An important sector in welcoming the Golden Indonesia program in 2045 is health. As one of the countries that has successfully passed the Covid-19 pandemic with a good predicate, Indonesia has an uneven number of hospitals throughout the archipelago. It is a sector that is capital-intensive, science and technology-intensive, human resource-intensive, regulatory-intensive, and, at the same time, a sector that has dense problems (Kholisoh, 2023). In addition to malpractice issues, services related to communication and the attitude of health workers are a source of many problems that occur in hospitals (Waine et al., 2022).

Violations often occur when patients expect to get maximum treatment but feel otherwise. Problems related to dissatisfaction with hospital services occur in almost all hospitals in Indonesia (Tangel et al., 2019). especially government hospitals that seem indifferent to patients. Hospital competition nowadays, there is a growing awareness of hospital management regarding violations against patients.

If nurses provide care that does not meet the standards, then they are considered negligent. Negligence in nursing practice is a nurse who does not use the level of nursing skills and knowledge that is by the SOP standards used in caring for patients or injured people. The success and creation of health goals for the community certainly cannot be separated from the role of health workers as the main health servants who are required to work professionally and responsibly (Riasari, 2021).

As an organization that often interacts with the public, maintaining good relations between the public and the organization is very important. This is certainly to build, develop, and maintain mutual understanding between the organization and the community. Public relations functions as a liaison between the institution and the general public (Rahardi, 2019). Public relations is tasked with disseminating information and building, maintaining, and growing good relationships so that the organization is viewed favorably (Harahap, 2017). Every organization, including government and private hospitals, needs public relations. As a healthcare institution, hospitals must be responsive and productive in providing quality health services, which refers to health service performance (Imran, 2022). Because of this situation, hospitals must use professional concepts and strategies in all fields, including public relations (Suparman et al., 2022).

The reputation of hospitals is increasingly at stake when many service violations arise that cause patients to be dissatisfied with the performance of hospital services (Ulansari et al., 2016). This is certainly caused by several factors, including a decline in the performance of the health workers themselves, complications in the patient service process, the overall speed of service, and the accuracy of medical personnel in diagnosing patient illnesses and certainly complicated bureaucracy (Lestari et al., 2023). When patients come to the hospital, they bring great expectations to get maximum service that can ease the burden of the disease they feel. Patients have hope to recover when they are in the hospital, meeting with nurses and doctors who work there with good service standards (Sari & Basit, 2020). Creating a feeling of happiness is one of the best supports for patients in chronic conditions that nurses can provide, but sometimes this is not done by nurses (Lestari & Astuti, 2021).

However, this becomes a problem in itself where the expectations of the patient do not get the maximum response from medical personnel, especially nurses, in providing services to patients. Good communication skills possessed by a nurse are the most effective tool for obtaining information (Anjaswarni, 2016) to help patients understand the importance of communication. However, effective communication is not always obtained. Many patients feel uncomfortable, so the information conveyed is not appropriate, and this causes different perceptions of the disease diagnosis process, which results in errors in medical treatment actions taken by nurses and doctors (Afrilia & Christiani, 2020).

The role of a hospital public relations must be able to overcome this. as an officer who gets the nickname as a firefighter during a crisis. A hospital public relations must be able to solve these problems (Lin et al., 2022) how a hospital public relations must provide good service communication training and overcome the form of violation of expectations that occurs between nurses and patients in the hospital (Paramita et al., 2020).

Health communication is very important because it is how medical personnel, especially nurses, extract information from patients during hospitalization (Naufalia & Ali, 2023). To decide what to do about a patient's complaint and condition, one must ask direct questions and gather information thoroughly. Conversely, patients must be able to communicate well, providing true and accurate information about their health problems. Some previous research related to the study of public relations and violations that occurred by Sri Wahyuningsih in 2019 regarding public relations strategies in improving the image of the organization, here researchers found several strategies related to improving the reputation of the Royal Surabaya Hospital in improving services to patients (Wahyuningsih et al., 2019).

Another study conducted by Sutan Harahap in 2017 related to the performance of public relations at the Tanjung Pura Pontianak Hospital, where in this study, it appears what performance is carried out by hospital public relations to overcome the obstacles of problems that occur both internally and external problems with external parties, including problems that often occur between nurses and patients. The problem of satisfaction with health services provided by nurses to patients whose results are beyond expectations (Harahap, 2017).

Another study was also conducted by Maharani Imran in 2022 with the title, namely Improving the Reputation and Image of the Hospital through Public Relations Strategies, where a public relations person is required to be able to solve problems that are a challenge for hospitals in this era, how hospitals must provide good service to patients with good communication between patients and medical personnel in the hospital. The highest level of communication occurs between nurses and patients, especially in the inpatient room. The highest level of communication occurs between nurses and patients, especially in the inpatient room how PR overcomes various problems that arise due to misperceptions between nurses and patients (Imran, 2022). Some of the research above has similarities with the research that researchers do in This is how the role of hospital public relations in dealing with forms of violation of expectations that occur between patients and nurses at UNS Surakarta Hospital.

Expectation violation theory is packaged in the form of propositions that indicate empirical relationships between two or more variables and is abstract enough to generate many testable hypotheses (Carroll, 2016). In general, people believe that interpersonal communication and human behavior determine these statements (Griffin et al., 2018). One of the communication theories, specifically interpersonal communication theory, was first introduced by Judee K. Burgoon and friends around the 1970s. This theory is also known as the expectancy violation theory. The influence of nonverbal communication and human behavior is discussed in this theory. Expectation violation theory later evolved into nonverbal expectation violation theory, which was also proposed by Judee K. Burgoon in the 1980s and 1990s. This theory explains how humans damage their own space. Expectation violation theory was created to address this conflict. It incorporates research from a communication standpoint by considering what communicators expect, the meaning they give to proxemic patterns, and the impact of alternative spatial and distance arrangements (Adiwibowo, 2016). According to expectancy violation theory, the interpretation of a message does not depend on what is said or how it is delivered. Instead, the interpretation of a message is determined by the situation, the reward value of others, and how well the message meets the individual's expectations. When what we expect to happen in an interaction does not happen, we will note how often it happens and pay more attention to other events that occur. When someone breaks the rules, such as standing too close or saying inappropriate things, a violation of expectations occurs (Burgoon, 2016).

This research uses a descriptive qualitative case study research design. This research is based on the results of interviews with nurses in charge of oncology inpatient wards, oncology surgical patients, and public relations of UNS Hospital. Interviews were conducted with interview guidelines that had been prepared by the researcher so that they remained focused on the research objectives located in the inpatient ward and public relations room of UNS Hospital. Research with the case study method is to state the theory and research statements that must be answered and aims to find out about something in depth and detail.

Researchers use the case study method to describe the form of violation of expectations that occurs and how the role of Public Relations of UNS Hospital in overcoming violations of expectations that occur between nurses and patients. In this qualitative research, the type of research applied is descriptive research. The purpose of descriptive research is to provide a systematic, factual, and accurate description of the facts and characteristics of a particular population or area to improve the quality of the research (Ibrahim et al., 2018). This study collected data through field observations, interviews, and discussions. The informants used in this study were public relations, nurses, and patients at UNS Hospital. This study used a sampling technique to determine informants; this technique is purposive, which is expected to represent the research population and is tailored to the data needs of the study (Sugiyono, 2014). The data source used by researchers is primary data derived from field observation observations of public relations, nurses, and patients at UNS Hospital, as supporting data in this study using secondary data in the form of literacy and documents such as data from medical records or EC.

In the process, this research uses standardized provisions in determining nurses and patients as sources of interviews. The patients interviewed were patients who occupied the VIP treatment room of as many as three people and class 1 nursing room of as many as two people, then the nurses on duty in the wardroom were three people each and were supported by the results of interviews from public relations of UNS Hospital.

Research that uses descriptive types requires data validity testing. This is used so that this research can be accounted for regarding the validation of the data obtained. In this study, researchers used a data validity test where data validity testing was carried out through credibility, transferability, dependability, and confirmability (Nurdin & Hartati, 2019). To test the validity of this study, the type of data credibility is used, namely by observation and increasing rigor at UNS Hospital. In qualitative research, the reality obtained is heterogeneous and always changing so that nothing is fixed and repetitive, as in the continuous observation of the behavior and activities of selected nurses or patients. Because the data collected is considered reliable. In addition, it is mentioned that qualitative data analysis is carried out directly, interactively, and continuously until final data is reached. Data analysis is carried out in three stages, namely data reduction, data presentation, conclusion drawing, and verification (Zuliani et al., 2023). To analyze the data, a pattern of matching was used. This means that the researcher compares the results of the study with the hypothesis in the theory to conclude.

Great expectations by patients regarding the hospital services they get are important things that must be considered by medical personnel, especially nurses, in providing health services. UNS Hospital has its challenges in overcoming violations of expectations that occur between nurses and patients, especially inpatients. As the only hospital, as an educational institution under the auspices of the Ministry of Education, UNS Hospital is trying very hard to improve its branding so that public confidence in seeking treatment continues to increase.

Based on patient data at UNS Hospital in the span of December 2022 - January 2023, the high Bed Occupancy Rate (BOR) of the hospital makes health workers, especially nurses, overwhelmed in caring for patients, see Table 1. The increase in patients in this time frame has caused various problems, one of which is the violation of nurses' service expectations for patients.

UNS Hospital was built on land located on Jalan Ahmad Yani No. 200 Kampung Makam Haji, Kartasura District, Sukoharjo Regency, which is a hospital under the auspices of the Ministry of Education and is managed by health professionals from their fields, see detail characteristis of UNS Hospital at Table 1, and for the nurses at UNS Hospitals at Table 2. The researcher's consideration made this choice because UNS Hospital is a type c hospital that serves patients in the western Surakarta region and its surroundings. UNS Hospital, as a teaching hospital, certainly has a heavy burden on how to show and compete with similar hospitals in the Surakarta area. There has been no previous research with similar themes conducted at the hospital. From the above considerations, the researcher decided to use UNS Hospital to find the root of the problem. Through the initial interviews that researchers conducted, they found violations of nurses' communication expectations with patients.

At the time of the initial meeting between the nurse and the patient in the inpatient room, they did not know each other, so the patient had high expectations of the nurse's behavior in the inpatient room. Nurses take care of patients, especially after the action and stay in the inpatient room experienced by the patient. The form of interaction carried out by nurses towards patients in the inpatient room is that nurses will introduce themselves, say greetings, and say names. Introductions with pediatric patients are slightly different because they are usually afraid, so nurses use a different communication language style than the treatment of adult patients. In contrast to what was conveyed by the patient when interviewed, during the interaction, there was a violation of expectations experienced by the patient and the patient's family towards the medical care behavior of a nurse. Patients felt disappointed with the nurse's actions because they felt they did not receive clear and detailed information. Violation of expectations in this case might be minimized if the nurse uses non-verbal communication with eye gaze or apologies with hand movements placed in front, with a smile, the patient's perception will likely be different. The results of this research taken from interview of ten informants, detail of informants availabel at Table 3.

According to expectation violation theory, communication violations can be categorized as good or bad, positive or negative, see detail results of interview at Table 4. Violations can be judged positively or negatively depending on how one sees the offending person. Nurses in carrying out health service tasks to patients are not alert, sometimes even doing things that unwittingly cause violations of expectations in patients. as revealed by one informant:

"After the operation, the next step was not explained because I met a nurse, so I asked her (nurse) only answered to wait for the results first, I mean, for example, after the OP tomorrow, I can go home, or if the results are bad, I can stay another week or what, I have to prepare and inform my family, so I finally just gave up, I don't want to ask anymore." (WY patient interview, April 1, 2023)

In the context interview results, nurses do not explain detailed information to patients, and body gestures and communication used also do not show empathy and seem slow in the health service process. This certainly brings a bad image regarding services to UNS Hospital. Patients feel ignored because nurses provide information gradually. The nurse did not explain in detail what the patient should do. Although the nurse only came to check the tension and impulse hose, there was no verbal communication. The patient hopes that nurses will be more empathetic so that they show a caring attitude towards patients when providing care.

In communicating, nurses use body language that is not polite. This makes patients feel uncomfortable and will affect their health conditions, both when nurses extract information about patient complaints to determine further action and when patients are in the inpatient room. as conveyed by one of the patients.

"... after the operation, the night was immediately taken to the inpatient room, maybe because at that time it was already 11 o'clock, maybe the nurse was already sleepy, I asked her the answer was a bit unconnected, in my heart, never mind tomorrow morning I will ask further, I was also lazy when asked how come the answer was a bit unpleasant, silent, no attention" (TN patient interview, March 26, 2023).

The third assumption of this expectation violation theory is that people can make predictions related to verbal communication, such as eye contact, touch, body language, etc. The communication conveyed by the nurse at that time, both in language and behavior, was disrespectful and uncaring, even though the situation occurred in the evening hours, when people usually rest, so the nurse should be more adept at communicating in such situations. The violation of expectations that occurred was caused by the nurse's lack of ability to carry out the care process for the patient.

"Yes, at first I didn't understand, the intention was to get better quickly, to be hospitalized here, when the bandage was about to be changed, I complained that it was a bit painful, and there was a little blood while continuing to change the bandage with her when cleaning and changing the bandage, I should have used cotton, but I forgot to bring it, then I used a tissue near the table, two wraps of bandage, I said it was safe, in my opinion, how come the wraps were less, but the nurse said it was." (patient interview DY, April 01, 2023)

Patients feel disappointed with the nurse's actions because they feel they are not receiving clear and detailed information. If the nurse uses non-verbal communication with eye gaze or with a hand gesture in front and a smile to apologize in this case, the patient's perception will likely change.

The role of hospital public relations is needed in overcoming the obstacles faced by the hospital, as stated above, how public relations can provide solutions to the forms of violations that have occurred between nurses and patients in the inpatient room. Nurses already feel they are doing their job well in terms of operational standards, but that is not enough because what nurses serve are humans, and humans have a stimulus to judge someone's actions positively or negatively. In this case, the role of public relations is to apologize for the violation received by the patient, and then, as a solution, nurses who still have work experience under 2 years are given regular training related to effective communication in carrying out their nursing duties. as conveyed by Public Relations of UNS Hospital as follows:

"Here (UNS Hospital), every 6 months, there is always coaching for nurses, especially for new nurses who have worked for less than one year, this is to avoid unpleasant things from the patient's point of view and to maintain that no services are missed by the SOP to achieve superior hospital accreditation." (PR, March 20, 2023)

Public relations (PR) play an important role in pandemic situations where PR tries to show a positive image, namely a sense of security and comfort in hospital services. The role of public Relations has four categories, namely: (1) Expert Advisor or Expert Prescriber, (2) Communication Facilitator or Communication Facilitator, (3) Problem Solving Process Facilitator, (4) Communication Technician or Communication Technician (Littlejohn et al., 2017). to overcome the form of violation of expectations that occurs between nurses and patients, of course, public relations must have a strategy (Brilhante et al., 2024). One of the duties of public relations is as a hospital expert advisor, a role that has the function of providing input to management about the conditions that are happening to maintain a positive reputation in the community.

The second role must also be carried out about resolving a violation that occurs between nurses and patients, where public relations must be able to become a facilitator between the two parties so that a mutually beneficial solution is found. The most important thing in carrying out the role of public relations, namely being a bridge between the two parties to solve problems peacefully, being a facilitator in finding the best solution expected by both parties so that the problem of violating patient expectations by nurses does not need to go to the realm of law.

In expectancy violation theory, discrepancies with expectations have consequences. Stimulus value is the term used to describe this deviation or violation. Stimulus value means that when a person's expectations are violated, their interest or attention will be stimulated, which prompts them to use certain mechanisms to deal with the violation that occurred (Carroll, 2016). If there is a stimulus, a person's interest or attention to the deviation will increase, and attention to the message will decrease. The source of the stimulus will be the main focus.

According to Levine, when there is a stimulus, a person's interest or attention to the deviation will increase, and attention to the message will decrease. The source of the stimulus will be the main focus of one's attention. The types of stimuli given to a person can be divided into two categories: the first is cognitive stimuli, namely alertness or orientation toward violations, which is what is called cognitive stimuli. When a person gets cognitive stimuli, their intuition will increase (Adynski et al., 2022). then the second is physical stimuli, where the behavior that communicators do during the interaction includes getting out of an uncomfortable talking distance, changing their perspective during the interaction, and other things (Jun et al., 2021). According to Richard West and Lynn H. Turner in the book Introducing Communication Theory: Analysis and Application, there are three assumptions of expectation violation theory, namely, first, expectations encourage human interaction, second, expectations of human behavior are learned, and finally, people make predictions about nonverbal behavior.

The violation of expectations that occur between nurses and patients is the subject of this study. This study focuses on the form of violation of expectations by nurses towards patients in the inpatient room of UNS Hospital. These factors include individual communicator factors, relational factors, and context factors. The form of violation of expectations that occurs between nurses and patients can be broken down into 3. Namely, nurses are less alert in responding to patients in terms of health service actions and slow ways of communicating. In the second form, where nurses use body language that is less polite in carrying out the health service process to patients in the inpatient room, verbal and non-verbal communication provided by nurses is considered less positive by patients. This is indicated by the response to verbal and non-verbal communication given by nurses to patients. Then the third form of violation of expectations is the lack of ability and knowledge of nurses in carrying out health service tasks to patients. This is certainly influenced by how long the nurse's work experience is as well as age and gender. Violation of expectations received by patients greatly affects the reputation of the hospital. The research reveals how the strategy of public relations of UNS Hospital performs its role as an expert advisor, a facilitator, and a provider of solutions to problems that arise. This study managed to reveal the form of violation of expectations committed by nurses against UNS Hospital patients; there are three things: the first is that nurses are not alert in responding to patient complaints, the second is that nurses use impolite body language in the communication process and the third is the lack of ability and knowledge of nurses in the process of patient care in the inpatient room. Then, from the form of violation of expectations that occurred, the Public Relations of the hospital performed three roles of public relations, the first of which was as an expert advisor, where public relations provided input to management regarding the case that occurred, then secondly that public relations as a facilitator between the two disputing parties, and finally the third that hospital public relations acts as a bridge that provides solutions or solutions by providing intensive training to nurses at UNS Hospital.

This work was supported by the Politeknik Indonusa Surakarta, Surakarta, Indonesia.

Conceptualization, Eni Lestari, Andre Noevi Rahmanto; methodology, Eni Lestari, software, Andre Noevi Rahmanto.; validation, Eni Lestari.; formal analysis, Eni Lestari.; investigation, Eni Lestari.; resources, Andre Noevi Rahmanto.; data curation, Andre Rahmanto.; writing—original draft preparation, Eni Lestari.; writing— review and editing, Eni Lestari.; visualization, Eni Lestari.; supervision, Eni Lestari.; project administration, Andre Rahmanto.; funding acquisition, Eni Lestari

This research received no external funding. Funding for this study was carried out independently.

The research team stated that the primary data from this study could not be accessed by the public. "Not applicable".

The authors declare no conflict of interest.