The Analysis of Surgery Patients Anxiety Reviewed from Pre Operative Services at Dr. R. M Djoelham Binjai Public Hospital

Surgery is a form of therapy that can threaten the integrity of a person's body and soul. The psychological response that usually occurs in preoperative patients is anxiety. Anxiety is an emotional reaction to subjective individual judgment, which is influenced by the subconscious and the cause is not specifically known. Type of research is quantitative and qualitative research (method mixed). This research was conducted at DR. R.M Djoelham general hospital Binjai. Qualitative population of surgeons, anesthetists and nurses at RSUD DR. RM Djoelham Binjai, samples obtained by Purposive Sampling as many as 33 people. Data were analyzed by univariate, bivariate (Chi Square), Multivariate (logistic regression). Based on these results it is concluded that there is a relationship between providing information, consultation and education on patient anxiety. Based on the results of the bivariate analysis, it is found that there is a relationship in the dimension of Information Giver has a value of p (sig) 0.037, consultation (sig) 0.005, education p (sig) 0,002. The concluded that there is a relationship between providing information, consultation and education on patient anxiety. Based on the results of interviews from informants, it was found that the provision of information, consultation and education before or after the operation had been implemented, both DPJP doctors, anesthetists and nursing staff.


Introduction
Surgery is a form of therapy that can threaten the integrity of a person's body and soul. Surgery that is planned can cause physiological and psychological responses in the patient. The psychological response that usually occurs in preoperative patients is anxiety. Anxiety is an emotional reaction to subjective individual judgment, which is influenced by the subconscious and the cause is not specifically known.
Based on data obtained from the World Health Organization (WHO), the number of patients with surgery has increased significantly from year to year. It was recorded that in 2011 there were 140 million patients in all hospitals in the world, while in 2012 the data had increased by 148 million people. Operations in Indonesia in 2012 reached 1.2 million people. Data obtained from the General Hospital DR. R.M Djoelham in 2019 there were 447 patients who were operated on (Kuraesin, 2009).
Before undergoing surgery, the patient will be exposed to various stimuli that can trigger anxiety that can cause stress until after surgery. Anxiety will respond with several changes in the body, especially in vital signs. Changes that occur can include an increase in blood pressure, pulse and respiration. If the increase is too large, the heart's work and oxygen demand will also increase. The body copes with this with an increase in blood pressure, palpitations, and shallow In Indonesia, the prevalence of anxiety disorders ranges from 6-7% of the general population (more women than men). According to Arifah & Trise in sembiring (2019) at the Sleman Regional General Hospital, it was found that from 31 respondents, 54.8% of pre-operative patients experienced anxiety, patients stated that the causes of anxiety varied, among others: not understanding about surgery, fear with the situation in the operating room, and how it will be after surgery (Mundakir, 2006).

Methods
The type of research used in this research is quantitative and qualitative research (mixed method) (Nursalam, 2016). Quantitative data collection using questionnaires, respondents are asked to fill out the questionnaire given, then qualitative data collection through interviews to see field findings which are carried out separately and later to see whether the results confirm each other and aim to know in depth the analysis of surgery patient anxiety in terms of preoperative waiter. The sample is the object under study and is considered to represent the entire population (Sugiyono, 2012). Sampling using purposive sampling, which is a sampling technique with certain considerations that aim to make the data obtained will be more representative. The population in this study amounted to 447 people. The sample to be taken in this study amounted to 33 using the Slovin formula.

Univariate Analysis
Univariate analysis in this study will explain the frequency distribution of each research variable, namely age, gender, education level, ASA status, information provision, pre anesthetic visits, consultation and education. With respondent patients who will be operated on we see as follow:   Based on table 3 it can be seen that of the 33 respondents, the majority of respondents with a high school education level were 27 (81.8%) respondents, while respondents with a tertiary education level were 6 (18.2%) respondents.  Based on table 5, it can be seen that from 33 respondents, most of the respondents rated good in providing information to 19 (57.6%) respondents, while respondents rated poor in providing information in as many as 14 (42.4%) respondents.  Based on table 7, it can be seen that of the 33 respondents, most of the respondents rated good in consultation with 23 people (69.7%) of respondents, while respondents who rated bad were 10 (30.3%) respondents. Based on table 8, it can be seen that of the 33 respondents, most of the respondents with a good anxiety level were 28 (84.8%) respondents, while the respondents with a bad anxiety level were 5 people (15.2%). Based on table 9. it can be seen that of the 33 respondents, most of the respondents who did not experience anxiety were 27 (81.8%) respondents, while 6 (18.2%) experienced enxiety. Based on table 10, it is known that of the 33 respondents studied, most of the respondents were not anxious as many as 27 respondents. Of the 27 respondents, there were 9 (27.3%) respondents who rated poor in providing information and 18 respondents (54.5%) who rated good in providing information. And of the 6 respondents who were anxious, there were 5 (15.1%) who rated poorly in providing information and 1 (3.1%) who rated good at providing information. So it can be concluded that there is a relationship between the level of anxiety and the provision of information in RSUD DR. R.M DjoelhamBinjai in 2020. Based on table 11, it is known that of the 33 respondents studied, most of the respondents who were not anxious were 27 respondents. Of the 27 respondents, there were 6 (18.2%) respondents who rated poor in providing information and 21 respondents (63.6%) who rated good in providing information. And of the 6 respondents who were anxious, there were 5 (15.2%) who rated poorly in providing information and 1 (3%) who rated good at providing information. It was concluded that there was no relationship between pre-analysis visits with anxiety levels in RSUD DR. R.M Djoelham Binjai in 2020. Based on table 12, it is known that of the 33 respondents studied, most of the respondents who were not anxious were 27 respondents. Of the 27 respondents, there were 22 (66.7%) who rated good at counseling and 5 people (15.2%) rated bad. Of the 6 respondents who were anxious, there were 1 (3%) respondents who rated good at the consultation and 5 respondents (15.2%) rated it as bad. Based on the results of statistical test calculations, the p-value is 0.005 <0.05, so it can be concluded that there is a relationship between consultation and the patient's anxiety level at RSUD DR. R.M Djoelham Binjai in 2020. 0.002 <0.05, so it can be concluded that there is a relationship between education and anxiety levels in RSUD DR. R.M Djoelham Binjai in 2020.

Multivariate Analysis
Multivariate analysis used logistic regression (binary multiple regression) through several steps, including: Conduct a selection of variables that have the potential to be included in the model variables that are selected as candidates or those that are considered significant.
In this modeling, variables that have a p value <0.25 in the bivariate test (chi-square test) are put together in the multivariate test. From the results of the bivariate test, the variables used as candidate models in the logistic regression test (binary multiple regression) were workload, responsibility, and job security variables.
Furthermore, the variables entered in the selection of model candidates were tested simultaneously with the enter method to identify the variables that had the most significant influence (p <0.05).  Table 14 shows that there are 3 variables with p value <0.25, namely the provision of information, consultation and education. Thus, the 3 (three) variables deserve to be included in the multivariate model.

Informant I (Surgeon)
"We usually see the patient's anxiety from the vital sign, but in fact it's very easy to assess it. We can see from the patient's face that changes, we just bring it in the form, like in the narrative, we didn't shoot him straight away, for example the father got this disease, yes no, we took him first. so that the atmosphere is not too shocked, yes whatever the story is, it is not easy to accept an illness, yes, we take it first in a way, ask the light, then we will explain it slowly.

Informant II (Anesthetist)
"The factor of anxious patient is because it has been conceptualized in the community in general, if after the operation is dead, that's what has been conceptualized so we can't avoided it, therefore I am of the opinion that most of the patients who will be operated on are definitely worried.

Informant III (Nurse)
"At first, we Anamnese, we asked how his condition was this morning, was he worried? If he was anxious, we immediately gave education so that his anxiety was reduced, usually the patient was worried.

Informant I (Surgeon) "Dead. all of them are most afraid of death, yes, the term people hear about the operation, what if the story of the operation is true, but we see the case again whether the disease is serious or not, when people tell the operation they remember death and another one is sick, afraid of times when you tell me. surgery because it deals with the third knife is aesthetic
Informant II (Anesthetist)

"There are many factors from anxious patients, but the most feared thing is death because of the problem of this operation, it has been conceptualized in the general public if after the operation is dead, it is conceptualized so we can't avoid it"
Informant III (Nurse) "Maybe they don't understand how the operation is, in the operating room, that's why they are often afraid, because the operation is a creepy picture, so they are afraid or worried. They might think the operation is creepy.

Informant IV (Surgical Room Management)
"What can make patients anxious is usually not given an explanation so patients ask questions about the operation, how afraid are they also with the tools in the operating room, especially patients who have never been operated on at all. impact when adults do not really have a big impact because the patient enters we already given the medicine "

Informant III (Nurse)
"What we assess we are studying the vital sig, breathing, blood pressure is afraid that he will want to operate, if anxious is vital, the sig can go up, sometimes the pulse can also quickly tend to get cold sweat or even have trouble sleeping."

Informant I (surgeon)
"Like this, if for that we tell you that if this is not done, the danger is this, but if we do this the risk is like this, we will tell you what the complications are after this, for example appendicitis, if this is not operated, soon it will break the operation rules with a small incision. he was already broken, so he had to undergo a laparotomy, so it was one more difficult and more threatening then the treatment was even more difficult, now we go back to the family again "

Informant II (Anesthetist)
"Yes, first, we will give an explanation first. If the patient has been given an explanation, the patient feels anxious. Usually we give the drug, right? The anesthetic task includes controlling the patient's condition.

Informant III (nurse)
"If from the nurse, maybe we keep asking about the situation before the operation, yes, most of the patients are worried, but we are trying to keep educating the patient that the operation is not as scary as they think.

Informant IV (Surgical Room Management Staff)
"We will collaborate with the doctor on how we can reduce this anxiety, automatically the nurses in the room before the operation we will introduce ourselves to our patients, we will provide a little explanation about how the operation is performed and how the level of anesthesia will be closer to us. and her anxiety level decreased.

Analysis of the relationship between the provision of perioperative information (inform choice) on the level of anxiety in surgery patients
Based on the results of the study, it is known that of the 33 respondents studied, most of the respondents were not anxious as many as 27 respondents. Of the 27 respondents, there were 9 (27.3%) respondents who rated poor in providing information and 18 respondents (54.5%) who rated good in providing information. And of the 6 respondents who were anxious, there were 5 (15.1%) who rated poorly in providing information and 1 (3.1%) who rated good at providing information. Based on the results of the statistical test calculation, the p value of significance was 0.037 <0.05. So it can be concluded that there is a relationship between the level of anxiety and the provision of information in RSUD DR. R.M Djoelham Binjai in 2020.
Perioperative information and patient involvement in decision making are very important in determining patient satisfaction. Providing information before the operation is carried out is always provided by health workers, be it nurses or doctors, and when I ask the patient directly, the patient answers that information about surgery can relieve patient anxiety and the patient can understand the information provided by the nurse. as well as doctors.
The results of this study are in line with the research conducted by Lubis (2019)  that there is a relationship between providing information and Patient Anxiety Level with a Pvalue of 0.001 (Lubis, 2019).
This result is also in line with the research conducted by Sawitri & Sudaryanto (2008) with the title of research on the effect of pre-surgical information provision on anxiety levels in major pre-surgery patients in the Orthopedic Ward, Kustati Hospital, Surakarta, which received a P-Value of 0,000, which means that there is a significant relationship. between the provision of preoperative information with a reduction in the level of anxiety in patients (Sawitri & Sudaryanto, 2008).
This is in line with the research conducted by Lapian et al. (2016) with the title The Relationship of Providing Information before surgery with the level of family satisfaction of patients at Prof. DR.R.D. Kandou Manado with research results there is a relationship between providing information with the level of family satisfaction of patients with the chi square test obtained a significant value of p = 0.000 <0.05 (Lapian et al., 2016).

Analysis of the Relationship between the Pre Anesthesia Visit to the Anxiety Level of Operation Patients
Based on the results of the study, it is known that of the 33 respondents studied, most of the respondents who were not anxious were 27 respondents. Of the 27 respondents, there were 6 (18.2%) respondents who rated poor in providing information and 21 respondents (63.6%) who rated good in providing information. And of the 6 respondents who were anxious, there were 5 (15.2%) who rated poor in providing information and those who rated good In providing information as much as 1 (3%) of respondents. Based on the results of the statistical test calculation, the p value of significance is 0.624> 0.05, so it can be concluded that there is no relationship between pre-analysis visits and anxiety levels in RSUD DR. R.M Djoelham Binjai in 2020.
Pre-anesthetic evaluation is the first step in a series of anesthetic actions performed on the patient, aiming to determine the patient's preoperative physical status (ASA), analyze the type of surgery, have the type and technique of anesthesia, predict possible complications, prepare drugs and anesthesia. In elective surgery, pre-anesthetic evaluation is carried out a few days before surgery, then the day before surgery, then in the morning before the patient is sent to the operating room and finally in the central surgical installation preparation room (IBS) to determine the physical status of ASA. In emergency surgery, pre anesthetic evaluation is carried out in the emergency room surgery preparation room (IRD), because the time available for evaluation is very limited, so the information about the disease is less accurate (Mangku & Senapathi, 2010).
When I interviewed the anesthetist, the doctor said the pre-anesthetic visit was usually done the day before the patient was going to be operated on, and during the visit the anesthetist explained the procedure to be done regarding anesthesia, for example in which part of the body the injection will be done, what are the effects from anesthetic drugs, and at the pre-anesthetic visit the doctor also saw the patient's vital sign status whether this patient could be operated on tomorrow.
The results of this study are not in line with the research conducted by Sari (2019) ( Sari, 2019).

The Relationship of Consultation to the Anxiety Level of Operation Patients
Based on the results of the study, it is known that of the 33 respondents studied, most of the respondents who were not anxious were 27 respondents. Of the 27 respondents, there were 22 (66.7%) who rated good at counseling and 5 people (15.1%) rated bad. Of the 6 respondents who were anxious, there were 1 (3%) respondents who rated good at the consultation and 5 respondents (15.2%) considered it bad. Based on the results of statistical test calculations, the p-value is 0.005 <0.05, so it can be concluded that there is a relationship between consultation and the anxiety level of patients at RSUD DR. R.M Djoelham Binjai in 2020.
Counseling is the process of providing objective and complete information, carried out systematically with a combination of interpersonal communication skills, guidance techniques and mastery of clinical knowledge, which aims to help a person recognize his current condition, the problem at hand and determine a way out or in order to overcome the problem (Saifuddin, 2002).
This is in accordance with the research on the effect of counseling on anxiety in pre-operative Orif / Oref patients in the Dr. H Slamet Martodirdjo Pamekasan Hospital Joining room, anxiety can occur to anyone, especially patients who are going to undergo surgery anxiety can passed down by counseling. Counseling is a relationship between two people, where one person tries to help the other person to solve his problem in the context of adjustment. Nursing counseling is a form of nursing service to help reduce or resolve client problems, especially psychological and intellectual problems (Mundakir, 2006). Some of the nursing diagnoses that arise relate to patients who are going to undergo surgical procedures, namely anxiety, lack of knowledge, risk of infection and pain, so they need the right handlers. Nurses have the longest contact in handling patient problems and the role of nurses as nursing care providers, advocates, educators, coordinators, collaborators and consultants so that nurses in their efforts to heal patients become very important to adapt and resolve patient psychology (Saifuddin, 2002).
The results of this study are in line with research conducted by  with the title The effectiveness of providing nursing counseling to reduce the level of anxiety of major preoperative patients in the rose room of Kajen Hospital, Pekalongan Regency in 2018, based on the results of the study. Wilcoxon signed ranks test statistic p value of 0.001 <0.05, which means that there is a significant difference between pre and post .
The results of this study are in line with the research conducted by Utomo (2008) with the title of research on the effect of counseling on the anxiety level of Sectio Sesarea patients at RSU. PKU Muhammadiyah Delanggu Klaten, while the results of this study show that counseling has a very significant effect on the level of anxiety in patients before the operation of the cesarean section with the result p value = 0.006 <0.05 (Utomo, 2008).
The results of this study are in line with the research conducted by Sukariaji (2017) with the research title The Effect of Providing Health Education Using Spinal Anesthesia Booklet on Anxiety in Sectio Caesarea at RSUD Dr. Tjitrowardojo Purworejo with the following research results: t-test paired p value 0.000 <0.05 which means that there is a significant effect of providing health education using the spinal anesthesia booklet on anxiety in caecarea section patients at RSUD, Dr. Tjitrowardojo Purworejo (Sukariaji, 2017).

Analysis of the Relationship of Education to Patient Anxiety Levels
Based on the results of the study, it is known that of the 33 respondents studied, most of the respondents who were not anxious were 27 (81.8%) respondents. Of the 27 respondents, 26 (78.8%) rated education as good and 1 (3%) rated bad. Meanwhile, from 6 respondents who were anxious and rated good on education, 2 (6%) respondents and those who rated bad were 4 (12.2%) respondents. Based on the results of the calculation of the statistical test, the p-value is 0.002 <0.05, so it can be concluded that there is a relationship between education and anxiety levels in RSUD DR. R.M DjoelhamBinjai in 2020.
The results of this study are in line with research conducted by Kusumawardhani (2016) with the title of research The effect of preoperative education on anxiety levels in preoperative ORIF (open reduction internal fixation) patients at RSUPN Dr. Cipto Mangunkusumo Jakarta, the results of this study were obtained P -value = 0,000, it can be concluded that there is an effect of education on the level of anxiety in preoperative ORIF patients at RSUPN DR Cipto Mangunkusumo (Kusumawardhani, 2016).
The results of this study are in line with the research conducted by Warouw et al. (2018) with the title of the impact of education on anxiety in patients with preoperative cataracts at the Eye Hospital of North Sulawesi Province. the effect of education on patient anxiety in preparation for cataract surgery at the Eye Hospital of North Sulawesi Province (Warouw et al., 2018).

Multivariate
The results of the multivariate analysis of this study indicate that the Education Variable is the dominant dimension influencing the Anxiety Levels of Preoperative Patients at RSUD DR RM Djoelham Binjai City. Simultaneously, these variables are variables related to the level of anxiety and it can be seen that the logistic regression analysis produces 1 variable that is most related to the anxiety level of patients in RSUD DR. RM Djoelham Binjai in 2020 with p value <0.05, namely the Education variable with a significant 0.027 (p value <0.05), OR = 86.222 (95% CI = 1,681 -4422,217) meaning that the educational variable has a chance of 86 times The level of anxiety of patients at RSUD DR. R.M DjoelhamBinjai in 2020.

Conclusion
There is a significant relationship between the variables of providing information with preoperative patient anxiety at the Regional General Hospital DR.R.M Djoelham, Binjai City. There is a significant relationship between the consultation variable and the preoperative patient anxiety at the Regional General Hospital DR.R.M Djoelham, Binjai City. There is a significant relationship between the educational variables and the preoperative patient anxiety at the Regional General Hospital DR.R.M Djoelham, Binjai City. The relationship between pre-anesthesia variables and patient anxiety in this study is less significant, this happens because the anesthetist does not perform a pre-anesthetic visit. In this study, the educational variable is a variable that affects the anxiety of surgery patients at the Regional General Hospital DR.R.M Djoelham, Binjai City. Based on the results of the study, according to information from informants, the surgeon had applied the information before the operation was carried out. the process of providing information must always be given unless it is in an emergency, for example, the patient is no longer cooperative. Based on the results of the study, according to information from informants about counseling, counseling has been implemented by health staff and the result is that patients can understand and reduce patient anxiety. Based on the results of the study, according to information from educational informants to patients who will be undergoing surgery, the operation has been done from the start when the patient was recommended for surgery and has been shown to significantly reduce patient anxiety.