The Effect of Nursing Intervention-based Levine Conceptual Model Program on

Rehabilitation Process among Fractur Patients

in H. Adam Malik Hospital, Medan

ABSTRACT
Introduction: The nursing intervention program was a strategy for the rehabilitation process among
fracture patients. A concept of Levine is a practical nursing theory using energy conservation, energy,
structural integrity, personal integrity, and social integrity. The study aimed to identify the effect of
nursing intervention-based Levine on the rehabilitation process among fracture patients in H. Adam
Malik Hospital, Medan.

Methods: A quasi-experiment, pre-test, and post-test with equivalent control group design were applied
in this study. Sixty-two respondents were selected into the experimental group (n=31) and control group
(n=31) by using a consecutive sampling technique. Data were analyzed using a Wilcoxon Signed Rank
Test. The patients' rehabilitation on fracture included sleep disorder, pain, anxiety, and family support.

Results: The results showed a significant effect of patients' recovery on fracture among patients after
receiving nursing intervention-based Levine than before receiving the intervention with p-value = 0.000
(p <0.05).

Conclusion: In conclusion, there is significantly different nursing intervention-based Levine on energy

conservation, energy, structural integrity, personal integrity, and social integrity. The nursing intervention
program based on Levine's conceptual model could be part of the independent nursing intervention to deal
with recovery in fracture patients.

Keywords: Levine conceptual model, rehabilitation fracture patients.

INTRODUCTION

Fractures are musculoskeletal disorders due to bone damage, the pressure that exceeds the ability of the
bone to withstand pressure, excessive stress on the bone, direct punches, sudden movements, indirect
trauma, falls from heights, and work accidents (Belleza, 2016). It could affect massive trauma and
difficult to perform activities.

Fractures cause malfunctioning parts of the body that cause permanent disability and even cause death
after the trauma experienced. It caused significantly changed. It may cause significant changes in a
person's life, with the results that lose independence. Thereby, immediately for fracture recovery is
required(Black &Hawks, 2014).

Fractures recovery Fracture recovery is a stage of the fracture
beginning of the trauma until the fracture process. Therefore,
experienced. Fractures recovery from injury need Recovery of
different recovery time from a few weeks to months depending
severity of the fracture (Whiteing, 2008).
healing process that starts from the
the body could recover the damage
a fracture due to trauma requires a
on the type of trauma, location, and

Data from the World Health Organization (WHO) in 2011 revealed that fractures incidence of
approximately 5.6 million people died due to accidents, and 1.3 million people experienced permanent
physical disabilities. In addition, Basic Health Research, the Republic of Indonesia in 2018, also showed
that fractures were significant impacts on lower limbs 67.9%, upper limbs 32.7%, head 11.9%, back
6.5%, chest 2.6%, and abdomen 2.2%.
The prevalence of fractures in North Sumatera were 864 people included lower limb fractures as many as
549 people (63.5%), upper limb fractures were 250 people (28.9%), pelvic fractures were 39 people
(4.5%), and spinal fractures such as 26 people (3.1%) (Moesbar, 2013). The pilot survey conducted at H.
Adam Malik hospital, Medan in 2018, showed that 196 people with lower limb fractures were 94 people,
upper limb fractures were 45 people, 31 shoulder and upper arm fractures, 26-foot fractures.

Fractures patients are often physically and psychologically changed. The physically changed included
sleeping disorder, pain, anxiety, and low family support (Potter, Perry, Stockert, & Hall, 2016). It could
hinder the recovery process of fracture healing. Factors were associated with fractures recovery, including
age, length of hospitalized, and other complications (Corrarino, 2015).

Data from the USA stated that the incidence of fracture recovery were 7.9 million people every year, and
5-10% of them have recovery disorder (Buza & Einhorn, 2016). Moreover, Swedia mentioned that
61fractures people have normal recovery between 17 weeks, while 27 people of them were slowly
recovered in 35 weeks, and 16 of people were abnormal fractures at 69 weeks of the recovery process
(Karladani et al., 2001). A study from the United Kingdom found that An individual physical strength
may accelerate fracture recovery by an average of 30% accelerated recovery within 12 weeks (Mirhadi,
Ashwood, & Karagkevrekis, 2013).

In maintaining the ability of fracture patients to resist obstacles, make appropriate adaptations, and deal
with disabilities, a conceptual conservation model is required in this study. Fractures patients Fracture
patients often have complex problems such as sleep disorders, pain, anxiety, and low family support.
Therefore, fracture patients have limited activities and are still dependent on other people around them
(Alligood & Tomey, 2014).

The concept of the Levine model was a as complicated step. Thus it could impact on functional of life
among individuals even faced with difficult challenges. The conceptual of Levine model Levine's
conceptual model aims to maintain the needs of individuals who use the principle of conservation
(Abumaria, Hastings, & Sakraida, 2015).

Problems often found in fracture patients in the hospital are sleep disorders, pain, anxiety, and low family
support. These complex problems can be overcome by carrying out nursing interventions based on
Levine's conceptual model. Levine's conceptual method uses the Levine conservation model of energy
conservation, conservation of structural integrity, conservation of personal integrity, and conservation of
social integrity (Abumaria, Hastings, &Sakraida, 2015). This study aimed to identify the effect of nursing
intervention-based Levineconcept on fractures recovery among fracture patients at H. Adam Malik
Hospital, Medan.

MATERIALS AND METHOD

The quasi-experimental study design was applied in this study to examine the effect of the nursing
intervention-based Levine conceptual model program on the rehabilitation process among fracture
patients. The study was conducted in H. Adam Malik Hospital, Medan, between August 10th and October
29th, 2019. Sixty-two samples consisted of 31 samples allocated in the experimental group and 31 samples
for the control group. We applied a nonprobability sampling with consecutive sampling to select the
samples. This method is a strategy to choose all individuals found and met with the inclusion criteria
(Polit & Beck, 2012). The criteria inclusion included; (a) Fracture patients aged between 17 to 65 years
old, (b) all Hospitalized patients with fracture conditions, (c) fracture patients who willing to receive
nursing intervention-based Levine conservation model, (d) cooperative in discussion process, (e)
rehabilitation length between 1 to 3 months. Data were gathered using a Sleep Quality Scale (SQS) to
measure sleeping disorders. Hamilton Anxiety Rating Scale (HARS) was used to measure anxiety level,
and Family Support Scale (FSS) was used to measure family support. Three experts have validated those
questionnaires with the validation scores included the Sleep Quality Scale (SQS) was 0.94, Hamilton
Anxiety Rating Scale (HARS) was 0.97. Family Support Scale (FSS) was 0.98. Test-retest was applied to
measure the reliability of the questionnaire with Cronbach's alpha of Sleep Quality Scale (SQS) was 0.80,
Hamilton Anxiety Rating Scale was 0.86, and the Family support scale was 0.81. Also, the pilot study was
conducted at DR Pirngadi hospital, Medan, which is showed the nursing intervention-based Levine was
feasible to be implemented and was a significant difference in sleep disorder (p-value=0.000), anxiety (p-
value=0.004), and family support (p-value=0.000). Before data collection process, the ethical
consideration had been approved by ethical committee, Faculty of Nursing, North Sumatera University.
Informed consent was signed by all respondents who willing to participate in this study. Informed concent
dan menjelaskan tujuan penelitian dan manfaat penelitian bagi responden. Analisis data yang digunakan
adalah paired t-test. Paired t-test digunakan untuk mengidentifikasi pengaruh program intervensi
keperawatan berbasis model konseptual Levine terhadap pemulihan pasien fraktur pada kelompok
intervensi dan kelompok kontrol.

RESULTS
Description of Respondents’ Characteristics
Table 1. The distribution of frequency and percentage of characteristic demographic data among the
intervention and the control group (n=62)
Intervention Control
Data
f % f %
Aged
17-25 years old 9 29.0 9 29.0
26-35 years old 6 19.4 10 32.3
36-45 years old 3 9.7 2 6.5
46-55 years old 6 19.4 5 16.1
56-65 years old 6 19.4 5 16.1
>65 years old 1 3.2 - -
Gender
Male 21 67.7 26 83.9
Female 10 32.3 5 16.1
Education
Junior high school 4 12.9 1 3.2
High school 23 74.2 24 77.4
Diploma 3 1 3.2 3 9.7
Bachelor 3 9.7 3 9.7
Occupation
Housewife 5 16.1 - -
Entrepreneur 10 32.3 17 54.8
Private employees 5 16.1 5 16.1
Farmer 1 3.2 4 12.9
Student 8 25.8 5 16.1
Civil servant 2 6.5 - -
Duration of hospitalized
One day to 1 week 14 45.2 23 74.2
 2 to 3 week 10 32.3 6 19.4
1 to 2 month 6 19.4 2 6.5
Three month 1 3.2 - -
The results showed that most distribution of respondents’ characteristics based on the aged among the
intervention group was 17-25 years old (29.0%). Also, the control group showed that most of the
respondents were 26-35 years old (32.3%). The distribution of respondents based on gender among the
intervention group were male (67.7%). Whereas among the control group also showed that most of them
were male (83.9%). Regarding respondents' characteristics based on education, most of the respondents in
the intervention group were high school (74.2%). The control group also stated that most of them were
too high school level (77.4%). The distribution of respondents based on occupation, both the intervention
group (32.3%) and the control group (54.8%), were an entrepreneur. In terms of the distribution of
respondents based on the duration of hospitalized showed that 45.2% of the intervention group have one
day to 1 week on length of hospitalized. Also, among the control group mentioned that most of them were
hospitalized within one day to 1 week (74.2%).

Rehabilitation of patients' fractures

Table 2. The distribution frequency and percentage on patients' rehabilitation of fractures among the
intervention group and the control group before receiving the nursing intervention-based Levine model
(n=62)
Intervention Control
Rehabilitation of patients Pre Post Pre Post
fractures f % f % f % f %
Sleep disorder
Very poor 26 83.9 - - - - - -
Poor 5 16.1 - - 31 100 31 100
Good - - 8 25.8 - - - -
Very good - - 23 74.2 - - - -
Mean ± SD 66.10 ± 3.655 47.87 ± 6.328 90.55 ± 3.686 89.65 ± 4.294
Min-Max 59-73 38-56 85-99 80-99
Pain
Light 8 25.8 31 100 20 64.5 23 74.2
Mild 23 74.2 - - 11 35.5 8 25.8
Severe - - - - - - - -
Mean ± SD 3.71 ± 0.529 2.06 ± 0.512 3.19 ± 0.703 3.10 ± 0.651
Min-Max 2-4 1-3 2-4 2-4
Anxiety
Light - - 1 3.2 - - - -
Mild - - 30 96.8 - - - -
Severe 31 100 - - 31 100 31 100
Mean ± SD 58.19 ± 3.240 29.52 ± 5.476 56.19 ± 3.902 55.52 ± 4.419
Min-Max 52-64 20-43 51-63 47-63
Family support
Good - - 31 100 - - - -
Enough 24 77.4 - - - - - -
Poor 7 22.6 - - 31 100 31 100
Mean ± SD 38.81 ± 7.534 61.84 ± 1.508 56.19 ± 3.902 54.97 ± 3.071
Min-Max 27-58 57-64 51-63 49-62
Based on the results showed that the distribution of patients' rehabilitation of fracture on sleep disorder
among intervention groups before receiving the nursing intervention-based Levine model, the majority of
sleep quality was poor, which is 26 respondents (83.9%). Whereas among the control group before
receiving the standard care from the hospital, all of 31 respondents (100%) have poor sleep quality. For
the distribution of respondents after receiving the nursing intervention-based Levine, the majority
respondents were the better quality of sleep (74.2%), and among the control group after receiving the
standard intervention from the hospital, all respondents have a poor quality of sleep (100%).

The results of the study showed that the distribution of patients' rehabilitation of fractures on the pain
level among the intervention group before receiving the nursing intervention-based Levine model was 23
respondents (74.2%). While among the control group before receiving the standard intervention from the
hospital, the majority of respondents with mild pain were 20 respondents (64.5%). For the distribution of
respondents after receiving the nursing intervention-based Levine model, all of 31 respondents (100%)
were mild pain. Among the control group also after receiving the standard intervention from the hospital
showed that some of them were mild pain, with 23 respondents (74.2%).

Based on the results showed that the distribution of patients' rehabilitation of fracture on anxiety among
the intervention group before receiving the nursing intervention-based Levine model, all of 31
respondents (100%) were severe anxiety. Whereas the distribution of respondents after receiving the
nursing intervention-based Levine model, the majority of them, such as 30 respondents (96.8%), and
among the control group after receiving the standard nursing intervention from the hospital were severe
anxiety with 31 respondents (100%).

The results of the study also showed that the distribution of patients' rehabilitation of fractures on family
support among the intervention group before receiving the nursing intervention-based Levine model was
enough family support with 24 respondents (77.4%). Whereas among the control group before receiving
the standard nursing intervention from the hospital, all of the respondents were poor family support with
31 respondents (100%). While the respondents' distribution after receiving the nursing intervention-based
Levine model, all of 31 respondents (100%) have poor family support, and among the control group after
receiving the intervention based on the standard from the hospital also most of them have poor family
support with 31 respondents (100%).

The effect of the nursing intervention-based Levine model on the rehabilitation of fractures'
patients among the intervention group and the control group
Table 3. The effect of the nursing intervention-based Levine model on patients' rehabilitation of fractures'
patients among the intervention group and the control group (n=62)
Rehabilitation of Intervention Control
fractures’ patients Mean SD Z p-value Mean SD Z p-value
Sleep disturbance
Pre-test 88.77 4.318 -4.862 0.000 90.55 3.686 -2.032 0.042
Post-test 47.87 6.328 89.65 4.294
Pain
Pretest 3.71 0.529 -4.824 0.000 3.19 0.703 -1.732 0.083
Post-test 2.06 0.512 3.10 0.651
Anxiety
Pretest 58.19 3.240 -4.862 0.000 56.19 3.902 -1.604 0.109
Post-test 29.52 5.476 55.52 4.419
Family support
Pretest 38.81 7.543 -4.865 0.000 56.19 3.902 -1.486 0.137
 Post-test 61.84 1.508 54.97 3.071

Based on the results of the bivariate analysis using the Wilcoxon Signed-Rank statistical test. It was
obtained the significance value of p-value in the intervention group before and after the nursing
intervention program based on the Levine conceptual model for the recovery of fracture patients (sleep
disturbance, pain, anxiety, and family support) α = 0.000 (p < 0.05). Thus, it can be said that the nursing
intervention program based on Levine's conceptual model influences the recovery of fracture patients
(sleep disorders, pain, anxiety, and family support) in patients who experience fractures.

The results of the bivariate analysis using the Wilcoxon Signed-Rank statistical test showed no effect on
the control group on fracture patient recovery (sleep disturbance α = 0.042, p > 0.05, pain α = 0.083, p >
0.05, anxiety α = 0.109, p > 0.05, and family support α = 0.137, p > 0.05). Thus it can be said that there is
no significant effect of an intervention on recovery among fracture patients. They have sleep disorders,
pain, anxiety, and family support in the control group in patients who have fractures.

DISCUSSION

Rehabilitation of fracture patients

The results of this study indicate that overall, respondents who experience fractures have poor sleep
quality. A study conducted by Crowley (2011) revealed that more than half of the adult population with a
history of falls having trouble sleeping disorders, which include duration and quality of sleep. Another
study from Andri, Panzilion & Sutrisno (2019) said that 30 respondents, 22 fracture patients, experienced
poor quality, and eight people had good sleep quality. (p-value 0.002). In addition, age and gender also
impact on sleep disturbance among fractures patients. Based on the results of the study found that men
have more sleep disorders compared to women. A study conducted by Swanson et al. (2015) stated that
men experience more sleep disorders compared to women.
Aged was a factor in pain. It caused pain increases when the respondent grows up and decreases gradually
in old age. Respondents have more positive emotions or suitable coping styles. Thus, it would be easier to
influence and cope with pain (Potter, Perry, Stockert, & Hall, 2010). Therefore, this can affect the pain
experienced by older respondents compared to younger respondents.

Gender also was associated with pain. More than half (67.70%) of respondents among the intervention
group were male, while 83.90% of respondents among control were also male. A study by Bhandari et al.
(2008) said that the majority of the male was much severe pain than female. It was due to males have
higher psychological pressure than females.

Age also one of the factors on anxiety level. The mean average of age among the intervention group was
36.68. Less than half of them (29%) were late teens at the age of 17-25 years and had severe anxiety. The
previous study from Thomas & D’Silva (2015) mentioned that aged between 31 to 50 years old could
impact on anxiety level. This shows that the level of anxiety increases with the age of the respondent.
Another study conducted by Bhandari et al. (2008) stated that adulthood affects severe anxiety and
experience a high prevalence of pain.

The results of the study showed that family support among the intervention group was better after the
implementation of the nursing intervention-based Levine model. The study from Lin & Lu (2005)
explained that one of the factors associated with fractures recovery among patients with hip fractures was
family support. Family support is needed to recover the process among patients with fractures. It could
help an individual to improve the coping mechanism more useful to be better in fractures recovery.
The effect of nursing intervention-based Levine model on rehabilitation among fractures patients in
the intervention group and the control group
Based on the study, results showed that the nursing intervention-based Levine model was a significant
effect on sleep quality (α=0.000, p<0.05). Nursing intervention conducted in this study to increase the
sleep quality among fractures patients was Benson Relaxation Technique. This finding showed any
significant effect on the sleep quality of the respondents (p-value 0.000). A study from Rahman,
Handayani & Sholehah (2019) stated that the Benson relaxation technique could improve sleep quality
among elderly patients.
The nursing intervention-based Levine model also showed a positive effect on pain (α=0.000, p<0.05).
Fracture patients with pain could use non-pharmacology management, such as deep breathing techniques
(Brunner, 2010). This study implemented the deep breathing relaxation technique to reduce pain among
fracture patients. Based on the results showed that there is a significant effect on the intervention on pain
among respondents (p-value 0.000). Another study from Seheno (2010) stated that deep breathing
relaxation technique was effective in reducing pain post operated of fracture.

The nursing intervention-based Levine model also could provide a positive impact on anxiety (α=0.000,
p<0.05). The intervention conducted in this study to reduce anxiety among fracture patients, such as
muscle progressive relaxation techniques. Based on this intervention showed that there is a positive effect
of the intervention on anxiety among respondents (p-value 0.000). A study from Astuti & Ruhyana (2015)
said that muscle progressive relaxation technique could reduce anxiety levels among pre operated
fractures patients. In addition, another study from Zhao et al. (2012) also said that muscle progressive
relaxation technique could be used to reduce anxiety. It could suppress the sympathetic nerves and
suppress the tense experienced by the respondent reciprocally so that there will be counter conditioning.

Other findings showed the positive effect of the nursing intervention-based Levine model on family
support (α=0.000, p<0.05). The health education was implemented to educate fractures patients. This
finding indicated that there is a significant difference in the intervention on family support among
respondents (p-value 0.000). The result was consistent with the previous study from Penelitian Wijayanto
& Abdullah (2015) said that there is a positive effect of health education on anxiety levels among pre-
operated patients.

CONCLUSION
In conclusion, based on the results of this study, the main conclusion included: (1) There is positive effect
of nursing intervention-based Levine model on sleep disorder (2) There are significantly effect of nursing
intervention-based Levine model on pain (3) There are significantly effect of nursing intervention-based
Levine model anxiety (4) There is significant effect of nursing intervention-based Levine model family
support. The findings recommended applying the different instruments for measuring sleep disorder, pain,
anxiety, and family support to identify the results effectively. Further studies also need to conduct a
similar study with longer and expected duration and frequency of nursing intervention-based Levine
models.

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