Community Nursing in Coastal Tourism through the Establishment of Coastal Health Center (POSKESPAN)

Coastal tourist nursing is intended for coastal tourists related to the risk of accidents that may occur during the coastal activity. The risk of accidents in tourists can occur due to bad weather, lack of rescue equipment, and the limited ability of the coast guard to perform first aid and emergency treatment. This study described the relationship between coastal tourist nursing with the prevention of injuries and the first aid of coastal accidents, as well as the working procedures and obstacles that might occur during the rescue. The research was conducted by the qualitative method through in-depth interviews with respondents consisting of tourists, Balawista, and health workers. The data is analyzed with qualitative descriptive analysis. The interview generates 14 themes related to activities on coastal such as the duties of Balawista, warning signs, means of communication, improvement of ability, accident cases, accident treatment, referral of cases, needs of infrastructure facilities, human resources needs, health care needs, infrastructure factors, human factors, situation factors, and how to cope with the problem. Those themes can be used as a reflection in following up the safety service efforts to coastal tourists. includes The aim this training to the This study aims to provide an tourist nursing regarding the prevention of risk handling accident on coast, the need for carrying out safety tasks on the coastal, and the obstacles encountered regarding safety on the coastal.


INTRODUCTION
The characteristics of coastal tourism in Bali focus on natural beauty, free access for the public, mass tourism that involves the masses of people who visit popular tourist destinations. The characteristic of tourist in Bali was recorded very diverse (Tunjungsari, 2018), not all of the tourists have special expertise about nature, local tourists, and tourists with different cultures, accompanied by the density of people in a limited location, directly and indirectly, have special problems related to health and tourism. There were only a few articles described coastal tourism specifically about the important aspects of prevention related to the safety and satisfaction of the tourists.
Disclosure about mortality rate due to coastal activity in Bali was also dominated by drowning cases by 53.5% (Usaputro and Yulianti, 2014), thus improving the case fatality rate in Badung Regency by 3.2% from 2016 -2017 based on a preliminary study to lifeguards in Kuta Beach. This condition cannot be compared with other coastal conditions due to the lack of data collection on the number of tourist visits on the coastal and the number of cases of other coastal accidents. This phenomenon reflects the weakness of efforts to prevent accident risks and to handle accident cases on the coast.
It was supported by the result of interviews conducted by researchers with the tourists in coastal, where 70% of data obtained said they did not know the existence of the coastal tourism rescue reinforcements (Balawista) as a team tasked with prevention and rescue on the coastal, the uniform used by Balawista and the warning prohibition signs on the coast still not socialized to tourists. The biggest accidents on the coast were caused by the behavior of people who do not know safety and do not comply with regulations according to safety standards. The results of a preliminary study conducted on the Balawista team on the coast of Badung regency, Bali Province, showed that the high number of accidents on the coast beside the proven characteristics of the waves that have the potential to cause high and extreme waves (Nurcahyo and Kisnarti, 2016). That cannot be controlled due to natural phenomena, so the anticipation efforts through early detection assessment of the ability of surfers need to be done to minimize the number of victims so that the assistance of novice surfers can be carried out.
The high number of accidents on the coast of Badung regency, Bali Province is also due to the negligence of tourists on warning signs on the coast, the lack of Balawista team compared to the number of tourists, limited sophisticated equipment, lack of ability to carry out rescue, and socialization of minimal accident risk prevention (Kusuma and Suryawan, 2016). So that, if the Balawista can explain about warning signs and tourist safety well, the accidents can be minimized.
The high number of accidents on the coast of Badung regency, Bali Province is also due to the negligence of tourists on warning signs on the coast, the lack of Balawista team compared to the number of tourists, limited sophisticated equipment, lack of ability to carry out rescue, and socialization of minimal accident risk prevention (Kusuma and Suryawan, 2016). So that, if the Balawista can explain about warning signs and tourist safety well, the accidents can be minimized. Regency, Bali Province by considering the high frequency of tourist visits, the existence of coastal rescuers, the high risk of coastal accidents even though the prevention has not been optimal. The technique of this research used in-depth interviews with the data sources were primary data and secondary data. Primary data sources were obtained from statements of tourists, Balawista, and health workers through the opened question, faceto-face interaction, and using unstructured interview guidelines.
Secondary data sources were based on the documentation and preliminary studies in the form of regulations and policies related to health in Badung Regency, regulations, and policies related to tourism in Badung Regency, Badung regional government policies, as a complement to the use of observation and interview methods. Data were analyzed using qualitative descriptive analysis techniques using a qualitative approach. The data analysis process begins with recording the results of interviews both through recorded and written records regarding the description of prevention of risk of injury on the coast, handling of accident cases on the coast, the need for carrying out safety duties for tourists, and the encountered obstacles regarding the safety of tourists on the coast. Processing interview data based on the keywords found to be sub-themes and finally getting the main theme or topic of the problem.
This research has also fulfilled the ethical requirements of research through the approval from the Ethics Committee of the Faculty of Nursing, University of Indonesia

RESULTS
The study conducted 17 participants consisted of 1) Six Balawista, 5 tourists, 6 health workers from Community Health Center in charge of the coastal. Entire participants have reached the data saturation. The characteristics of the participants were described in table 1.  The theme that was also explored was that safety warning signs posted on the coastal were interpreted differently between Balawista and tourists. Balawista and health workers perceive the color and meaning of the flag according to the coastal safety rules, namely the red flag is not allowed to swim and the yellow flag is allowed to swim, such as the following data: "Red flags" (P1, P3, P4, P12, P13,) "red flags and yellow" (P1, P3, P4, P12) "red flags of danger"(P1)"red is not allowed to swim ... "(P3, P4, P12, P13) "red yellow is safe for swimming" (P1, P3, P4, P12,13).
Refresher on the technique of handling coastal accident cases was carried out by Balawista every Friday at the Balawista's office. It was supported by the Balawista The results of theme exploration to answer the handling of accident cases on the coastal were described based on the theme of accident cases on the coastal, how to handle cases on the coastal, and case referrals. According to Balawista and tourist participants, cases of accidents on the coast include drowning, overheating, injury, and bleeding, jellyfish stings, which usually occur when the holidays. This was conveyed by Balawista participants as follows: "drowning…."(P1,P2,P4,P8,P9,P10,P13)"bleeding..(P1) "overheating.."(P1) "stung by jellyfish…"(P1)2) "the wound due to hitting the board…"(P4, P12, P13) "during the holidays…"(P1) ''during school holidays….''(P2,

P4) "holidays, new years, Eid Al-Fitr…."(P3)
Based on an interview with Balawista, the accident on coastal often occurred due to the lack of understanding, lack of information, lack of discipline by tourists, the ability to swim by tourists, and crowded visitors. According to tourists because they do not know the existence of Balawista and safety signs on the cost, they neglected self-safety during the travels, such as the following statement: "Do not understand signs" (P2, P10, P13) "lack of information.." (P2, P4) "lack of discipline" (P1, P2, P8, P9, P12) "lack of swimming ability" (P4, P13) "when the visitors is dense… " (P1)" do not know the The theme of referral of coastal accident cases usually directed to government hospitals and international hospitals on the grounds of proximity to the coastal, international standard and according to victim insurance, so far they have never made a case referral to Community Health Center as a health facility that covers the coastal area due to the lack of medical equipment and the unresponsive medical treatment. According to Balawista, cases of coastal accidents that have been referred to the hospital are not subject to further monitoring. This can be seen from the following participant statements: "referred to international hospitals (P1, P2, P3, P4, P12, P13, P11, P14, P15, P16) "never The results of the theme exploration to answer the need for infrastructure needed on the coastal were explained through the themes of the need for infrastructure, human resource needs, and health service needs on the coast.
Related to the statement from Balawista, the theme of the infrastructure needed on the coastal requires an increase in the number of guard centers on the coastal, there is a need for guidelines for handling accident cases on the coastal, there is a need for safety leaflets and the addition of medicines. According to tourists, there is a need for buoys and oxygen when handling accident cases on the coast. According to the three participants, the most needed need is medicine on the coastal, as stated by the following participants: Based on the results of interviews with the Regional Headman, it was explained that "the number of health workers in the health center is limited" "the supply of medicines were limited from the tourism office", "there is no cross-sectoral cooperation", "training is not routine" "needs trained health personnel" "coastal safety brochure" "not yet referred to the community nursing center", "there is no record of reporting of coastal accidents".

DISCUSSION
Community nurses need to build a partnership with the community and cooperate with the community, therefore community nurses need to provide encouragement or empowerment to the community in order to create active participation from the community (Yu et al., 2014). Building public health is inseparable from efforts to increase capacity, leadership, and community participation (Nies and McEwen, 2015). Priority targets for nursing services in the community carried out in vulnerable or high-risk communities due to health problems, communities with difficult geographical conditions such as remote areas, disaster-induced communities or others, communities with higher rates of health due to morbidity or mortality rates than other areas, or communities with low health care coverage (Stanhope and Lancaster, 2016). One of the community nursing activities in a particular setting that community nurses do in interacting with tourists on the coast, becomes the realm of community health nursing in a particular area on the coast, in the risky population of both individuals, groups, and communities.
Community health nursing strategies include group processes, health education, empowerment, and partnerships (Stanhope and Lancaster, 2016). The community health nursing strategy aims to increase community participation in solving health problems.
Based on a statement from Pender et al., (2011), every group process that occurs in the community aims to raise self-sensitivity, elicit solidarity, and mutual respect through existing social support systems.
Health education can be effective when it can make an improvement in knowledge, attitudes, skills, and even influence changes in the behavior or lifestyle of individuals, families, and groups (Pender et al., 2011). Community capacity is an effort to improve the ability of individuals, organizations, and communities to develop existing potentials, skills, resources, and geographic excellence by reconsidering the strengths and opportunities of community capabilities in development (Suarez-Balcazar et al., 2008).
For this reason, community capacity building is an activity to develop potential, skills, community resources in accordance with the capabilities of the community.

Community Capacity
Community capacity in the context of tourism includes organizations, communities, and individuals (Flaspohler, 2008). Community capacity is the capacity of people in the community to participate in tourism activities (Aref and Redzuan, 2009). Community capacity moving parallel with community development, community capacity building is very important in tourism development. Moscardo (2008) explained community capacity building is necessary for community development and participatory processes at the community level. The capacity of the community in tourism development can be seen as the capacity of people in the community to participate in tourism activities (Cupples, 2005). Fiona (2007) stated that community capacity building is an important factor in strengthening the welfare of individuals and local communities, with the support of local authorities. Community capacity building is the ability to empower citizens to manage themselves.
Based on the results of Salanguit (2009), conducted in Naga City, Philippines shows that community capacity building can be done by engaging the potential of local communities through improved skills and access to information. Involving the role of Balawista in maintaining the safety in coastal also can cultivate confidence in themselves to engage tourists more aware with the threat of disaster in coastal areas. Increased confidence in self-ability is also felt in students after being directly involved in the implementation of disaster management in the field (Hindriyastuti et al., 2019). Community capacity at the organizational level requires the role of professionals to help provide services in community development (Aref and Redzuan, 2009). Community capacity can be done with local development partnerships by local governments, private parties, and other public sources. According to Nies and McEwen (2015), community health development as an approach in community organizing combines concepts, objectives, and processes of public health and community development.
Community nurses in public health development are identifying community needs related to health and then developing, approaching, and evaluating health development goals through partnerships with other related professions. Therefore, knowing the characteristics of the community is a requirement to gain public acceptance of health services and improve health services in a particular communities.

Prevention
Precautions consist of three measures in accordance with the expected objectives and results. Primary prevention is used to prevent the risk of injury, injury, and disability of individuals and groups susceptible to health problems, in the form of environmental protection health promotion (Lancaster and Stanhope, 2014)

Empowerment
Empowerment is a process of developing knowledge and skills to improve people's abilities (Anderson and Mc Farlane, 2011). Empowerment is also a process that allows people to choose, control, and make decisions about their lives, with mutual respect for everyone (Friedman, Bowden and Jones, 2002). Community empowerment will ultimately result in community self-reliance. Lertputtarak (2012) stated that community participation in the planning and development of tourism development is indispensable from a sustainable tourism perspective. On the ground of this, engaging the community for developing the tourism can add a value to national tourism.

The Role of Community Nurses
Nurses in the nursing coastal tourism community can conduct health education related to the use of safety signs, the use of safety tools, safe limits of the swim, the spread of safety leaflets, early detection of vital sign measurements on coastal communities, handling cases of accidents on the coast before victims are referred to the health service.
Community nurses should be able to use the resources in the community and help the community make decisions to maintain and improve their health (J. A. . Nurses can act as defenders/advocates in helping the community overcome the problem (Ben-Natan, Ben-Sefer and Ehrenfeld, 2009). Community nurses can review and identify clients' health needs, design nursing plans to meet clients' needs, supervise and evaluate the impact on services provided (J. A.   (Nies and McEwen, 2015). Nurses in the nursing coastal tourism community can conduct activities as case managers, ranging from planning by helping to identify resources in the coastal community, motivating and coordinating in meeting the needs of community health services on coastal tourism, organizing all accident prevention and handling activities, supervising all service activities on the coast.
Community nurses with a variety of research activities, applying research results and nursing practices, collecting data, designing, and disseminating research results are used to identify the nursing interventions (Kulbok and Ervin, 2012). Nurses as liaisons assist in maintaining continuity between professional and non-professional officers.
Community nurses are expected to refer client issues to health care facilities as well as resources in the community such as health centers, hospitals, religious leaders, community leaders (Allender and Spradley, 2012). Nurses in coastal tourism nursing can act as a liaison to other referral health services, to other health professionals related to the problems experienced by coastal communities. Community nurses also become a facilitators in assisting Balawista in conducting hazard management process on the coast.
The role of nurses as facilitators based on Susilaningsih, Dayfi and Yudianto (2018) on this study is applied in the rescue of beach tourists in the form of facilitating the latest information and rescue facilities that can be applied in the rescue process.
Tourism generally has a socio-cultural impact on people and tourist destinations, such as changes in people's livelihoods with changes in work adapting to the needs of tourists, changes in cultural aspects of both language, tradition, and the transformation of norms and values. In addition to changing demographic aspects with an increase in the number of residents around the tourist area also changes the environmental aspects around tourist attractions such as traffic congestion, pollution (Sedarmayanti, 2014).
Coastal in Bali is a natural and cultural tourist attraction that has an attraction because of the special value of art and traditional ceremonies. Tourist attractions are all that are targeted by tourism. Attractions can be grouped into (Unga, 2011).

Duties of Coast Guard.
Balawista is a supporting element for quality of coastal tourism destinations for tourists who use all coast facilities, planning is important before making a tour related to the length of stay and the cost required during the tour visit (Crosskill, 2018). Balawista has daily tasks such as observing the weather conditions and the situation of the water area, determining and signaling the safety situation for coastal visitors, banning or allowing tourists to do activities in the water area, providing assistance to tourists who have experienced accidents on the coast (Dewi, 2009) take precautions and handling victims, provide information on safe swimming areas, conduct surveillance and urges, it is required to provide a sense of security and comfort of tourists to help the promotion of tourism towards the level of tourist visits (Wardhani, 2018).

Tourist.
Tourists are all people who travel intending to gain pleasure, not to work, to settle, and to make a living (Irawan, 2010). Characteristics of tourists who tour on the coast include in mass tourism, tourists usually come to famous and popular tourist destinations, involving masses of people (Weaver, 2012). Mass travel often involves package holiday deals such as visiting theme parks, sunbathing on popular coast. Tourism Safety. Safety concerns efforts to develop programs to prevent injuries, improve public safety, conduct partnerships between governments, non-governmental, community organizations, and individuals (Davis, 2014). Thus, public safety is an activity related to crime reduction and prevention efforts through improved services and partnerships. Public safety is the responsibility of all parties includes governments, other community institutions, organizations and associations, and also communities (Gondek & Tabaczniuk, 2011).

Causes of Accidents.
Based on the results of research from Khosravi et al., (2014), the biggest cause of accidents is due to unsafety behavior and unsafe environmental conditions. Unsafety public behavior such as disobeying regulations, being less cautious, not following existing safety procedure standards, not using unqualified safety tools, environments or equipment, natural factors (Khosravi et al., 2014). The high mortality and disability rates are also affected by the severity of accidents experienced by victims, the lack of knowledge and attitude of health workers towards the handling of accident emergency patients, and the lack of equipment available.

Characteristics of Balawista. Nurhanifah (2015) explained that older officers
show low-quality treatment in handling patients, productivity decreases in line with a person's age. A higher level of education can make it easier for a person to absorb the information he or she receives and be able to implement it in real behavior. Formal education shapes a person's value especially in receiving new materials (Yacoub, Miranti and Herkulana, 2016). Work experience can increase new information and insights. A person with a long working life tends to adapt to the work environment so that it can affect comfort in work (Saragih, Rosita and Rumapea, 2011).

CONCLUSION
Identified descriptions related to injury risk prevention, handling of incidents of accidents on the coast, safety needs and safety barriers encountered on the coast into 14 themes described based on the participant's statement, namely the theme of Balawista duty on the coast, warning signs on the coast, means of safety communication on the coast, improvement of Balawista capabilities on the coast, cases of accidents on the coast, how to handle cases on the coast, case referrals, needs for infrastructure facilities, human resources needs, health care needs on the coast, infrastructure factors, human factors, situation factors and how to solve problems.
The model of nursing coastal tourist through POSKESPAN is one of the service activities provided for tourists visiting the coast related to the prevention of the risk of injury and the handling of accidents on the coast. This model is suitable for coast tourism in Bali, because of the high health risks of tourists when visiting coast tourism, the high number of tourist visits especially during vacation, tourists with different cultures and characters, tourists focus only on natural beauty without thinking about the health risks encountered when doing coast tourism, tourist activities in coast tourism to sunbathing, swimming and surfing without specific skills about nature.
The model of nursing coastal tourists through POSKESPAN requires the involvement of Balawista as a coastal rescuer team, with the involvement of a team of Community Health Center nurses and related stakeholders include local government, Tourism Office, Health Office, community leaders, and other coastal communities. The role of Balawista and Community Health Center nursing team in the nursing model of coastal tourists through this POSKESPAN, is expected to help tourists conducting safe coast tourism activities, and tourists feel satisfied to enjoy coast tourism in Bali.

RECOMENDATION
There needs to be dissemination to the health sector and tourism sector towards the existence of the coastal tourist nursing model (KWP) through POSKESPAN as another alternative to community-sourced health efforts in Indonesia. POSKESPAN is more towards handling the emergency outside the building, targeting coastal communities in a particular order of the coast, placing the nursing team of Community Health Center as the manager of the POSKESPAN for primary and secondary prevention while guiding Balawista activities as a cadre of POSKESPAN, cross-sector partnerships, involving local governments.