The Degradation of Cortisol in Coronary Heart Patients Receiving

Islamic Nursing Care: A Pilot Study

Abu Bakar

, Nursalam

, Kusnanto

, Merryana Adriani

and Siti Nur Qomariah

Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Public Health Faculty, Universitas Airlangga, Mulyorejo, Surabaya, Indonesia

Health Sciences Faculty, Gresik University, Gresik, Indonesia

Keywords: Islamic Nursing, Coronary Heart, Cortisol, Psycho-spiritual.

Abstract: Islamic nursing care provides a nursing service intended for worship, based on the Qur'an and Hadith to

reach the blessings of Allah SWT. This study aims to analyze the influence of Islamic nursing care towards

psycho-spiritual comfort and cortisol of coronary heart patients. The research design was pre-experimented

with a control group designs only as post-test design. The population of the study are heart patients in

hospital wards. A sample of 20 respondents was selected using a consecutive sampling technique.

Independent variables are the Islamic Nursing Care and the dependent variable is the psycho-spirituality of

coronary heart patients. Psycho-spiritual data were measured using a questionnaire and the patients’ levels

of cortisol. Analysis was conducted using independent t-test statistics with the significance level α <0,05.

Results showed that Islamic nursing care influenced the psycho-spirituality of coronary heart patients with a

p value = 0,036. There was no effect of Islamic nursing care on cortisol levels of coronary heart patients

with p = 0.688 (α ≥ 0.05). The mean of the cortisol treatment group decreased compared to the control

group. Islamic nursing care enhances psycho-spiritual comfort and lowers coronary heart patients' cortisol.

Psycho-spiritual heart patients in subsequent studies should be observed in detail for clinical signs, such as

electrocardiography and biomarkers.

1 BACKGROUND

The anxiety of coronary heart patients is often

associated with adverse cardiovascular outcomes for

people who have suffered heart attacks (Nur'aeni,

Ibrahim, & Agustina, 2013). Anxiety sufferers with

untreated coronary heart disease may increase the

risk of CHD from non-fatal to life-threatening

(Shibeshi, Young-xu, & Blatt, 2007). Research

shows that spiritual or religious behavior greatly

supports the reduction of anxiety (Ai, Pargament,

Kronfol, Tice, & Appel, 2010). Previous research

has shown that nursing care is still more focused on

physical problems (Bakar & Kurniawati, 2013).

Circumstances indicate the need for Standard

Operating Procedures (SOPs) to carry out Islamic

nursing care.

Islamic nursing provides professional care that

adheres to the Islamic principles of Ihsan and

consistently provides guidance relating to worship

and health (Fadilah, 2009). Islamic nursing is a

service that is provided with an intention of worship

based on Al-Qur'an and Hadith to reach Allah SWT

(Sudalhar, 2011). Research shows that good nursing

care is closely related to patient satisfaction

(Kurniawati et al., 2013). Patient satisfaction can be

described as patient psycho-spiritual comfort. The

comfort of Muslim patients (psycho-spiritual) is the

attainment of well-being through displaying

gratitude for all favors and accepting all trials from

God with patience and sincerity (Bonab, Miner, &

Proctor, 2013). Anxiety or psychiatric illness can be

cured by the method of faith shown; a person

becomes one of gratitude, patience, and sincerity

(Izzan, 2010). Gratitude, patience, and sincerity can

be seen biomolecularly by observing cortisol levels

(Ramadhani, 2007). Cortisol plays a role in ensuring

the availability of energy in the body for tackling

and preparing the body for stress (Guyton & Hall,

2014). The needs of Muslim patients (psycho-

spiritual) require fulfillment; in fulfilling the needs

of Muslim patients, the nurse needs to know the

habits of a Muslim patient (Barolia & Karmaliani,

2008). Islamic nursing care can fulfill a Muslim

Bakar, A., Nursalam, ., Kusnanto, ., Adriani, M. and Qomariah, S.

The Degradation of Cortisol in Coronary Heart Patients Receiving Islamic Nursing Care: A Pilot Study.

DOI: 10.5220/0008320000330037

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 33-37

ISBN: 978-989-758-336-0

patient's habits to assess their comfort (psycho-

spiritual). The purpose of this study is to analyze the

effect of providing Islamic nursing care for the

psycho-spirituality of coronary heart patients.

2 METHODS

The research design used was pre-experimental with

a control group for post-test only. The population in

the study comprised of cardiac patients in the patient

ward of the Haji Hospital, Surabaya. The sample of

20 respondents (10 respondents in the control group

and 10 respondents in the treatment group) were

selected using a consecutive sampling technique.

The independent variable in this study is Islamic

nursing care and the dependent variables are the

psycho-spiritual comfort and coronary heart disease

levels of cortisol.

Convenient psycho-spiritual and cortisol data

retrieval were performed for two months (March–

April 2017) according to these criteria: no

complications of arrhythmias and not in serious

condition. Psycho-spiritual data were measured

using a questionnaire consisting of the patience,

sincerity, and gratitude aspects developed by Bakar,

Adriani, Qomariah, & Hidayati (2017). The psycho-

spiritual questionnaire was valid and reliable with

Pearson correlation values in the range 0.726–0.974

and Cronbach alpha in the range 0.866–9 969.

Psycho-spirituality was also measured by the

cortisol levels in the blood using the enzyme-linked

fluorescent immunoassay (ELFA) method.

Measurements of the cortisol content were

performed by the Haji Hospital Laboratory in

Surabaya. This research was tested and declared

ethical by the Ethics Research Commission of the

Haji Hospital, Surabaya on 03 October 2016, with

the letter and number approval

No.073/26/KOM/ETIK/2016. The inferential

analysis used was the independent t-Test with SPSS

13 software, and the significance level α <0,05.

3 RESULTS

The results of data collections show the subjects

characteristics are as follows: both groups showed

similar characteristics in age, economy, education,

and period of treatment. Most respondents were

elderly. Their economic status was mostly in

adequate. The respondents’ education status was

mostly deficient and included both formal and non-

formal education. Based on the treatment period,

both groups had received long-term Islamic nursing.

The prognosis and treatment experience was

distinctly characteristic in both groups. The

prognosis of the control group was largely lighter

for heart disease than the treatment group.

Experiences treated by the most control groups

have experienced Islamic nursing care from the

treatment group, for the complete result can be seen

in Table 1.

Table 1: Distribution table of heart patient

characteristics.

Patients’

Characteristics

Number of

Control

Group/

percentage

Number of

Treatment

Group

ercenta

1 Age

a. 36–45 years

old

b. 46–55 years

old

c. 56–64 years

old

d. >65 years

old

Total

1/10%

3/30%

4/40%

2/20%

10/100%

0/0%

1/10%

6/60%

3/30%

10 /100%

Prognosis

a. UA

b. NSTEMI

c. STEMI

Total

5/50%

2/20%

3/30%

10/100%

2/20%

3/30%

5/50%

10/100%

3 Economic

Status

a. Deficient

b. Adequate

c. Good

Total

2/20%

5/50%

3/30%

10 /100%

2/20%

7/70%

1/10%

10/100%

4 Education

Status

a. Deficient

b. Adequate

c. Good

Total

6/60%

1/10%

3/30%

10/100%

7/70%

3/30%

0/0%

10/100%

5 Experience of

Treatment

a. 1 time

b. 2–3 times

c. ≥ 4 times

Total

1/10%

7/70%

2/20%

10 /100%

5/50%

2/20%

3/30%

10/100%

6 Period of

Treatment

a. 1 day

b. 2–3 days

c. ≥ 4 days

Total

0/0%

8/80%

2/20%

10/100%

0/0%

7/70%

3/30%

10/100%

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

Table 2 explains the effect of providing Islamic

nursing care for psycho-spiritual patients. The

psycho-spiritual level of patients in the treatment

group was higher than that of the control group. The

standard deviation value of the small treatment

group shows the psycho-spiritual patient at the same

level. Gratitude demonstrates an average deficiency

level in both groups. Patience and sincerity in both

groups were at a good level. There was no effect of

Islamic nursing care on cortisol levels. The mean

value of the cortisol examination in the treatment

group was lower than the control group. The average

level of cortisol in both groups was within the

normal range of morning cortisol levels.

4 DISCUSSION

4.1 Psycho-spirituality of Coronary

Heart Patients

Islamic nursing care can improve the psycho-

spirituality of the patient. The results of this study

are in accordance with previous research, which

stated that Islamic nursing care is closely related to

patient satisfaction and the religious culture of

patients (Fini, Mousavi, Sabdani, & Hajbaghery,

2012). Satisfaction, according to Islam, is full of

gratitude for the favors of God in physical, spiritual,

and social aspects (Fadilah, 2009). Psycho-spiritual

heart patients can be exemplified by the state of a

change in their condition. Coronary heart patients

are patient and sincere when they are healed but

there is still a disability encountered with patience

and when pain is severe or there is no hope to heal,

patients willingly accept this condition (Izzan,

2010).

Psycho-spiritual patients who show patience and

sincerity are found within the ‘good’ category. The

‘adequate’ category shows that patients still cannot

be patient and are unwilling to accept pain.

This situation is not in accordance with the

advice of the holy book of Al Qu'an of Surat Al

Baqarah verse 153, which states "O you who have

believed, seek help through patience and prayer.

Indeed, Allah is with the patient." The Word of God

is reinforced by the letter of Ash-Shu'ara 80: "And

when I am sick, He is the God who heals." This

verse shows that we must be sure God will help his

servant, for God Almighty heals the sick. Although

attempts are made, not everyone can recover as

before. Patience can also be demonstrated by

believing that everything that happens is the destiny

that God set for us. A Muslim must be sure that

whatever happens to them, they must have an

element of goodness.

Being sincere means to observe merely the act of

seeking the pleasure of Allah and purifying all sorts

of worldly deeds (Gymnastiar, 2006). Al Qur'an

letter of Al Bayyinah 5 states "And they were not

commanded except to worship Allah, [being] sincere

to Him in religion, inclining to truth, and to establish

prayer and to give zakah. And that is the correct

religion." Sincerity limitations, for example, do not

care if all human appreciation and praise is on him,

because his heart sincerely hopes only Allah's

pleasure, and he does not want others to pay

attention to his actions even though only small

(Taimiyah, 2016). Sincerity also includes all deeds

and words.

The study also found that patients were not

grateful for the conditions they experienced.

Patients' gratitude is not done, among others, most

patients do not perform the five obligatory prayers.

This situation indicates that the patient still cannot

practice and carry out God's commands in the

verses. The Qur'an Ibrahim 7 states “And

[remember] when your Lord proclaimed, 'If you are

grateful, I will surely increase you [in favor]; but if

you deny, indeed, my punishment is severe.'”. This

book explains that the ordeal that befell us, is merely

a sign of love and affection of Allah to his servants.

If one has finished treatment and has been given a

chance by God to heal again then one should be

grateful. Gratitude to God has given us mercy. We

must be grateful that God still gives us the

opportunity to repent and cleanse ourselves

(Taimiyah, 2016). Be grateful, not just say

Alhamdulillah, but put something according to its

Table 2: The differences in the patients’ psycho-

spiritual and cortisol tests.

Measurement

Control

Group

(X ±

SD)

Treatment

Group

(X ± SD)

Independent

t-test

Psycho-

spirituality of

atients

34,80 ±

5,09

39,10 ±

3,18

p = 0,036

Patience

13,80 ±

2,97

14,70 ±

2,50

Sincerity

12,90 ±

2,68

13,60 ±

1,65

Gratitude

9,40 ±

2,37

9,40 ±

0,70

Cortisol level

131,29

± 97,05

117,05 ±

51,57

p = 0,688

The Degradation of Cortisol in Coronary Heart Patients Receiving Islamic Nursing Care: A Pilot Study

function and the will of Allah (Taimiyah, 2016). The

health favors we have received we must do by God's

command to increase faith and piety. We always do

good to seek God's approval as proof of gratitude.

Regarding patients who are not grateful, it is

possible that the characteristics of patients are very

minimal, including a formal or non-formal education

status at a deficient level. This situation is in

accordance with research that states that knowledge

affects the formation of attitudes and behavior

(Utami & Supratman, 2009). Education related to

the psycho-spiritual, especially non-formal, is linked

to patients’ knowledge of religion. Other studies

have determined the effect of informal education on

the willingness or behavior of patients in worship

(Bakar & Kurniawati, 2013).

4.2 Cortisol

The results of biomolecular examinations of psycho-

spiritual indications of patients regarding cortisol

levels showed no significant effect. This result is

consistent with previous studies showing that the

cortisol levels of patients receiving dzikir

intervention was not significant compared to the

control group of patients with heart failure (Yusuf,

Nihayati, Iswari, & Okviasanti, 2017). The

insignificant level indicates that between the

treatment group and the psycho-spiritual condition

control, patients’ distress levels are the same. This

could be because the research patients are within the

elderly age range. An elderly age promotes a better

self-acceptance and consistent gratitude

(Sirojammuniro, 2015). This will affect the psycho-

spiritual biomolecular (cortisol) because acceptance

signifies the absence of distress. In theory, distress

produces prominent physiological responses in the

body with increased cortisol (Kunz-Ebrecht,

Mohamed-Ali, Feldman, Kirschbaum, & Steptoe,

2013).

The results of the cortisol treatment group

showed lower levels than the control group. The

reduction in cortisol levels in the treatment group

demonstrates a form of physiological adaptation of

the body to the stimulus from Islamic nursing care

demonstrate reduced distress at a hormonal level.

Hormonal changes due to positive cognitive

responses are sent by amigdala as a decoy towards

the hippocampus. Amigdala then stimulate the

hypothalamus through the hypothalamic-pituitary-

adrenal (HPA) axis to reduce CRH spending. A

decrease in CRH levels stimulate the anterior

pituitary to lower ACTH levels so that cortisol is

released into the controlled bloodstream (Newberg,

2011).

Cortisol patients who show an average decrease

can be used as guidance that Islamic nursing care

can promote changes in patients. This shows that

Islamic nursing care affects the learning process to

form the correct perceptions so that it can decrease

depression, which indicates decreased levels of

stress hormones in the body. Many previous studies

have shown positive results of cortisol use as an

indicator, including decreased levels of cortisol in

patients with leprosy distress who received modified

intervention Cognitive Behavioral Stress

Management (CBSM) - asthma Asmaul Husna

(Satiti, 2013). This situation shows that it is

important to maintain and continue improving

Islamic nursing care. Islamic nursing care affects

patients’ perception of stress as shown by the

physical or biological changes in the body of

respondents in the form of decreased cortisol levels.

5 CONCLUSIONS

The comfort that is experienced by coronary heart

patients is due to the success of Islamic Nursing

Asuha. The comfort characteristics can be assessed

from the patient's psycho-spiritual patience,

sincerity, and gratitude. Psycho-spirituality was

assessed using patients' cortisol levels and resulted

in an average degradation of the treatment group

compared to the control group. Subsequent research

should study clinical signs, such as

electrocardiography and biomarkers, when

observing psycho-spiritual heart patients. The

limitation of this study is that no data were collected

before action was taken.

ACKNOWLEDGEMENTS

We would like to acknowledge all the participants,

nurses, and other hospital staff who cooperated in

this study. We also acknowledge the Directorate of

Research and Social Dedication, the Ministry of

Research Technology, and the Higher Education of

Indonesia (Agreement No

004/ADD/SP2H/LT/DRPM/VIII/2017) for their

support during the conduct of this research, the

collection, analysis, and interpretation of data, in the

writing of the report, and the preparation of this

article.

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

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The Degradation of Cortisol in Coronary Heart Patients Receiving Islamic Nursing Care: A Pilot Study