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Medical Journal of Indonesia

Volume 18
Number 1
Jan - Mar 2009
pp 1 - 75
Medical Journal of Indonesia

Editorial note

Effect of NAC to parasitemia and plasma IL-12 level

Temu kunci tuber essential oil

Optimal water intake for the elderly

Phaseolus vulgaris and acarbose on glucose level

Abilities to control violence behaviour of schizophrenics

Testosterone level and cognitive function

Antropometric measurements and health risks

Basic principles of bioethics's teaching methods

Learning skills to increase clinical reasoning

Lung metastases of ameloblastic carcinoma

Conservative management of cornual ectopic pregnancy

Cytogenetics in oncology

Published by the Faculty of Medicine, University of Indonesia, Jakarta, Indonesia

Vol.18, No, I, January - March 2009 Abilities to control violence behaviour of schizophrenics 31

Influence of the abilities in controlling violence behavior to the length of stay of schizophrenic clients in Bogor mental hospital, Indonesia

Budi Anna Keliat1, Azrul Azwar2, Adang Bachtiar3, Achir Yani S. Hamid4

' Faculty of Nursing University of Indonesia, Jakarta

! Head of Health Science Institute Binawan, Formal Director General of Community Health in Ministry of Health Republic of Indonesia, Jakarta

3 Head oj Department of Administration and Policies in Faculty of Public Health, University of Indonesia; Lecture in Faculty of Public Health University of Indonesia, Jakarta

4 Head of Department of Mental Health Nursing in Faculty of Nursing, The president of nurses association Indonesia,


Tujuan Klien yang dirawat di rumah sakit jiwa di Indonesia mempunyai rerata lama hari rawat yang tinggi yatu 54 hari, dan yang paling lama dirawat adalah klien dengan diagnosa skizofrenia. Data rumah sakit jiwa pusal Bogor 2001, menunjukkan rerata lama hari rawat adalah US hari dan untuk klien perilaku kekerasan 42 hari. Penelitian ini bertujuan mengurangi lama hari rawat klien skizofrenia dengan perilaku kekerasan dengan meningkaikan kemampuan klien mencegah perilaku kekerasan.

Metoda Metuda penelitian yang digunakan adalah kuasi eksperimen dengan disain multipel seri ganda. Penelitian ditakukan di RSJP Bogor, dengan 152 responden (75 orang kelompok intervensi dan 77 orang kelompok non intervensi). Pendidikan diberikan kepada kelompok intervensi lentang cara mencegah perilaku kekerasan.

Hasil Dart hasil penelitian ditemukan bahwa rerata lama hari rawat klien kelompok intervensi adalah 23 hari dan kelompok non intervenxi 40 hari. Klien kelompok intervensi yang mempunyai kemampuan mandiri 86,6% dan kemampuan dengan bantuan 13,4% da/am mencegah perilaku kekerasan. Klien kelompak non intervensi semuanya tidak mempunyai kemampuan mengendalikan perilaku kekerasan. Klien dengan kemampuan mandiri dalam mencegah perilaku kekerasan mempunyai lama hari rawat yang lebihpendek aecara bermakna dibandingkan dengan klien yang tidak mempunyai kemampuan (p-value (1.025).

Kesimpulan Disimpulkan, pendidikan kesehatan tentang cara mencegah perilaku kekerasan dapat meningkatkan kemampuan klien dan selanjutnya memperpendek lama hari rawat seeara bermakna. (MedJ ladoncs 2009; 18: 31-5)


Aim In average, the length of hospital stay in mental hospitals in Indonesia is 54 days, the longest of which occur on schizophrenic clients. In Bogor Mental Hospital, the average length of stay is 115 days. Those with schizophrenic and violence behavior have 42 days length of slay. The purpose ofthis study was to reduce length of stay for schizophrenic clients by enhancing their abilities to control violence behavior.

Methods This is a quasi experimental study with multiple scries design. Study was conducted in Bogor Mental Hospital with 152 respondents (75 intervention and 77 non intervention). Training was given to the intervention group about the ways how to control violence behavior.

Results The results ofthis study showed thai the average length of stay in the hospital for the clients in intervention group was 23 days and non intervention group was 40 days. There were 86.6% of clients in intervention group that independently (without assistance) could control their behavior, whereas 13.4 % still need assistanl. All clients in non intervention group had no abililies to control their violence behavior. Clients who were independent in controlling violence behavior had significantly shorter length of stay compared to non independent clients (p <>

Conclusion Hence, the training control violence behavior can increase the abilities of the clients in controlling their violence behavior and resulting in shorter length of stay in hospital. (Med J Indones 2009; 18: 31-5)

Keywords: violence behavior, schizophrenia, training, length of stay.

Schizophrenia represents most common mental health are the illness itself and stigma of schizophrenia.'

problems and until recently remain unsolved in the Schizophrenia is a combination of positive symptoms

world. The client and iamilv have double burden which such as delusion, hallucination, disorjiani/c speech.

Keliat et al

disorganize behaviors (violence behavior), catatonic, and negative symptoms such as lack of functions, flat/ dull affect, withdrawal, and no initiative.1'2'3-4 Research related to violence behavior found that medical diagnosis of clients with violence behavior consist of: 49 % substance abuser, 45 % schizophrenia, and 34 % severe depression.5

Clients with mental disorders are often excommunicated and restricted because the society assumes that they are dangerous. Study conducted by The Canadian Mental Health Association3 found that 88 % respondents told that the clients were dangerous, 40% said they were retarded and 32 % told they could not functioning However, 20-30 % of the clients could earn normal live, 20-30 % showed symptoms and 40-60 % showed bad condition. Curing the clients with schizophrenia is possible, and maximal effort is needed.

Violence behavior consisted of violence to others, at self, to the environment, and verbally." Stuart and Laraia16 elaborated three strategies of nursing interventions for the clients with violence behaviors; which consist of: controlling, anticipation, and restraint. Strategy that was tested in this study was controlling strategy by providing training to the clients about how to control violence behavior. Four ways of controlling were taught, consisting of physical, verbal, spiritual and medication obedience.

Angry feeling can be sublimated through constructive physical activities by using power and energy. 13'I4'IN A physical relaxation activity such as deep breathing training is an alternative choice.4 In this study two physical ways was selected that more possible to be conducted; consisting of deep breath training, and beating pillow or mattress.

The most successful method in controlling violence behavior is by training how to speak assertively.16'" Emotion atmosphere such as dislike, sulky, and anger are the conditions which can result in violence behavior." Expressing the feeling verbally and willing confidentially without threaten represent assertive ways."1'" Direct communication training to others about deduction illogical request, telling complaints to others' attitudes, and giving praise to others can also control violence behavior.16 In this study we selected three ways to control violence behavior by verbal way, those were request assertively, refuse assertively, and express feeling assertively.

Clients desire to dominate and force others are considered as an immoral behaviors.14 For this case,

clients was assisted to respect their spiritual values and beliefs concerning anger behaviour. Clients were helped to transform their willing to dominate others trough religious activities and invoking to control others and themselves. This maneuver was aimed to help the clients to do two religious activities that formerly conducted.

Antipsychotic medications given to the schizophrenia clients with violence behavior are effective to reduce violence behavior that is a positive symptom of schizophrenia.16 Combination of antipsychotic therapy and self-management are the nursing interventions for the clients and their families.1''* In this research, clients were taught about medication management namely five right ways of taking medication: right name, right medicines, right doses, right frequency, and right routes. It was also explained the benefits of medication and effects of withdrawing from taking medication.

The main aim of this study was to know the relationship between client's abilities in controlling violence behavior and the length of slay in Bogor mental hospital.


This study is a quasi experimental research with multiple series design, conducted in Bogor mental hospital, Indonesia.

Respondents were the clients with violence behavior who were diagnosed as schizophrenia, and hospitalized in Bogor Mental Hospital. Respondents were randomly grouped into intervention and non intervention. Total respondents were 152 clients consisted of 75 patients in intervention group and 77 in non intervention group.

Clients in intervention group were trained in four ways to control violence behavior.

After training, the daily activities were scheduled and practiced continuously until they were considered independent. The ability was measured daily and classified into three categories: "independent" if the clients are able to control violence behavior without reminding and help by others; "assistance" if clients are able to control violence behavior according to the schedule but need to be reminded; "dependent or unable11 if clients could not control their violence behavior. The length of stay in the hospital was measured from admission day until they are discharged from the hospital.

Vol. 18, No. 1, January - March 2009

Abilities to control violence behaviour of schizophrenics 35

The average length of hospital stay in clients receiving

training to control violence behavior was 23 days and who were not trained was 40 days. This result gives an advantage for clients and their families because the expense of hospital ization can decrease by 17 days and the quality of life become better due to increase in residing at home compared to staying in the hospital. Length of stay was shorter than the average length of stay clients at mental hospitals in Indonesia, i.e 54 days'. In Bogor Mental Hospital as a whole the average length of stay is 115 days and specific for clients with violence behavior, it is 42 days.2 The decreased length of hospital stay and the improved psychosocial functioning in client resulted in a marked overall cost saving.19

Although have been better than the length of hospitalization in Indonesia, it is not yet equal to that in other countries as reported by Morrison,3 where the length of stay in the hospital of the client with violence behavior was only 14 days. The latest study by Boyd and Nikarts, Boyd*, found that the length of stay in the hospital varied from less than 7 days (brief short term), 7-14 days (very short term), 15-21 days (traditional short term), and > 21-120 days (long term care). Trained clients who were independent in controlling violence behavior were 86.6%. This proves that clients with mental disorders still have self-care abilities, and (here is still hope to improve their function. This finding could change public opinion that schizophrenic clients cannot function anymore.

The clients who were hospitalized for seven weeks or longer were 49 per cent less likely to be readmitted within a month compared to those who stayed only a week.2" Control and intervention group had length of hospital stays between 23 days - 40 days (3 weeks to 5.5 weeks), those had possibility for readmission within 30 days. There were many way to manage schizophrenia with violence, which could reduce more the length of hospital stays.1"

It is concluded that clients who were independent in controlling violence behavior had a significant shorter length of hospitalization than clients who were dependent in controlling violence behavior. Males had shorter length of hospital slay significantly than females. Moreover, in the frequency of admission, the clients who were hospitalized once or twice have significantly shorter length of hospital stay than the clients who were hospitalized in third times or more.


1. Johnson BS. Psychiatric-mental heallh nursing: adaptation and growth, (^ed). Philadelphia: JB Lippincott Company, 1997.p. 764-91.

2. Boyd MA, Nikart MA. Psychiatric nursing contemporary practice. Philadelphia: Lippincott, 1998.p.360-402,

3. Boyd MA. Psychiatric nursing: contemporary practice. Philadelphia, Lippincott & Wilkins, 2005.p.230-62.

4. Kaplan HI, Sadock BJ, Grebb J. A. Synopsis of psychiatry: behavioral sciences clinical psychiatry. (10th ed.). Baltimore: Williams & Wilkins, 2007.p.l329-55K.

5. Morison EF. The evolution of a concet: aggression and violence in psychiatric settings. Archieves of Psychiatric Nursing, Vol. Ill, No. 4 (August): p.245-53.

6. Stuart GW, Laraia MT. Principles practice psychiatric nursing (7*ed). Sl.Louis: Mosby, 2005.p.639-52.

7. Puckett A. Community mental health. Sydney: WB Saunders, 1993.p.223-50.

8. Rawlins RP, Williams SR, Beck CK. Mental health-psychiatric nursing: a holistic life-cycle approach. St. Louis: Mosby Year Book, 1993.p.207-23.

9. Videbeck SL. Psychiatric mental health nursing. Philadelphia: Lippincott, 200l.p.214-27.

10. Davis M, Eshelman ER, Me. Kay M. Panduan relaksasi & reduksi stress. Alih bahasa; Hamid AYS. and Keliat BA. Jakarta: ECO, 1995,

11. Townsend MC. Essentials of psychiatric mental heallh nursing (3'" ed). Philadelphia: FA Davis Company, 2005.

12. Drake RE, Mueser KT, Torrey WC, Miller AL, Lehman AF, Bond GR, Goldman HI I, LetTHS. Evidence-based treatment of skizophrenia. Curr Psychiatry Rep. 2000; 2(5):393-7.

13. Gibson DM. Reduced rehospitalizations and reintegration of persons with mental illness into community living: a holistic approach. Journal Psychosocial Nursing Mental Heallh Service, 1999; 37(11): 20-5.

14. Duxbury J. An evaluation of staff and palicni views of and siralegies employed to manage inpatient aggression and violence on one mental health unit: a pluralistic design. Journal of Psychiatric and Mental Health Nursing. 2002;9:325-37.

15. Toshiba M. Nursing care of schizophrenic patienl who impulsively repeals violence: (he case in which violence decreased by verbalizing feelings. Nippon Seijinkai Suda Hospital. 2005; 48(l):194-5.

16. Understanding mental illness and violence. Available at: WA' Accessed August 19* 2008.

17. Depkes Rl, Dirjen Yanmed. Informasi rumah sakit, Jakarta: Depkes Rl. 2000.

18. 'Rumah Sakit Jiwa Pusat Bogor. Laporan akuntabilitas kinerja RSJP Bogor years Anggaran 2001. Bogor- Nol publish, 200!.

19. llirayasu Y, Koni ML. Management of patient with acute psychosis. CME. Available at: viewarticle/420241. Accessed December 4"12008.

20. Hospital length of stay and readmission for individuals diagnosed wilh schizophrenia: Are Ihey related. Available al: Accessed January 8'h, 2009

21. Thomson LDG, Management of schizophrenia in condition of high security. Advanced in Psychiatric Treatment. 2000; 6: 252-60.

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