THE EFFECT OF HEAD’S LEADERSHIP AND NURSES’ JOB MOTIVATION ON NURSING PERFORMANCE IN THE HOSPITAL INPATIENT ROOM

Background: The fluctuated patient satisfaction level shows the need to improve nursing performance. Several factors that can improve nursing performance include leadership, job motivation, management, and environment. Leadership and job motivation become fundamental aspects of improving employee performance. Aim: This study analyzed the role of the head’s leadership and nurses’ job motivation on nursing performance in the Indonesian Red Cross Hospital Bogor's inpatient room. Methods: This study sampled 150 nurses in the inpatient room of the Indonesian Red Cross Hospital Bogor using the incidental random sampling technique. This study employed a path analysis with three variables: the head’s leadership and job motivation as exogenous variables and nursing performance as an endogenous variable. Results: Leadership of the heads of the inpatient room could increase job motivation and nursing performance. Conclusion: Managers' leadership and job motivation could partially and simultaneously affect the level of nurses' performance. The Indonesian Red Cross Hospital Bogor could provide regular training to every head of the room to enhance their leadership and nurses’ job motivation.


INTRODUCTION
To provide effective and efficient services to the community, public service providers should have excellent performance.
Government-owned or private-public service providers have to possess integrity, professionalism, neutrality, and freedom from any pressure and Corruption, Collusion, and Nepotism (KKN) (Hayat, 2014). Public health service providers specifically have to yield optimal performance to serve the community. Humans are the driving aspect and determine the success of an organization or institution. Notably, public health service providers must have proper assessment or evaluation and get attention from leaders. The Law of Republic of Indonesia No. 36 of 2014 concerning Health Workers stated that health workers have an essential role in health services. Employees, or particularly health workers, are essential for every organization to effectively and efficiently achieve their goals. An organization expects its members not only to be competent, skilled, or capable of carrying out a task but also to be willing to work hard and achieve optimal results for an organization or institution (Indriyati and Hayat, 2015).
The Law of Republic of Indonesia No.44 of 2009 defines hospitals as an integral part of the entire health care system. The Indonesian Ministry of Health outlines that public hospitals are in charge of efficiently and effectively carrying out health services by prioritizing healing and recovery in a harmoniously integrated manner to improve, prevent, and carry out referrals. It is expected that hospitals can carry out affordable quality health services and optimal results to satisfy the customers.
The on-going hospital service system has to be reviewed to anticipate global competition in this globalization era. It should meet the community needs due to changes in the epidemic, the development of science and technology, and the socioeconomic structure. Public scrutiny and criticism, mainly dissatisfaction with health services, become one of the hospitals' problems. Therefore, health workers' performance is the key to serve patients more efficiently and effectively and with productive and excellent services (Gunawan, 2016).
If health workers do not provide excellent services, they will be detrimental to patients and other parties associated with various administrative matters (Rakhmawati, 2008). For example, slow and convoluted new patient registration will insecure patients' data. However, excellent public service will be challenging to achieve when health workers cannot improve their performance.
The success of public services at the Indonesian Red Cross Hospital Bogoris is inseparably related to health workers' productivity and performance. The percentages of hospital visitor satisfaction levels within 3 years were 84.66% (2013), 83.55% (2014), and 82. 29% (2015). While, the Bed Occupancy Rates (BOR) was at 77.80% (2014) and 65. 71% (2015). The data show that the hopsital's patient satisfaction level decreased due to decreased service performance levels. Gunawan (2016) states that health workers' performance strongly influences service performance.
The decrease in health workers' performance seems not to stand alone. It turns out to be correlated or influenced by various factors. Presumably, the role of head's leadership and employee job motivation can be considered as two dominant factors that possibly had a positive effect on the health workers' performance at the hospital. This assumption is based on some propositions.
First, how far the role of leadership between the leaders and staff influences achieving common goals. Leadership can also be seen in the process of cooperation between leaders and staff. It can respond to employee performance directly or indirectly. The 2011-2015 hospital visitor satisfaction level shows that leadership can certainly positively affect the health workers' performance at the hospital.
Second, job motivation is a driving force to improve health workers' performance. In a functional context, job motivation can also have a positive effect on health workers' performance. After being studied in-depth and considering various factors, this study assumes that head's leadership and nurses' job motivation may positively affect the health workers' performance. Organizations that succeed in achieving their goals and fulfilling their social responsibilities will significantly depend on managers or leaders. Leaders' quality becomes the most important factor in the success or failure of both business-oriented and public organizations.
This study lay upon the assumption that the hospital administration focuses on improving health workers' performance to serve better services. It is unclear whether or not problems in resources apparatus caused a decrease in patient satisfaction level. It is important to identify means of providing excellent services from the perspective of leadership and job motivation.
Leadership style is a method used by a leader to influence the behavior of others. A leader should have specific characteristics, understand leadership characteristics, and have three leadership components, such as leader, followers, and situation. Paramita (2011) mention several effective leadership styles in an organization: charismatic, authoritarian, democratic, and moral. While work ethic contributes relatively small but is still significantly used as a dimension that may affect an organization's performance. However, leadership and work ethic should simultaneously give a relatively large and significant contribution to improving employee performance and organizational development. The research conducted by Paramita (2011) used a quantitative approach, as this present study did. Their study involved leadership style and work ethic that presumably affect performance, while this present study researched leadership and job motivation. The differences as mentioned above and similarities became references in this present study to understand how they structured the research variables and how leadership influences performance. Warella, Rachmawati and Hidayat (2006) found a mutual relationship between employee job motivation and performance. The higher the job motivation, the higher the employee performance level. While they also discovered the same results in leadership and employee performance variables. Moreover, they found a significant relationship between job motivation, workability, leadership styles, and employee performance. Another study conducted by Tri Sasongko (2016) found that leadership style negatively influences employee performance (t-value = 2.756), but job motivation does not affect it. Referring to other previous iesstudies, this study brought the importance of analyzing the effect of leaders' leadership and employee job satisfaction on their performance. The fluctuated patient satisfaction level at the Indonesian Red Cross Hospital Bogor shows inoptimal nursing performance. According to the Head of the Medical Records Division, a decrease in inpatient visits and poor services by inpatient nurses indicate a lack of performance. The outpatient satisfaction level in 2014 and 2015 decreased compared to 2013. Moreover, a decrease in BOR occurred in the same year.
Based on the background of the issue, this study only discussed factors that might affect employee performance at the Indonesian Red Cross Hospital Bogor. More comprehensive findings might come from identifying all possibly affecting factors, but it is the limitation of this study that cannot research all at the same time. This study only picked leadership and job motivation, which effect on employee performance was in question.

METHODS
This study used a quantitative method and path analysis, which is mainly used for (1) explaining the study's phenomenon or problem (Kuncoro, 2007). This study analyzed the effect of leadership and job motivation (X1 and X2) on nurse's performance (Y); (2) predicting the value of the dependent variable (Y) based on the value of the independent variables (X); (3) determining factors that identify the effect of the independent variable (X) on the dependent variable (Y); (4) exploring the mechanism (pathways) of the effect of the independent variable (X) on the dependent variable (Y).
According to Covey (2005), leadership is a proactive effort to strengthen primary value and potency from people around us through four dimensions. These dimensions were developed into 12 indicators in the questionnaire. First, the role model was defined from (1) attitude, (2) nature, and (3) behavior. Second, pioneer was assessed from (4) organizational strategy, (1) organizational goals, and (2) organizational vision. Third, the coordinator was reviewed from (1) work systems development, (2) work systems management, and (3) work systems directives. Lastly, the advocator was broken down into (1) work focus, (2) work methods, and (3) teamwork.
This study also adopted the hierarchy of needs by Maslow (2013). The job motivation variable had five dimensions: physiological needs, security needs, social needs, appreciation needs, and self-actualization needs. These dimensions were then developed into twelve indicators in the questionnaire items. Physiological needs were measured from (1) life needs, (2) service, and (3) entertainment. Security needs were broken down into (1) internal situation and (2) external situation. In addition, social needs were seen from (1) togetherness and (2) teamwork. Appreciation needs were defined based on (1) leader appreciation to staff, (2) staff appreciation to leaders, and (3) appreciation among staff. Self-actualization needs were described from (1) self-image and (2) work performance.
The questionnaires showed 0.159 validity, and the reliability scores on leadership, motivation, and performance variables were 0.912, 0.785, and 0.897, respectively. The results concluded that the questionnaires used were valid and reliable. Data collection was conducted through self-administered questionnaires from May to June 2016 and then analyzed using SPSS software.
This study's unit of analysis was inpatient rooms at the Indonesian Red Jurnal Administrasi Kesehatan Indonesia Volume 8 No 2 December 2020 Published by Universitas Airlangga doi: 10.20473/jaki.v8i2.2020.175-187 Cross Hospital Bogor, located at Jl. Raya Pajajaran No. 80 Bogor. The population was 241 nurses in 12 inpatient rooms. The researchers first obtained permission from respondents during the data collection by distributing informed consent, anonymity, confidentiality, and freedom sheet. According to Sugiyono (2011), samples taken from the population must be truly representative. This study calculated the exact number of samples using the Slovin formula (Bungin and Burhan, 2005). The final samples obtained were 150 nurses. It lay upon the selected confidence level of 95%, the alpha significance level of 5%, and the r table of 0.159.
The random sampling was used when the researchers selected the respondents they met during the data collection (Sugiyono, 2016). To be considered the samples, the respondents should be permanent inpatient nurses willing to be respondents. Meanwhile, inpatient nurses who were on leave or sick and worked for less than one year were not selected. The total amount of the sample fraction was adjusted with the number of units, while the fi value was calculated through a random sampling method.
There were nineteen respondents in Dahlia Room, nine in VK Room, fourteen in Orchid Room, sixteen in Rose Pavilion, twelve in Jasmine Pavilion, and eleven in Flamboyant Pavilion. Additionally, there were ten respondents in Allamanda Pavilion, eleven in Aster Room, twelve in Magnolia Room, fourteen in Gardenia Room, eleven in Chrysanthemum Room, and eleven in Ixora Room.

Respondents'Characteristics
Respondents' characteristics include age, gender, latest education, work period, and social status. Table 1 shows that the majority of respondents were female (72%) and had Associate Degrees (Diploma III) (91.3%). Most of the respondents were married (67.3%). Some of them were aged around 31 to 40 years (30.7%). Nearly half have worked for more than ten years (45.3%).

Distribution of Respondents' Response
As many as 63.5% of respondents agreed and strongly disagreed with the role model's function to improve staff performance. Covey (2005) asserts the role model is a characteristic that drives someone to be a leader. This study also obtains 44% in total disagreed with the role of pioneer in improving staff performance. Moreover, 89.3% agreed that the coordinator dimension might improve staff performance.
A total of 77.3% of respondents agreed that the advocator dimension also may increase staff performance as Covey (2005) states that empowering a leader's skill is an internal potential that can be inherited to each staff. Table 2 shows that 54.9% in total did not agree that the dimension of the physiological need may improve staff performance. However, 73.2% of the respondents agreed that security needs may be the one that may improve staff performance.
There were 65.5% of respondents agreed that appreciation needs may make employees perform well. Besides, 77% of the respondents positively responded towards the function of self-actualization in improving their performance. It is also relevant to the hierarchy theory by Maslow (2013). In terms of staff performance itself, 65.2% agreed that tasks' clarity may encourage staff to perform better at work.
Moreover, 67.1% of the respondents agreed that the assistance dimension was thought to improve task performance. Improvement in task performance also has something to do with the incentive, as 78.2% have said in the questionnaire. As many as 70.5% of the respondents also agreed that the evaluation dimension may

Calculation of Path Analysis
This study's path analysis model uses two independent variables as exogenous variables and one dependent variable as an endogenous variable. The exogenous variables are leadership (X1) and job motivation (X2), while the endogenous variable is nursing performance (Y).
The equation structure of the path diagram model (Y = ρyx1X1+ ρyx2X2 + ε) could identify the causal relationship between these variables. Overall, there are three path coefficients, including 1) path coefficient on the effect of leadership on nursing performance (ρyx1X1); 2) path coefficient on the effect of job motivation on nursing performance (ρyx2X2); and 3) path coefficient on the effect of other variables on nursing performance (ρyε). Furthermore, the effect of exogenous variables on endogenous variables and the significance test of structural equation models were calculated simultaneously  Based on Table 3, the correlation coefficient between the effect of leadership and job motivation on nursing performance was 0.748. It shows that the effect of leadership and job motivation on nursing performance was strong.
The determination coefficient of R square or R 2 yx2x1 equals to 0.559 or 55.9%. It means that a 55.9% variation in nursing performance could be further defined by variations in the effect of leadership and job motivation. In other words, the effect of leadership and job motivation on nursing performance was 55.9%. Meanwhile, the effect of other variables that this study did not examine was 44.1%. The results indicate that the path coefficient of non-examined variables on nursing performance (ƿYɛ) was 0.664. Based on the regression equation, the coefficient of the effect of leadership on nursing performance (ρyx1X1) was at 0.473. While, the coefficient of the effect of job motivation on nursing performance (ρyx2X2) was at 0.745. Overall, the structural equation model would beÝ= Jurnal Administrasi Kesehatan Indonesia Volume 8 No 2 December 2020 Published by Universitas Airlangga doi: 10.20473/jaki.v8i2.2020.175-187 9.157 + 0,473X1 + 0,745X2 + 0,664Ɛ.
Based on the F test (ANOVA), the path coefficient shows two independent variables that affected the dependent variable. Thus, the path analysis results could be made into structural equations as in the path diagram model. Figure 1.

Direct, Indirect, and Total Effect of Leadership on Nursing Performance
The score of the direct effect of leadership (X1) on nursing performance (Y) was 0.473 x 0.473, which equals to 22.4%. Meanwhile, the score of the indirect effect of leadership (X1) on nursing performance (Y) through job motivation (X2) was 0.473 x 0.435 x 0.409, which equals to 8.4%. Thus, the total score of the effect of leadership (X1) on nursing performance (Y) was at 30.8%. In conclusion, leadership could determine nursing performance as much as 30.8%.

Effect of Job Motivation on Nursing Performance
The score of the direct effect of job motivation (X2) on nursing performance (Y) was 0.409 x 0.409, which equals to 16.7%. Meanwhile, the score of the indirect effect of job motivation (X2) on nursing performance (Y) through leadership (X1) was0.409 x 0.435 x 0.473, which equals to 8.4%. Thus, the total score of the effect of job motivation (X2) on nursing performance (Y) was at 25.1%. In other words, job motivation could contribute to nursing performance by 25.1%. This study's discussion is based on the causality relationship of leadership and job motivation as antecedent variables (a cause) and nursing performance as a consequent variable (a phenomenon or consequence). With this idea, the discussion only includes analyzing both the partial and joint effects of leadership and job motivation on nursing performance.
The results of this study indicate that leadership affected nursing performance as much as 42.4%. This study found a meaningful causal relationship (causeeffect) of leadership and nursing performance. In other words, if leadership is improved, nursing performance will simultaneously increase too.
The respondents argued leadership could provide self-reflection on a good leader's attitudes and behaviors in performing and completing tasks. As leadership is considered as a pioneer, every leader can be the one who initiates to give an example of behaving or acting following the norms, ethics, and SOPs at the Indonesian Red Cross Hospital Bogor. This study's results are in line with the results of the research conducted by Putra (2013). He found that leadership affected employees' performance, as indicated by the value of β = 0.388. If leadership increases, employees' performance will increase positively (Putra, 2013). The same thing is found in the research conducted by Wiranata (2011). The correlation value of leadership and employees' performance was at 0.73, meaning a strong relationship between leadership and employees' performance.
In line with this study's results, Sari (2019) discovered no significant relationship of head's leadership style and nursing performance in the inpatient room of the GMIM Pancaran Kasih Manado Hospital. It can be said that the leadership style cannot be ascertained because each head of the room had a different way to organize and direct his subordinates. Further analysis of leadership style's effect can be done when the heads use a democratic, participatory, or autocratic leadership style (Gannika and Buanasasi, 2019).
This present study pointed out that leadership had the lowest value among the other dimensions. The head's leadership could be seen from their initiative, characteristics, and competencies that the nurses could emulate. Leaders can also give nurses trust to perform their tasks.
The partial effect of job motivation on nursing performance at the hospital was 37.80%. The significant effect indicates a meaningful causal relationship (causeeffect) between job motivation and nursing performance. In other words, job motivation will improve, so will nursing performance. A safe and conducive working environment and friendly colleagues inside or outside the hospital can improve job motivation (Finarti, Bachri and Arifin, 2016).
With similar findings, Putra (2013) found that motivation affected employees' performance as indicated by the value of β = 0.168, meaning that motivation and employees' performance will increase simultaneously. Motivation could be seen from employees' needs for achievement, patience, and honesty in facing workplace problems, unyielding attitude, and resilience towards failure (Putra, 2013).
The most desired dimension of job motivation was motivation to achieve good performance.
The dimension of physiological needs has the lowest value among the other dimensions, including daily recreation needs. When nurses feel bored, recreational activities might refresh and encourage them to perform better at work. Physiological needs may improve employees' productivity, efficiency, and effectiveness to achieve organizational goals. It avoids failure in work reporting an unexpected absence and substituting employees by the organization or voluntarily. When employees resign, organizations must spend resources recruiting, training, and developing replacements (Jason et al., 2011).
Fulfilled physiological needs can provide good job motivation. Fulfilling the recreation needs can eliminate boredom and improve job motivation, resulting in better performance (Wirawan, 2015). Considering physiological needs is undoubtedly much more complicated than the quality of health services that focuses on patient safety (Iqbal, Syed-abdul and Li, 2015). The quality of health services is a multidimensional concept, in which patient safety also needs to be improved to achieve better performance (Ghahramanian et al., 2017). The effect of leadership and job motivation on nursing performance was 55.9%. The double hypothesis tests found a direct effect of leadership, and nursing performance (22.4%) was greater than that of job motivation, which only reached 16.7%. As four dimensions in leadership, such as role model, pioneer, coordinator, and advocator, could support leaders to be a good role model, nurses can get motivated to perform better.
Additionally, there was a partial effect of job motivation on nursing performance by 16.7%. It indicates a meaningful causal relationship (cause-effect) between job motivation and nursing performance. The results also prove that motivation was one factor that affects the level of nursing performance at the Indonesian Red Cross Hospital Bogor. Leaders' perceptions of organizational risks are primarily based on technological solutions to protect organizational assets and their belief that staffs usually adhere to the established organizational security policies (Phipps, Prieto and Verma, 2012). This indicates that leadership plays a role as a leveraging factor for the organization.
Leaders who perform themselves as pioneers will be able to strengthen employees' understanding of vision and mission. Staff with a high level of knowledge about the organization's vision and mission will affect motivation and inspiration to perform well at work (Darbi, 2012). A high level of knowledge about the organization's vision and mission will make staff think critically and pursue better work positions with increased enthusiasm and innovation (Orhan, Erdoğan and Durmaz, 2014). Leadership could construct values that will undoubtedly help form an organizational culture to give a more significant contribution to staff and patient satisfaction (Barrow, 2019). Moreover, it also could increase staff involvement in their work. Strong hierarchical orientation and results-based options from organizational culture as good leadership outputs can improve hospital performance (Sopoh et al., 2018).
Apart from the results of analysis, this study still had some shortcomings. It suggests further research to reach more units of analysis at the hospital.