Educational Intervention on Self Efficacy among Postoperative Fracture: A Literature Review

DOI: http://doi.org.10.35654/ijnhs.v4i 2.442 Abstract. Fracture is a disruption of the normal discontinuity of bone and causes the surrounding tissue to be disrupted. Management of fractures is generally divided into recognition, reduction, retention, and rehabilitation. Exercises in the postoperative fracture patient rehabilitation program require patience and take a long time to achieve maximum cure. Nurses' therapeutic action in helping patients do rehabilitation exercises is by increasing the patient's self-efficacy to be independent in carrying out activities. Efforts to increase self-efficacy can be made through nursing interventions. This literature review aimed to explore the appropriate interventions on improving self-efficacy among postoperative fracture patients. Methods: This study was obtained from 4 databases, namely EBSCO, Key clinical, Willey, and Proquest, using inclusion and exclusion criteria. Results obtained. Decreased self-efficacy can occur in cases that require long action both for the healing process and chronic disease and when taking actions to maintain health, including post-surgery fractures. In conclusion, educational media will make it easier to provide interventions in increasing self-efficacy by paying attention to the factors that affect self-efficacy, namely master experience, vicarious experience, verbal persuasion, and emotional Arousal. The recommendation is that patients need support for adjusting the use of tools in providing education, providing logistics from samples in the application of education through technology media and to parents.


INTRODUCTION
Efforts to increase self-efficacy to motivate patients to rehabilitate through active ROM (range of motion) exercises can be made through nursing intervention. Increasing self-efficacy through nursing intervention provides education about the activities to be carried out, giving motivation that strengthens self-confidence in carrying out activities, providing examples of activities carried out, and using strategies in providing learning (8). The implementation of mobilization education has also been carried out preoperatively. It should have been carried out in the post-operation, but patients still do not do it. This is in line with Laderman researchers' research, which states that patients with acute and clavicle fractures have an excellent functional status when the following treatment and must also be accompanied by early mobilization during recovery (9).
From the explanation above, it can be seen that nurses need to think about various ways of providing appropriate nursing interventions so that patients can fully understand and participate in postoperative care by increasing self-efficacy.

OBJECTIVE
The study aimed to determine the effect of educational interventions as a nonpharmacological intervention to improve the self-efficacy in performing ROM exercises after the surgery process.

METHOD
A Literature review was applied in this study using PRISMA guidelines. The process of selecting the articles was shown in figure 1.1. Several studies were collected by authors using quantitative RCT methods to determine the best non-pharmacological interventions to overcome self-distrust in patients undergoing post-ORIF fracture measures.
The author collects articles related to research objectives through several stages of the search process using the keywords "Nursing education, Nursing intervention, Selfefficacy, and Low, low self-efficacy post-fracture." The database and search engine for English published articles consisted of database sources: EBSCO, Clinical Key, ProQuest, PubMed, and Willey, published in 2016-2021. This literature review results are described in a table about the results and their effectiveness in reducing self-efficacy.
From the literature search results through this database, 579 articles were identified. Then the screening process was carried out by eliminating the same articles, namely as many as 40 articles so that the remaining articles were 539 articles. The following procedure is to see the eligibility of the collected articles. The researcher only takes full-text articles and those that match the keywords. Articles that were excluded because they were not full text consisted of 174 abstracts and languages other than English, 174 articles that did not match the title. Self-efficacy should be the dependent variable, as many as 234 articles and articles with a sample of 123 pediatric patients... This literature review results are described in a table about the products and their effectiveness in increasing self-efficacy.

RESULTS
Based on the objectives to be achieved, the literature selection is carried out through PRISMA, described in Figure 1. All articles obtained are experimental designs that apply the nursing intervention to increase self-efficacy.
The literature results show four types of interventions used to improve selfefficacy, namely multifactorial, education, home care, health belief models. Most of the interventions use the education that has been modified or added to other interventions, where direct education is combined with indirect education. Educational media is generally divided into direct, face-to-face, or indirect education using the media(10)

Educational media face to face
Face-to-face educational media is education by presenting teachers and those receiving learning in a room. There will be meaningful and real interaction between the educator and the one receiving the instruction in face-to-face teaching. Face-to-face education has a psychological, emotional effect on absorbing education and finding solutions to problems in providing education.
Like the research conducted by Dautel et al., namely examining the influence of face-to-face educational intervention in transitional care after inpatient rehabilitation of physical activity and functional performance in Hip and Pelvic Fractures' cognitive impairment group. The technique of providing education was multifactorial. It was face-to-face counseling for a maximum of 60 minutes, followed by delivering training instructors consisting of 2 modules, namely module 1, training based on physiotherapists and sports scientists who are experienced in elderly rehabilitation. Meanwhile, module 2 is counseling. And exercises performed by nurses, social workers, and gerontologists (11). This study was also conducted by Hang et al., where this study aimed to look at direct face-to-face educational intervention to increase the self-efficacy of elderly patients who experienced total HIP replacement surgery. The nursing intervention uses the Empowerment education program by providing counseling support to improve selfconfidence in self-care, provide advice on problem-solving skills, and make decisions to do exercises. There are three essential programs: observation, 20 minutes of physical activity, and patients' responses to total HIP replacement surgery. In the conditions before and two days after the HIP replacement surgery, patients are given the education to increase cell efficacy in making decisions to do exercises and then given physical exercise education that the patient will do for 20 minutes per day. At the 2nd, 6th and 10th weeks, researchers will see the education response that has been given by looking at daily exercise activities, pain, and wound situations through the diary that has been delivered (12).
Research with face-to-face education is also in line with Cal et al. intervention with attention to the Health Belief Model in providing education when making home visits. The research objectives will be explained on the first visit, followed by conducting initial tests and giving health education guidelines. There is material on the importance of arm exercises. These exercises are done every day, recording every day and measuring the carried out arms every week. The second visit was carried out after three months, and the third visit after six months of the first visit. According to the first visit to a cancer patient, activities were carried out to measure the arms and nursing interventions according to the first visit to a cancer patient (13).
Research by providing face-to-face education by paying attention to sources that can increase mothers' cell-efficacy during breastfeeding was also carried out by researchers Piro et al. Researchers collected mothers who had low self-efficacy during breastfeeding. The intervention is given education using existing materials by developing educational programs through literature reviews based on motivating patients for two weeks (14).

Indirect educational media
Indirect education is independent learning from online documents, online exercises, online assignments, online knowledge sharing via electronic media. Research that used education indirectly in increasing self-efficacy was carried out by Wang et al., where they conducted educational interventions utilizing the telephone to improve self-efficacy in patients with a stoma. The intervention group's invention using the phone contained the application with modules: appointment, diagnosis via photos, and consultation by the telephone. Researchers will teach patients and families how to use this application before returning home, making it easier for patients and families to receive this education. Furthermore, after the first month, the third and the six nurses will evaluate the patient by telephone based on the patient's photos. The patient will receive education to solve the problem according to the nurse's direction from the telephone direction; patients no longer need to go to the polyclinic (15).
This study is in line with the research conducted by Paragas et al., which aims to determine the effect of positive and negative message framed information videos on knowledge of diabetes management and self-efficacy in patients with type 2 diabetes. The video's intervention was accompanied by giving examples of patients who violated and did not violate the rules established in maintaining health. Using animation, positive examples were given to the intervention group, and negative examples were given to the control group. This intervention was designed and validated by an endocrinologist, diabetes nurse educator (16).

Combining face-to-face education with indirect education
Education combines direct and indirect education, namely by combining the educational media with the provision of intervention in one case. Research by combining direct and indirect education as in the study conducted by Turan et al. The intervention was carried out by providing face-to-face education and continued telephone following up on the patient's condition. Patients are given educational interventions accompanied by booklets while in the inpatient room. Instruction is provided for 30-45 minutes. During this session, the patient is invited to ask questions and is supported by answers that help identify critical points. This research was conducted by a research and assistant who was already proficient in conducting interviews. After that, a discussion session by telephone was held in the first, third, and eighth weeks. In this telephone discussion, what language constitutes an obstacle and contributes to disease, and the researcher directs actions that can be taken to improve the patient's healing process (17).
The previous study examines the effect of education through the use of the telephone on increased self-efficacy in patients with rheumatoid arthritis. At the start of the study, the researchers provided face-to-face education about medication diet and exercise skills, which lasted for about 20-40 minutes. Furthermore, planned educational interventions will be given by telephone four times for 12 weeks. Specialist rheumatology nurses carried out this telephone educational intervention at weeks 2, 4, 8, and 12 weeks after the patient was discharged from the hospital(18).

DISCUSSION
Self-efficacy is the confidence that a person has when experiencing a problem or deciding to do something long. From the above cases, chronic cases and the process of healing too long lead to less self-efficacy, namely in cases of post-fracture HIP and pelvic, lymphedema cancer, myocardial infarction, diabetes mellitus, stoma, rheumatoid arthritis, post replacement HIP fracture surgery, as well as mothers during breastfeeding. This is following the sources that cause self-efficacy to be formed. Interaction with the family environment, such as parents, siblings, peers, and other adults, will include a person's self-efficacy. The formation of self-efficacy depends on adjusting oneself to the problem.
Nursing interventions can be carried out from both the main and supporting interventions to increase self-confidence or self-efficacy. From the literature obtained above, education combined with media users can increase patient self-efficacy from hospitalization to home. The interventions used are multifactorial media, animated videos, a health belief model approach, and standard education using the latest literature. The interventions used are adjusted to the sources that influence self-efficacy, namely mastery experience, vicarious experience, verbal and psychological persuasion.
Master experience is a self-efficacy from one's daily experience, where the more experienced a person will have a high self-efficacy. Research conducted by other researchers states that multifactorial education has a beneficial impact on increasing self-efficacy related to activities, quality of life, and daily life activities. This education provides counseling to see and explore experiences that patients have in dealing with current situations. It is followed by providing training modules for HIP and pelvic fracture patients (11).
Vicarious experience is self-efficacy that will grow from observing other people without having to wait for the impact first. By following the impact that other people have, the patient will always try to achieve his beliefs. This is in line with the research conducted using animated video interventions, which showed pictures that positively impacted the intervention group in diabetes patients in maintaining the health of their feet (16).
Verbal persuasion is a self-efficacy that can be achieved by social persuasion. Giving good suggestions can increase a person's self-efficacy. The education provided by adding to the latest literature will convince patients to improve their self-efficacy in breastfeeding mothers. (14) Emotional Arousal is a self-efficacy formed because of the patient's emotions so that the patient's self-efficacy decreases because turbulent emotional situations can bring down the patient. During the healing process, the patient's feelings are monitored through distance education using the telephone three times in patients with myocardial infarction. (17). The same study was conducted on patients with Rheumatoid Arthritis by monitoring their emotions four times (18).
Providing education by combining self-efficacy sources can also be done in increasing self-efficacy. Other researchers have done this, such as examining the selfefficacy of HIP and Pelvic fractures patients using multifactorial education. (11). The use of education with the Health Belief Model approach in patients with cancer (13). In stoma patients, after being discharged from the hospital, educational interventions will be given through a mobile application, where there are learning modules according to self = efficacy sources. (15).

CONCLUSION
Based on the discussion results, it is explained that a decrease in self-efficacy can occur in cases that require long action both for the healing process and for chronic diseases and when taking steps to maintain health. Patients who experience postoperative fractures take a long time in the healing process to cause a decrease in self-efficacy. Nursing intervention towards self-efficacy is in education by paying attention to the factors that influence self-efficacy, namely master's experience, vicar experience, verbal persuasion, and emotional Arousal. The use of educational media will make it easier to intervene, but there are weaknesses in intervening. The strengths effectively guide care shifting from inpatient to home, easy access, and cheaper rehabilitation process costs. Parents.