Relationship of Nurses’ Workload with Islamic Spiritual Nursing Care Competence in Hemodialysis Unit

Nurses as care providers are obliged to meet the needs of patients in a bio psychosocial and spiritual way. The high activity of nurses in serving patients affects their work results, so it is important to pay attention on the workload of nurses in providing nursing services and the competence of Islamic spiritual nursing care. The purpose of this study was to determine the relationship between the workload of nurses and the competence of Islamic spiritual nursing care in hemodialysis unit. This research was a correlational quantitative research by using a cross-sectional research design. The respondents were 24 hemodialysis nurses who were selected by using total sampling technique. The data was collected by online questionnaire. The data analysis used a non-parametric Spearman rank test. This study obtained p-value 0.001 and correlation coefficient 0.628 which indicated a significant relationship between the workload of nurses and the competence of Islamic spiritual nursing care in hemodialysis unit. The researchers recommended that nurses can provide a particular Islamic spiritual nursing care in hemodialysis units since spirituality is highly important for patients with chronic diseases and nurses as care providers are obliged to meet patient needs both psychosocially and spiritually.


Introduction
Nurses as care providers are obliged to meet the needs of patients in a biopsychosocial and spiritual way. Nurses play a role in fulfilling basic human needs including oxygen, nutrition, fluids and electrolytes, elimination, safety, cleanliness and physical comfort, rest and sleep, physical, spiritual, emotional activities, communication, as well as preventing and overcoming physiological reactions (Kurniati & Abidin, 2018). The high activity of nurses in serving patients will affect their work results, so it is very important to pay attention to the workload of nurses in providing health services (Nurjanah et al., 2017). The workload is a task given to the workforce or employees to be completed within a certain time by using the skills and potential possessed by the workforce (Aprilia, 2017). Workload analysis can be seen from the aspect of tasks performed based on the main functions and additional functions, the number of patients who must be treated, work capacity under the education obtained, working time, and the completeness of the facilities obtained to complete the job properly (Nurjanah et al., 2017).
The workload in the hemodialysis room is determined based on the level of dependence and risk. Dependence indicates the degree of dysfunction or disability of the patient to perform self-care activities, and the risk of the patient experiencing adverse events or complications (Barrios et al., 2017). Nurses who have a workload that is too heavy will cause physical or mental fatigue and other emotional reactions that affect the patient's spiritual fulfillment. Based on research Barahama et al., (2019) of 58 respondents who work in the hemodialysis room, 39 respondents (67.2%) have a heavy workload and 19 respondents (32.8%) have a light workload. This is in line with research Barrios et al., (2017) The workload of nurses in the hemodialysis room is 60% direct care and 40% indirect care.
The fulfillment of spiritual needs is very necessary for patients who experience chronic and terminal illnesses, such as hemodialysis patients, which is a terminal disease. Fulfillment of spiritual needs maintained by nurses can relieve suffering and help the process of physical and mental healing, especially the process of adapting to the illness they are experiencing and preparing for a quiet and peaceful death (Ronaldson et al., 2017).
Based on the experience of researchers while practicing at Rumkit Dustira that CKD patients undergoing hemodialysis feel sad and afraid, experience nausea after hemodialysis, unstable blood pressure, shortness of breath, leg cramps, and difficulty sleeping. Spiritual changes include losing hope in life, feeling useless, feeling anxious, depressed, and distant from God.
Nurses need to pay attention to the spiritual needs of patients, this is very important because it can be used as a method of coping and strength to help patients find meaning in life and reduce difficulties. However, in practice in clinical settings, the fulfillment of the spiritual needs of patients is still not optimal and is not the focus of attention of health workers. Several studies have shown that nurses are not optimal in providing fulfillment of the spiritual needs of patients. Saharudin et al., (2018) reported that many nurses claimed not to have a clear understanding of the implementation of spiritual concepts in nursing, were incompetent in providing care because they were not given guidance on spiritual nursing care during their education, and experienced confusion.
Nurses who view humans holistically, need to pay attention to the spiritual needs of their patients. The role of the nurse must of course be under the authority and competence that must be possessed. Competence is the ability to do work based on skills and knowledge and is supported by work attitudes that are determined by the job (Halawa et al., 2020).
Competencies that must be possessed by nurses in holistic nursing include their knowledge, skills, attitudes, beliefs, experiences, roles, and professional responsibilities as nurses, as well as human relationships that form the basis for nurses in carrying out nursing care (Aydin & Hicdurmaz, 2019). Study Hajbaghery et al., (2017) show that from 250 nurses, the average competence of nurses in spiritual care is 57 nurses (23%) have poor competence, 128 nurses (51%) have moderate competence, and 65 nurses (26%) have good competence. This illustrates that the spiritual care competence of nurses has a competence score that is more than adequate.
Nurses have an important role in the competence of Islamic spiritual nursing care in hospitals, but in practice meetings, the spiritual needs of patients are still not optimal and are not the focus of nurses' attention. Nurses are only oriented to the routine of daily tasks, this spiritual aspect seems to be neglected so that this condition is contrary to the nursing paradigm which is based on holistic care. This is because the spiritual dimension does not seem to be an important thing for an individual and has no effect on his health, this is evidenced by the high workload of nurses, the absence of data on spiritual documentation of patients treated at the hospital, nurses ignorance of competence. spiritual upbringing.

Research Design
This study used a correlational quantitative design with a cross-sectional approach.

Population and Sample
The population in this study were nurses who worked in the unit hemodialysis RSUD Al Ihsan Provinsi Jawa Barat with as many as 24 nurses. The sampling technique in this research is total sampling. The reason for taking total sampling is because according to Sugiyono (2017) the total population is less than 100, the entire population is used as a research sample. So as many as 24 nurses are willing to be respondents. Samples taken from this study were 24 people.

Instrument
The data collection technique was carried out using a questionnaire instrument. The first questionnaire consisted of a demographic data questionnaire that included gender, age, education, and length of work while in the hemodialysis room. The questionnaire assessing the workload of nurses and islamic spiritual nursing care competence uses a Likert scale with 5 alternative answers, namely strongly agree (SS), agree (S), uncertain (R), disagree (TS), strongly disagree (STS). consists of 65 questions. A questionnaire to assess the workload of nurses using a questionnaire from Prihandhani & Gandari (2019) and islamic spiritual nursing care competence questionnaire taken from the journal (Azarsa et al., 2015).
The instrument charging time takes 10-15 minutes. Interpretation of nurse workload category score X>165 indicates heavy workload; 105≤ X < 165 indicates a moderate workload, and a score of X < 105 indicates a light workload. Interpretation of the islamic spiritual nursing care competence category with a score of X> 73.3 indicating severe competence; 46.7 X < 73.3 indicates moderate competence, and score X < 46.7 indicates high competence.
To ensure the authenticity of the instrument, the researcher has tested the validity and reliability of the instrument on the hemodialysis unit Rumah Sakit Muhammadiyah Bandung by taking 13 nurses. The results of the validity test of the nurse's workload questionnaire were 0.921while the spiritual care competence questionnaire, the value of content validity through Cronbach's alpha is 0.92, and reliability value from the nurse's workload questionnaire was 0.937 while the Islamic spiritual competence questionnaire was 0.924.

Research Procedure
Data collection was carried out in the hemodialysis unit RSUD Al Ihsan Provinsi Jawa Barat in July 2021. Data collection was carried out by filling out the link to the nurse's workload questionnaire and the competence of Islamic spiritual nursing care.

Data Analysis
Data analysis used a computer program through univariate and bivariate tests. The univariate test is used to describe the characteristics of respondents such as gender, age, education, length of work, workload, and competence. The normality test of nurses' workload data with Islamic spiritual nursing care competence using the Shapiro Wilk test showed that the data were normally distributed with a significance value of 0.155 for nurses' workload and 0.178 for islamic spiritual nursing care competence (p value> 0.05). The bivariate test was used to determine the relationship between the nurse's workload variable and the Islamic spiritual nursing competence variable. Bivariate analysis using Spearman rank test because it uses ordinal categorical data scale.

Ethical Approval
This research has been approved by the Health Research Ethics Committee of Universitas 'Aisyiyah Bandung with Number 22 / KEP.01 / UNISABANDUNG / VI / 2021.

Characteristics of Respondents
The Characteristics of respondents who participated in the study are described in Table 1.  Table 1 shows that the sex of most hemodialysis nurses is female (62.5%), the most age is in the range of 31-40 years as many as 16 people (66.7%), the most hemodialysis nurse education is diploma Nursing education as many as 20 people (83,3%), the most length of work in the hemodialysis room is in the range of 6-10 years as many as 12 people (50%), the workload of nurses mostly has a heavy workload of 13 people (54.2%) and a moderate workload as many as 11 people (45.8%), and the competence of Islamic spiritual nursing care nurses have high competence as many as 19 people (79.2%) and moderate competence as many as 5 people (20.8%). Table 2 shows that the non-parametric spearman rank test obtained a p-value of 0.001 and a correlation coefficient value of 0.628. The decision to test the hypothesis is that if the p-value < 0.05 then H0 is rejected, while if the p-value is > 0.05 then H0 is accepted. The results of this study indicate that p-value 0.001 < 0.005, it can be concluded that H0 is rejected, which means that there is a relationship between the workload of nurses and the competence of Islamic spiritual nursing care in the hemodialysis unit.

Discussion
Characteristics of respondents based on gender found that the majority of respondents were female as many as 15 people (62.5%) this shows that it is very clear that women dominate in this study. This is because the interest of men to become a nurse is still less than that of women. Gender is a biological categorization that can be identified from self-identity.
Characteristics of respondents based on age found that the majority of respondents were more than 30 years old and less than 40 years old as many as 16 people (66.7%). The results of this study indicate that the majority of respondents are of productive age. Humans who are in a productive period will be able to optimize their ability to produce a result from what they do (Etlidawati & Arini, 2020). At the productive age, humans still have high enthusiasm to do the work they face. The older a person is, the level of ability and strength of a person will be more mature in thinking and working, someone who is more mature tends to be more trusted.
Characteristics of respondents based on education found that the majority of respondents had a diploma nursing education as many as 20 people (83.3 %), while nursing undergraduate education was 1 person (4.2 %), and nursing professional education was 3 people (12.5% %). In this study, the majority of nurses had diploma Nursing education. High education from a nurse will provide optimal service.
Characteristics of respondents based on length of service, it was found that most respondents worked more than 5 years and less than 10 years as many as 12 people (50%). The results of this study indicate that the length of work of respondents is between less than 10 years. It is clear that the respondents already have sufficient flight hours in providing nursing care. .001 . N 24 24 **. Correlation is significant at the 0.01 level (2-tailed).
Characteristics of respondents based on workload found that the majority of respondents had a heavy workload of 13 people (54.2%) and as many as 11 people (45.8%) had a moderate workload. This happens because the workload he faces is too much so he is unable to overcome every obstacle in carrying out nursing care. These working conditions require employees to give their work, but all of this depends on each individual, meaning that these tasks will be completed properly or not depending on how someone lives the workload he feels.
Characteristics of respondents based on the competence of Islamic spiritual nursing care, it was found that the majority of respondents had high competence as many as 19 people (79.2%) and had moderate competence as many as 5 people (20.8%). The competence of nurses in performing Islamic spiritual nursing is seen as a benchmark criterion in assessing the performance of the health care system and as a nurse's professional responsibility in meeting the spiritual needs of patients.
The results showed that the workload of nurses in the hemodialysis unit had a heavy workload and the competence of Islamic spiritual nursing care was in the high category. Based on the results of interviews with nurses in the hemodialysis during the pandemic some nurses were infected with COVID-19, requiring nurses to self-isolate at home. This causes the workload of nurses increase.
Nurses are the health workers who deal directly with clients both healthy and sick. Nurses are obliged to meet the needs of patients biopsychosocial and spiritual. The results of this study are supported by research conducted by Kurniati & Abidin, (2018) that patients as recipients of biopsychosocial and spiritual health services make nurses as care providers, where nurses must meet the needs of their patients including oxygen, nutrition, fluids, and electrolytes, elimination, safety, physical cleanliness and comfort, rest and sleep, physical, spiritual, emotional activities, communication, and preventing and overcoming physiological reactions.
Quality nursing services can be fulfilled if there is a balance between the number of staff and the workload of nurses in a hospital (Pusat Data Dan Informasi, 2017). The high activity of nurses in serving patients will affect their work results, so it is very important to pay attention to the workload of nurses in providing health services (Nurjanah et al., 2017). Mundakir et al., (2017) said in their research that a high increase in workload will affect the productivity of nurses and nurses' moods may not be in line with patient expectations. If the workload is reduced, the service will be better and the spiritual needs of the patient will be well met. But research Mundakir et al., (2017) are contradictory with this study because most of the nurses in hemodialysis unit RSUD Al Ihsan Provinsi Jawa Barat have a heavy workload but in Islamic spiritual nursing care competence has a high category.
Factors that influence the heavy workload of nurses and the high competence of Islamic spiritual nursing care according to Astuti & Lesmana (2018) in his research shows that a high workload will not burden nurses, but can improve performance because the ability of nurses has reached work standards. Furthermore, high work motivation, where motivation is an influential condition for generating, directing, and maintaining behavior related to the work environment (Purwaningsih et al., 2017).
Motivation is the driving force that contributes as much as possible to the success of the organization in achieving its goals. The organization will succeed in achieving its goals and objectives if all components of the organization seek to display optimal performance. In line with research Tricahyono (2015) states that the higher the motivation of nurses, the higher the persistence of nurses in providing spiritual nursing care to patients.
The results of this study are also under the research of Naibaho et al., (2015) which explains that intrinsic motivation is an individual's driving factor for achievement that comes from within the individual including achievement, recognition, responsibility, opportunities for advancement, and job satisfaction. Extrinsic motivation is an individual driving factor that comes from outside the individual which includes compensation, work security and safety, working conditions, policies, status, and interpersonal relationships. Nurses will have a good performance in providing spiritual nursing care if there are incentives and rewards from the hospital in carrying out their professional duties and responsibilities. Arini et al., (2015) state that someone who has high spirituality will have a tendency not to hurt others, care for their environment with love, help someone to determine steps well, will be more meaningful in life, can take lessons from life experiences, and always introspect. Nurses' spirituality can also develop with support from the workplace. This means that nurses are not only free to develop their spirituality but are also facilitated by the work environment and encouraged by the leader of their work units.
The role of nurses must of course be under the authority and competence they have. Special competencies that must be possessed by Islamic nurses in fulfilling spiritual nursing care for Muslim patients are: creating an environment that meets the requirements for carrying out worship practices, helping patients with taharah, helping patients pray, guiding prayers, being able to read and write the Koran, memorize prayers for the sick, creating an environment that protects the patient's genitals, facilitating patients for additional worship such as providing the Koran, prayer tools, Islamic readings, and Islamic music and mentalkin patients during the time of death (Dewi & Anugerah, 2019).
The competence of nurses in performing Islamic spiritual nursing care is seen as a benchmark for assessing the performance of the health care system. However, in practice, only some nurses provide spiritual care and due to various reasons such as role ambiguity, lack of adequate knowledge and skills about spiritual care, and the provision of spiritual care, nurses are often neglected.
Univeristas 'Aisyiyah Bandung has collaborated with various hospitals in West Java, one of which is RSUD Al Ihsan Provinsi Jawa Barat, which has excellent programs in the field of education in the development of Islamic spiritualbased complementary nursing and Islamic spiritual nursing care (AKSI). Universitas 'Aisyiyah Bandung and RSUD Al Ihsan Provinsi Jawa Barat as providers of nursing services based on Al Islam and Kemuhammadiyahan attach great importance to spiritual care not only during illness but also throughout life. In Islam, spirituality cannot be separated from the spiritual aspects of life. Some religious activities must be carried out in daily life, all of which aim to get the pleasure of Allah SWT.
Work has become a necessity for every Muslim who has family members. Work is not only to make ends meet but also a means to create and maintain honor. Islam will certainly reward those who work well. Even work can be a field of reward if it is intended to worship God. As Allah says in the Qur'an Surah Al-Insyiqaq verse 6: Meaning: "Hi mankind, indeed you have worked earnestly towards your Lord, then surely you will meet Him". The content in this verse, Allah reveals that humans in their lifetime work earnestly to achieve their goals. Every human step leads to the end of his life, namely death. This means returning to Allah. Therefore, people will know about the good and bad of the work they have done (Tafsir Ibn Kathir).

Conclusion
Based on the results of the study, there was a relationship between the workload of nurses and the competence of Islamic spiritual nursing care in the hemodialysis unit. The workload of nurses has a heavy workload (54.2 %). The competence of Islamic spiritual nursing care is in the high competence (79.2%). Some factors affect the workload of nurses in the heavy category and high competence of Islamic spiritual nursing care, including the ability of nurses who have achieved