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PRENATAL KONFORUN TRAVMATİK DOĞUM ALGISINA ETKİSİ

Year 2024, Volume: 12 Issue: 2, 604 - 617, 20.06.2024
https://doi.org/10.33715/inonusaglik.1382829

Abstract

Araştırmanın amacı, gebelerde prenatal konforun travmatik doğum algısına etkisinin incelenmesidir. Kesitsel türde olan araştırmanın verileri Nisan-Eylül 2023 tarihleri arasında toplanmıştır. Araştırmanın örneklemini, dahil edilme kriterlerini taşıyan ve üçüncü trimesterde bulunan 233 gebe oluşturmuştur. Verilerin toplanması aşamasında tanıtıcı bilgi formu, prenatal konfor ölçeği ve travmatik doğum algısı ölçeği kullanılmıştır. Verilerin analizi SPSS 27.0 paket programı kullanılarak yapılmıştır. Gebelerin travmatik doğum algısı puan ortalamasının 86.25±25.58 olduğu ve gebelerin %41.2’sinin yüksek düzeyde travmatik doğum algısına sahip olduğu bulunmuştur. Gebelerin prenatal konfor puan ortalamasının 64.52±9.85 ile iyi düzeyde olduğu belirlenmiştir. Prenatal konfor ile travmatik doğum algısı arasında anlamlı ilişki saptanmamıştır. Gebelerin prenatal konfor puan ortalaması ile gebenin yaşı, eğitim durumu, gebelik sayısı, gebeliğin planlı olma durumu ve multipar olma arasında anlamlı bir fark olduğu sonucuna varılmıştır. Ayrıca travmatik doğum algısı ile gebenin yaşı, eğitim durumu, gebelik sayısı, multipar olma durumu, son doğum deneyimi ve mevcut gebeliğin tanımı arasında istatistiksel olarak anlamlı fark olduğu sonucuna ulaşılmıştır. Gebelerin iyi düzeyde prenatal konfora sahip olduğu, ancak travmatik doğum algılarının oldukça yüksek olduğu sonucuna ulaşılmıştır. Ebelerin, klinik ortamda, gebelerin travmatik doğum algısını azaltacak ve prenatal konforlarını arttıracak girişimleri planlaması ve uygulaması önemlidir.

References

  • Aktaş, S. (2018). Multigravidas’ perceptions of traumatic childbirth: Its relation to some factors, the effect of previous type of birth and experience. Medicine Sience, 7(1), 203-209. https://doi.org/10.5455/medscience.2017.06.8728.
  • Amakawa, E. ve Sugiura, K. (2022). Pregnancy-related comfort: a survey on pregnant women during their second and third trimesters. Kawasaki Journal of Medical Welfare, 27(2), 179-188.
  • Anderson, C. A. (2017). The trauma of birth. Health Care for Women International, 38(10), 999-1010. https://doi.org/10.1080/07399332.2017.1363208.
  • Attarha, M., Keshavarz, Z., Bakhtiari, M. ve Jamilian, M. (2016). The outcome of midwife-mother relationship in delivery room: A qualitative content analysis. Health, 8(4), 336-343. https://doi.org/ 10.4236/health.2016.84035.
  • Aydın Özkan, S., Kaya Şenol, D. ve Aslan, E. (2020). Üçüncü trimester gebelerde konfor düzeyi ve etkileyen faktörler. Dokuz Eylül Üniversitesi Hemşirelik Yüksekokulu Elektronik Dergisi, 13(2), 92-99.
  • Barut, S., Uçar, T. ve Yılmaz, A. N. (2022). Comparison of pregnant women’s anxiety, depression and birth satisfaction based, on their traumatic childbirth perceptions. Journal of Obstetrics and Gynaecology, 42(7), 2729-2737. https://doi.org/10.1080/01443615.2022.2106832.
  • Bay, F. ve Sayiner, F. D. (2021). Perception of traumatic childbirth of women and its relationship with postpartum depression. Women & Health, 61(5), 479-489. https://doi.org/10.1080/03630242.2021.1927287.
  • Bjelica, A., Cetkovic, N., Trninic-Pjevic, A. ve Mladenovic-Segedi, L. (2018). The phenomenon of pregnancy—A psychological view. Ginekologia polska, 89(2), 102-106. https://doi.org/10.5603/GP.a2018.0017.
  • Cibralic, S., Pickup, W., Diaz, A. M., Kohlhoff, J., Karlov, L., Stylianakis, A., ...Eapen, V. (2023). The impact of midwifery continuity of care on maternal mental health: A narrative systematic review. Midwifery, 116, 103546. https://doi.org/10.1016/j.midw.2022.103546.
  • Derya, Y. A., Akça, E., Kamalak, H. ve Gökbulut, N. (2021). Doğum Sayısı, doğum şekli ve gebeliğin planlı olma durumunun lohusalarda posttravmatik gelişim ve konfora etkisi. Mersin Üniversitesi Sağlık Bilimleri Dergisi, 14(3), 366-377. https://doi.org/10.26559/mersinsbd.828603.
  • Dursun D. (2019). Gebelerde evlilik uyumunun doğum korkusuna etkisi. (Yüksek Lisans Tezi). Ordu Üniversitesi, Ordu.
  • George, D. ve Mallery, M., 2010. SPSS for windows step by step: a simple guide and reference, 17.0 update (10a ed.) Boston, Pearson. Ghanbari-Homayi, S., Fardiazar, Z., Meedya, S., Mohammad-Alizadeh-Charandabi, S., Asghari-Jafarabadi, M., Mohammadi, E. ve Mirghafourvand, M. (2019). Predictors of traumatic birth experience among a group of Iranian primipara women: a cross sectional study. BMC Pregnancy and Childbirth, 19(1), 182. https://doi.org/10.1186/s12884-019-2333-4.
  • Hall, P. J., Foster, J. W., Yount, K. M. ve Jennings, B. M. (2020). Comfort in labor: "Like being able to exhale". The Journal of perinatal & neonatal nursing, 34(1), 38–45. doi: 10.1097/JPN.0000000000000455.
  • Haines, H. M., Rubertsson, C., Pallant, J. F. ve Hildingsson, I. (2012). The influence of women’s fear, attitudes and beliefs of childbirth on mode and experience of birth. BMC Pregnancy and Childbirth, 12, 1-14. https://doi.org/10.1186/1471-2393-12-55.
  • Henriksen, L., Grimsrud, E., Schei, B., Lukasse, M. ve Bidens Study Group (2017). Factors related to a negative birth experience - A mixed methods study. Midwifery, 51, 33–39. https://doi.org/10.1016/j.midw.2017.05.004.
  • Kaya Şenol, D., Aydın Özkan, S. ve Aslan, E. (2021). Adaptation of the prenatal comfort scale into Turkish: A validity and reliability Study. Florence Nightingale Journal of Nursing, 29(2), 221-228. https://doi.org/10.5152/FNJN.2021.20051.
  • Kolcaba, K. ve Di Marco, M. A. (2005). Comfort theory and its application to pediatric nursing. Pediatric Nursings, 31(3), 187-194.
  • Matvienko-Sikar, K. ve Dockray, S. (2017). Effects of a novel positive psychological intervention on prenatal stress and well-being: A pilot randomised controlled trial. Women and birth: Journal of the Australian College of Midwives, 30(2), 111–118. https://doi.org/10.1016/j.wombi.2016.10.003.
  • Nakamura Y. (2010). Nursing intervention to enhance acceptance of pregnancy in first-time mothers: focusing on the comfortable experiences of pregnant women. Japan Journal of Nursing Science: JJNS, 7(1), 29–36. https://doi.org/10.1111/j.1742-7924.2010.00134.x
  • Nakamura, Y., Takeishi, Y., Ito, N., Ito, M., Atogami, F. ve Yoshizawa, T. (2015). Comfort with motherhood in late pregnancy facilitates maternal role attainment in early postpartum. The Tohoku Journal of Experimental Medicine, 235, 53-55. https://doi.org/10.1620/tjem.235.53.
  • Özdemir, Ş. (2021). Kuşaklararası travmatik doğum algısının nullipar gebelerde doğum korkusu ve gebelik stresine etkisi. (Yüksek Lisans Tezi). İnönü Üniversitesi, Malatya.
  • Rouhe, H., Salmela-Aro, K., Toivanen, R., Tokola, M., Halmesmäki, E. ve Saisto, T. (2013). Obstetric outcome after intervention for severe fear of childbirth in nulliparous women - randomised trial. BJOG: An International Journal of Obstetrics and Gynaecology, 120(1), 75–84. https://doi.org/10.1111/1471-0528.12011.
  • Sedov, I. D., Cameron, E. E., Madigan, S. ve Tomfohr-Madsen, L. M. (2018). Sleep quality during pregnancy: a meta-analysis. Sleep medicine reviews, 38, 168-176. https://doi.org/10.1016/j.smrv.2017.06.005.
  • Sheen, K. ve Slade, P. (2018). Examining the content and moderators of women's fears for giving birth: A meta‐synthesis. Journal of Clinical Nursing, 27(13-14), 2523-2535. https://doi.org/10.1111/jocn.14219.
  • Srinayanti, Y., Anggraeni, S., Litasari, R. ve Lismayanti, L. (2023). The Relationship Between Pregnancy Discomfort and Physical Activity of Third Trimester Pregnant Women. Asy-Syifa: Journal of Science and Technology Nursing, 1(2), 51-56. https://doi.org/10.52221/asyjstn.v1i2.354.
  • Stojanow, K., Rauchfuss, M., Bergner, A., & Maier, B. (2017). Anxiety in high-and low-risk pregnancies and its influence on perinatal outcome. Mental Health & Prevention, 6, 51-56. https://doi.org/10.1016/j.mhp.2017.03.001.
  • Şahin, M. (2020). Gebelerde travmatik doğum algısı ve anne bağlanması ilişkisi. (Yüksek Lisans Tezi). Ordu Üniversitesi, Ordu.
  • Takeishi, Y., Nakamura, Y., Atogami, F. ve Yoshizawa, T. (2011). Development of the prenatal comfort scale. Journal of Japan Maternity Nursing, 11, 11-18.
  • Türkmen, H., Yalniz Dilcen, H. ve Aslantekin Özçoban, F. (2021). Traumatic childbirth perception during pregnancy and the postpartum period and its postnatal mental health outcomes: a prospective longitudinal study. Journal of Reproductive and Infant Psychology, 39(4), 422-434. https://doi.org/10.1080/02646838.2020.1792429.
  • Ünver, H., Özşahin, Z. ve Tekdal, A. G. (2022). Gebelerde covid-19 korkusunun gebelik stresi ve travmatik doğum algısına etkisi. Ebelik ve Sağlık Bilimleri Dergisi, 5(2), 71-78. https://doi.org/10.5152/JMHS.2022.222327.
  • Üst, Z. D. ve Pasinlioğlu, T. (2015). Primipar ve multipar gebelerde doğum ve postpartum döneme ilişkin endişelerin belirlenmesi. Sağlık Bilimleri ve Meslekleri Dergisi, 2(3), 306–317. https://doi.org/10.17681/hsp.96963.
  • World Health Organization (2018). WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization.
  • Vannier, S. A. ve Rosen, N. O. (2017). Sexual distress and sexual problems during pregnancy: Associations with sexual and relationship satisfaction. The Journal of Sexual Medicine, 14(3), 387-395. https://doi.org/10.1016/j.jsxm.2016.12.239.
  • Yalnız, H., Canan, F., Genç, R., Kuloğlu, M. M. ve Geçici, Ö. (2016). Development of the traumatic birth perception scale. Turkish Journal of Medical Sciences, 8(3), 81-88.
  • Yıldırım, G. ve Bilgin, Z. (2021). Risk status and traumatic birth perception in pregnancy. Perspectives in Psychiatric Care, 57(4), 1897-1904.
  • Yılmaz, B., Sel, İ. ve Şahin, N. H. (2021). Kadınların kişilik özelliklerinin travmatik doğum algısına etkisi. Dokuz Eylül Üniversitesi Hemşirelik Fakültesi Elektronik Dergisi, 14(4), 423-432. https://doi.org/10.46483/deuhfed.882663.
  • Yin, X., Sun, N., Jiang, N., Xu, X., Gan, Y., Zhang, J., ...Gong, Y. (2021). Prevalence and associated factors of antenatal depression: Systematic reviews and meta-analyses. Clinical Psychology Review, 83, 1-8. https://doi.org/10.1016/j.cpr.2020.101932.

The Effect of Prenatal Comfort on The Perception of Traumatic BirthClinics

Year 2024, Volume: 12 Issue: 2, 604 - 617, 20.06.2024
https://doi.org/10.33715/inonusaglik.1382829

Abstract

The aim of the study is to examine the effect of prenatal comfort on the perception of traumatic birth in pregnant women. The data for the cross-sectional study were collected between April and September 2023. The study sample consisted of 233 pregnant women who met the inclusion criteria and were in the third trimester. In the data collection phase, a demographic information form, prenatal comfort scale, and traumatic birth perception scale were used. The data analysis was performed using SPSS 27.0 software package. It was found that the mean traumatic birth perception score of pregnant women was 86.25±25.58 and 41.2% of pregnant women had a high level of traumatic birth perception. The mean prenatal comfort score of the pregnant women was 64.52±9.85 and was found to be at a good level. No significant relationship was found between prenatal comfort and the perception of traumatic birth. It was concluded that there was a statistically significant difference between the mean prenatal comfort score of pregnant women and factors such as the age of the pregnant woman, educational status, number of pregnancies, planned pregnancy status and being multiparous. Additionally, a significant difference was found between the perception of traumatic birth and factors such as the age of the pregnant woman, educational status, number of pregnancies, being multiparous, last birth experience, and description of the current pregnancy. It was concluded that pregnant women had a good level of prenatal comfort, but their perception of traumatic birth was quite high. It is important for midwives to plan and implement interventions to reduce the perception of traumatic birth and increase prenatal comfort among pregnant women in the clinical setting.

References

  • Aktaş, S. (2018). Multigravidas’ perceptions of traumatic childbirth: Its relation to some factors, the effect of previous type of birth and experience. Medicine Sience, 7(1), 203-209. https://doi.org/10.5455/medscience.2017.06.8728.
  • Amakawa, E. ve Sugiura, K. (2022). Pregnancy-related comfort: a survey on pregnant women during their second and third trimesters. Kawasaki Journal of Medical Welfare, 27(2), 179-188.
  • Anderson, C. A. (2017). The trauma of birth. Health Care for Women International, 38(10), 999-1010. https://doi.org/10.1080/07399332.2017.1363208.
  • Attarha, M., Keshavarz, Z., Bakhtiari, M. ve Jamilian, M. (2016). The outcome of midwife-mother relationship in delivery room: A qualitative content analysis. Health, 8(4), 336-343. https://doi.org/ 10.4236/health.2016.84035.
  • Aydın Özkan, S., Kaya Şenol, D. ve Aslan, E. (2020). Üçüncü trimester gebelerde konfor düzeyi ve etkileyen faktörler. Dokuz Eylül Üniversitesi Hemşirelik Yüksekokulu Elektronik Dergisi, 13(2), 92-99.
  • Barut, S., Uçar, T. ve Yılmaz, A. N. (2022). Comparison of pregnant women’s anxiety, depression and birth satisfaction based, on their traumatic childbirth perceptions. Journal of Obstetrics and Gynaecology, 42(7), 2729-2737. https://doi.org/10.1080/01443615.2022.2106832.
  • Bay, F. ve Sayiner, F. D. (2021). Perception of traumatic childbirth of women and its relationship with postpartum depression. Women & Health, 61(5), 479-489. https://doi.org/10.1080/03630242.2021.1927287.
  • Bjelica, A., Cetkovic, N., Trninic-Pjevic, A. ve Mladenovic-Segedi, L. (2018). The phenomenon of pregnancy—A psychological view. Ginekologia polska, 89(2), 102-106. https://doi.org/10.5603/GP.a2018.0017.
  • Cibralic, S., Pickup, W., Diaz, A. M., Kohlhoff, J., Karlov, L., Stylianakis, A., ...Eapen, V. (2023). The impact of midwifery continuity of care on maternal mental health: A narrative systematic review. Midwifery, 116, 103546. https://doi.org/10.1016/j.midw.2022.103546.
  • Derya, Y. A., Akça, E., Kamalak, H. ve Gökbulut, N. (2021). Doğum Sayısı, doğum şekli ve gebeliğin planlı olma durumunun lohusalarda posttravmatik gelişim ve konfora etkisi. Mersin Üniversitesi Sağlık Bilimleri Dergisi, 14(3), 366-377. https://doi.org/10.26559/mersinsbd.828603.
  • Dursun D. (2019). Gebelerde evlilik uyumunun doğum korkusuna etkisi. (Yüksek Lisans Tezi). Ordu Üniversitesi, Ordu.
  • George, D. ve Mallery, M., 2010. SPSS for windows step by step: a simple guide and reference, 17.0 update (10a ed.) Boston, Pearson. Ghanbari-Homayi, S., Fardiazar, Z., Meedya, S., Mohammad-Alizadeh-Charandabi, S., Asghari-Jafarabadi, M., Mohammadi, E. ve Mirghafourvand, M. (2019). Predictors of traumatic birth experience among a group of Iranian primipara women: a cross sectional study. BMC Pregnancy and Childbirth, 19(1), 182. https://doi.org/10.1186/s12884-019-2333-4.
  • Hall, P. J., Foster, J. W., Yount, K. M. ve Jennings, B. M. (2020). Comfort in labor: "Like being able to exhale". The Journal of perinatal & neonatal nursing, 34(1), 38–45. doi: 10.1097/JPN.0000000000000455.
  • Haines, H. M., Rubertsson, C., Pallant, J. F. ve Hildingsson, I. (2012). The influence of women’s fear, attitudes and beliefs of childbirth on mode and experience of birth. BMC Pregnancy and Childbirth, 12, 1-14. https://doi.org/10.1186/1471-2393-12-55.
  • Henriksen, L., Grimsrud, E., Schei, B., Lukasse, M. ve Bidens Study Group (2017). Factors related to a negative birth experience - A mixed methods study. Midwifery, 51, 33–39. https://doi.org/10.1016/j.midw.2017.05.004.
  • Kaya Şenol, D., Aydın Özkan, S. ve Aslan, E. (2021). Adaptation of the prenatal comfort scale into Turkish: A validity and reliability Study. Florence Nightingale Journal of Nursing, 29(2), 221-228. https://doi.org/10.5152/FNJN.2021.20051.
  • Kolcaba, K. ve Di Marco, M. A. (2005). Comfort theory and its application to pediatric nursing. Pediatric Nursings, 31(3), 187-194.
  • Matvienko-Sikar, K. ve Dockray, S. (2017). Effects of a novel positive psychological intervention on prenatal stress and well-being: A pilot randomised controlled trial. Women and birth: Journal of the Australian College of Midwives, 30(2), 111–118. https://doi.org/10.1016/j.wombi.2016.10.003.
  • Nakamura Y. (2010). Nursing intervention to enhance acceptance of pregnancy in first-time mothers: focusing on the comfortable experiences of pregnant women. Japan Journal of Nursing Science: JJNS, 7(1), 29–36. https://doi.org/10.1111/j.1742-7924.2010.00134.x
  • Nakamura, Y., Takeishi, Y., Ito, N., Ito, M., Atogami, F. ve Yoshizawa, T. (2015). Comfort with motherhood in late pregnancy facilitates maternal role attainment in early postpartum. The Tohoku Journal of Experimental Medicine, 235, 53-55. https://doi.org/10.1620/tjem.235.53.
  • Özdemir, Ş. (2021). Kuşaklararası travmatik doğum algısının nullipar gebelerde doğum korkusu ve gebelik stresine etkisi. (Yüksek Lisans Tezi). İnönü Üniversitesi, Malatya.
  • Rouhe, H., Salmela-Aro, K., Toivanen, R., Tokola, M., Halmesmäki, E. ve Saisto, T. (2013). Obstetric outcome after intervention for severe fear of childbirth in nulliparous women - randomised trial. BJOG: An International Journal of Obstetrics and Gynaecology, 120(1), 75–84. https://doi.org/10.1111/1471-0528.12011.
  • Sedov, I. D., Cameron, E. E., Madigan, S. ve Tomfohr-Madsen, L. M. (2018). Sleep quality during pregnancy: a meta-analysis. Sleep medicine reviews, 38, 168-176. https://doi.org/10.1016/j.smrv.2017.06.005.
  • Sheen, K. ve Slade, P. (2018). Examining the content and moderators of women's fears for giving birth: A meta‐synthesis. Journal of Clinical Nursing, 27(13-14), 2523-2535. https://doi.org/10.1111/jocn.14219.
  • Srinayanti, Y., Anggraeni, S., Litasari, R. ve Lismayanti, L. (2023). The Relationship Between Pregnancy Discomfort and Physical Activity of Third Trimester Pregnant Women. Asy-Syifa: Journal of Science and Technology Nursing, 1(2), 51-56. https://doi.org/10.52221/asyjstn.v1i2.354.
  • Stojanow, K., Rauchfuss, M., Bergner, A., & Maier, B. (2017). Anxiety in high-and low-risk pregnancies and its influence on perinatal outcome. Mental Health & Prevention, 6, 51-56. https://doi.org/10.1016/j.mhp.2017.03.001.
  • Şahin, M. (2020). Gebelerde travmatik doğum algısı ve anne bağlanması ilişkisi. (Yüksek Lisans Tezi). Ordu Üniversitesi, Ordu.
  • Takeishi, Y., Nakamura, Y., Atogami, F. ve Yoshizawa, T. (2011). Development of the prenatal comfort scale. Journal of Japan Maternity Nursing, 11, 11-18.
  • Türkmen, H., Yalniz Dilcen, H. ve Aslantekin Özçoban, F. (2021). Traumatic childbirth perception during pregnancy and the postpartum period and its postnatal mental health outcomes: a prospective longitudinal study. Journal of Reproductive and Infant Psychology, 39(4), 422-434. https://doi.org/10.1080/02646838.2020.1792429.
  • Ünver, H., Özşahin, Z. ve Tekdal, A. G. (2022). Gebelerde covid-19 korkusunun gebelik stresi ve travmatik doğum algısına etkisi. Ebelik ve Sağlık Bilimleri Dergisi, 5(2), 71-78. https://doi.org/10.5152/JMHS.2022.222327.
  • Üst, Z. D. ve Pasinlioğlu, T. (2015). Primipar ve multipar gebelerde doğum ve postpartum döneme ilişkin endişelerin belirlenmesi. Sağlık Bilimleri ve Meslekleri Dergisi, 2(3), 306–317. https://doi.org/10.17681/hsp.96963.
  • World Health Organization (2018). WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization.
  • Vannier, S. A. ve Rosen, N. O. (2017). Sexual distress and sexual problems during pregnancy: Associations with sexual and relationship satisfaction. The Journal of Sexual Medicine, 14(3), 387-395. https://doi.org/10.1016/j.jsxm.2016.12.239.
  • Yalnız, H., Canan, F., Genç, R., Kuloğlu, M. M. ve Geçici, Ö. (2016). Development of the traumatic birth perception scale. Turkish Journal of Medical Sciences, 8(3), 81-88.
  • Yıldırım, G. ve Bilgin, Z. (2021). Risk status and traumatic birth perception in pregnancy. Perspectives in Psychiatric Care, 57(4), 1897-1904.
  • Yılmaz, B., Sel, İ. ve Şahin, N. H. (2021). Kadınların kişilik özelliklerinin travmatik doğum algısına etkisi. Dokuz Eylül Üniversitesi Hemşirelik Fakültesi Elektronik Dergisi, 14(4), 423-432. https://doi.org/10.46483/deuhfed.882663.
  • Yin, X., Sun, N., Jiang, N., Xu, X., Gan, Y., Zhang, J., ...Gong, Y. (2021). Prevalence and associated factors of antenatal depression: Systematic reviews and meta-analyses. Clinical Psychology Review, 83, 1-8. https://doi.org/10.1016/j.cpr.2020.101932.
There are 37 citations in total.

Details

Primary Language Turkish
Subjects Nursing (Other)
Journal Section Araştırma Makalesi
Authors

Rumeysa Taşkın 0000-0001-5176-157X

Ayla Kanbur 0000-0003-4086-4244

Gamze Akpınar 0000-0001-8047-0173

Early Pub Date June 3, 2024
Publication Date June 20, 2024
Submission Date October 29, 2023
Acceptance Date March 29, 2024
Published in Issue Year 2024 Volume: 12 Issue: 2

Cite

APA Taşkın, R., Kanbur, A., & Akpınar, G. (2024). PRENATAL KONFORUN TRAVMATİK DOĞUM ALGISINA ETKİSİ. İnönü Üniversitesi Sağlık Hizmetleri Meslek Yüksek Okulu Dergisi, 12(2), 604-617. https://doi.org/10.33715/inonusaglik.1382829