital of Pringsewu in 2019, Ha hypothesis is accepted and Ho is rejected.
Work stress originating from workload can affect the quality of a nursing care service, one of which is the implementation of Nursing Discharge Planning. This is in line with previous research conducted by Yani Sri et al (2017) finding that 11 respondents (30.6) experienced mild stress levels, 16 respondents (44.4%) experienced moderate stress and 9 respondents (25%) experienced severe stress. There is a relationship between the workload of nurses in the ICU Room with nurse stress levels p value 0.016.
Another study conducted by Akbar MT et al (2018) succeeded in proving the influence of work stress, workload and individual characteristics on nurse performance and research conducted by Wollah Miranda et al (2017) showed the results that there were 15. 6% of nurses experiencing stress high level of work in the Emergency Room and ICU at Pancaran Kasih Hospital in Manado. These findings are strengthened by the results that there is a relationship between work stress and the quality of nurse performance.
Unresolved work stress can affect the quality of a task, one of which is the implementation of Discharge Planning. Job stress can be overcome by stress management. According to the National Safety Council stress management is a rational, directed and therefore effective effort to deal with stress. One of stress management to reduce stress level is by doing progressive muscle relaxation which is included in the physical strategy.
In line with research conducted by Ilmi Z.M., et al (2017) proves that there is an effect of progressive muscle relaxation on the stress levels of female prisoners. In this study researchers only applied 6 times a week for a period of 25-30 minutes. In contrast to researchers do that is only 2x and after that respondents do independently according to nurse hours.
In a study conducted by Lisa M. Kath et al (2013) at 36 hospitals in Southwestern United States, the role or excessive workload was a predictor of stress with an increase of 13%.

Figur 1. Discharge Planning Process
The Discharge Planning implementation process in Aster Room at Mitra Husada Hospital based on the results of research that is often overlooked is health education in accordance with the patient's condition. There are already several disease leaflets that are often treated in the Aster room, but in practice leaflets are not given to patients. Nurses only provide Discharge Planning in the form of time to return control to the hospital, and do not provide information when and where to get health care from the nearest health service and who the family will treat patients after returning from the hospital. The following is the flow and conditions for implementing Discharge planning according to Nursalam (2008). This is evidenced by the results of research conducted by researchers at Mitra Husada Hospital of Pringsewu Lampung in 2019 that there are differences in work stress before and after the intervention with a p-value of 0.001. With the stress of work stress on nurses, nurses' compliance in carrying out Discharge Planing increases as evidenced by the results of the analysis with p-value of 0.001. It can be concluded that work stress management is effective for improving Discharge Planning service quality.

Conclusions and Recommendations
Based on the results of the analysis above it can be concluded that workload stress management is effective for improving the quality of patient Discharge Planning services. By using the PMR method nurses can reduce the level of stress that comes from workloads. Apart from the results of the SPSS analysis after the PMR stress management was carried out, the implementation of the Discharge Planning slightly changed, especially in the provision of health education and other Discharge Planning sequences at the time of patient return in care in the Aster Room of Mitra Husada Hospital of Pringsewu Lampung.
Progressive stress management should be carried out every day at the beginning of the service shift and at the end of the shift in order to reduce the level of stress that can affect the quality of nursing services in the hospital. Decomposition of job analysis in each shift needs to be done by nurses in the nurse's pocket book. For hospitals, it is necessary to re-calculate the number of nurses' needs and rearrange a complete discharge planning format.