APPLICATION OF STRUCTURAL EQUATION MODELING ( SEM ) FOR ANALYSIS OF THE EFFECT OF PERCEPTION ON PROFESSIONALITY, KNOWLEDGE AND MOTIVATION OF NURSES ON THE IMPLEMENTATION OF PATIENTS SAFETY PROGRAMS IN THE INPATIENT ROOM OF

Patient safety is a priority for implementation of the five important safety issues in hospital, because of patient safety issues related to the quality and image of the hospital it self.Therefore patient safety is the first priority to be implemented and it is related to the issue of the quality and image of the hospital.Objective in this study was to determine the effect of Perception variables about Professionalism, Patients Safety Knowledge and motivation of nurses on the implementation of patient safety programs in the Inpatient Room of RSUD X Regional Hospital Semarang.This research method was quantitative observational analytic a cross sectional research with purposive sampling, and amount of respondent are 120.Obstain data was processes with SPSS Amos 24 software .The results showed that the perception variable about nursing professionalism (0.377)

Patient safety is a priority for implementation of the five important safety issues in hospital, because of patient safety issues related to the quality and image of the hospital it self.Therefore patient safety is the first priority to be implemented and it is related to the issue of the quality and image of the hospital.Objective in this study was to determine the effect of Perception variables about Professionalism, Patients Safety Knowledge and motivation of nurses on the implementation of patient safety programs in the Inpatient Room of RSUD X Regional Hospital Semarang.This research method was quantitative observational analytic a cross sectional research with purposive sampling, and amount of respondent are 120.Obstain data was processes with SPSS Amos 24 software .The results showed that the perception variable about nursing professionalism (0.377) had the most positive and direct effect on the implementation of patient safety programs compared to the direct influence of patient safety knowledge (0.223) and patient safety motivation (0.266) patient safety implementation programs. This means that the increase in the implementation of patient safety programs is greatly influenced by the role of perception of nursing professionalism. 289 8% to 98.2% for diagnostic errors , and 4.1% to 91.6% for medication errors. Continued development of research on patient safety in various regions in Indonesia, but until now there has been no national study.
Based on patient safety incident reports in 2011, the number of patients safety violations was 11.23% committed in the care unit, 6.17% & in the pharmaceutical unit and 4.12% by doctors (KKPRS, 2015).
Various countries have reported the number of patient safety incident in hospitals, although the reports do not yet describe the whole. The National Patient Safety Agency reports that from April 2016 to March 2017 there were 1,925,281 incidents in the United Kingdom. Ministry of Health Malaysia reported 2,769 incidents occurred in 2016. In Indonesia based on the KKPRS report there were 144 incidents (2009), 103 incidents (2010) ), and 34 incident reports in the first quarter of 2011. (Nasution, 2018).
The target of patient safety in accreditation carried out by KARS (Hospital Accreditation Committee) refers to JCI and PERMENKES No. 11 of 2017 concerning patient safety in hospitals in article 8 paragraph 2 states that patient safety targets consist of 6 points which include accuracy patient identification, increased effective communication, increased safety of the drug that needs to be watched, certainty in the right location; right procedure; right patient operation, reduction in risk of infection related to health services and reduction in the risk of falls (Depkes RI, 2017).

Literature Review
According to Soehardi, (2014) explains perception is defined as a process in which individuals give meaning to stimuli from the environment based on the impressions captured by the five inderannya. Blais (2015) argues that professional health workers are health workers who have special abilities and expertise in their fields so that they are able to carry out their duties and functions as health workers to the maximum.
The Indonesian National Nurses Association ( 2019 ) defines the practice of professional nursing as an act of providing professional nursing care both independently and in collaboration which is adjusted to the scope of authority and responsibility based on nursing knowledge. There are a number of reasons that a nursing practice is professional, that is, autonomy at work, being responsible and accountable, independent decision making, collaboration with other disciplines, advocating and facilitating client interests.
According to Notoatmodjo (2014) knowledge about patient safety is the result of tofu and this happens after people have sensed a certain object. Sensing occurs through the five human senses, namely the sense of sight, hearing, smell, taste and touch. Most of the knowledge about human patient safety is obtained through the eyes and ears. Knowledge of patient safety or cognitive actions of a person knowledge of patient safety includes memories about things that have been learned and stored in memory. These things are known to be factors that influence the knowledge of patient safety such as educational background, socioeconomic and employment.
Meanwhile, according to Siagian (2015), states that the work motivation of nurses is a driving force for someone to contribute as much as possible for the success of the organization to achieve its goals. With the understanding, that the achievement of organizational goals means also achieved the personal goals of the members of the organization concerned.
According to Hariandja (2014), said performance is the result of work produced by employees or actual behavior that is displayed in accordance with their role in the organization.
Patient safety is a system where a hospital makes nursing care for patients so patients are safer in undergoing their care which includes risk assessment, identification and management of matters related to patient risk, reporting and analysis of incidents, ability to learn from incidents and follow-up and the implementation of solutions to minimize the risk and to prevent injuries caused by mistakes caused by carrying out an action or not taking the action that should be taken (Depkes RI, 2017). Hadian, Kholil, and Syahfirin Abdullah (2019) stated that motivation and involvement of patient have positive impact to safety program. Implementation of patient safety in hospitals refer to IPSG (International Patient Safety Goal) which is a target that must be achieved by an hospital that is accredited by the Joint Commission International for international standards of hospital accreditation. IPSG itself has been applied in many Indonesian hospitals through policies listed in 290 Regulation of the Minister of Health No. 11 of 2017 concerning Patients Safety in hospitals. The patient safety targets is identifying patients correctly, increasing effective communication, increasing awareness of medications that need to be watched, ensuring procedures, locations and correct surgical patients, reducing the risk of infection due to health care and reducing the risk of injury to patients falling

Method:-
The type of research is quantitative observational analytic cross-sectional research with purposive sampling, and the amount of respondent is 120. The data consists of primary and secondary data. Primary data obtained through observation, questionnaires and interviews, while secondary data obtained through literature study. Data analysis through SEM (Structural Equation Model) method was originally used Covariance Analysis which was developed by Joreskog (1973), Kesling (1972) and Wiley (1973) .SEM is a combination of two separate statistical methods namely factor analysis (factorial analysis) developed in psychology and psychometrics as well as simultaneous equation modeling developed in econometrics (Ghozali, 2017). By SEM method efect of exogenous variables to indegenous variables can be idenfied (Hasanah, Nurul, and Sugiarto, 2019). Based on Table 4.1 it can be seen that the majority of nurses in the inpatient room of RSUD X Regional Hospital Semarang who are female respondents are around 75.8 percent. In addition, the majority of nurses are aged between 20-30 years, around 55 percent while nurses are aged over 40 years it's only been around 3.3 percent. So it can be said that the majority of nurses are young. Furthermore, based on their level of education, nurses are still dominant D-III graduates or around 58.3 percent and the rest are S1 or Nurse graduates. Whereas nurses who have completed their education until master degree do not yet exist. If seen from work experience, the majority of nurses work for at least 5 years in the inpatient room RSUD X Regional Hospital Semarang, which is around 60 percent. While nurses who have worked more than 10 years there are around 15.8 percent. Although the social demographic conditions of the nurses are quite diverse from a number of things, overall the nurses have attended training related to patient safety.

Instrument Quality Test data
The next step in analyzing research data is to test the validity and reliability of the list of questions or questionnaires submitted. In distributing questionnaires, respondents were given 24 questions representing each research variable where each variable was measured based on 6 questions. The instrument quality test is carried out to find out whether the research instruments have met the validity and reliability criteria. Following are the results of testing the validity and reliability based on the distribution of questionnaires to 120 respondents.

Validity Test
Validity test aims to measure the quality of research instruments. The instrument is said to be valid if the instrument can measure what should be measured (Cooper and Schindler, 2014). In this study, validity testing will be carried out using the Confirmatory Factor Analysis (CFA) method with the help of AMOS software. The CFA adopted in this study was used to evaluate the convergent and discriminant validity of the measurement scale. According to 291 Heir et al, (2014) a research instrument can be accepted if the loading value of each item is ≥ 0.4. CFA test is performed on exogenous variables, endogenous variables and on the full model.

Confirmatory Factor Analysis (CFA) Exogenous Variables
The construct variable is a research variable that cannot be measured directly but can only be measured based on certain indicators with the support of existing theories. The construct variable that is thought to influence other variables is called the exogenous variable. Exogenous variables in this study include perceptions of professionalism, knowledge and motivation. The validity test of the exogenous variables with CFA was carried out on the three exogenous variables. The results of processing the CFA model on exogenous variables are presented in

Confirmatory Factor Analysis (CFA) Endogenous Variables
The construct variables that are influenced by other variables or affect and are influenced by other variables simultaneously are called endogenous variables. Endogenous variables in this study include the implementation of patient safety programs. The results of processing CFA models on endogenous variables are presented in   294

Reliability test
The reliability test is used to test the level of how large a gauge measures in a stable and consistent manner whose magnitude is indicated by the coefficient value, namely the reliability coefficient (Sugiyono, 2016). In this study the reliability test uses the value of Construct Reliability (CR) and Variance Extract (VE). Items on a construct variable are said to be reliable if the value of CR ≥ 0.70 and the value of VE ≥ 0.50 (Ghozali, 2017). Based on calculation of 120 respondents obtained the results of reliability for each construct variable as follows

Descriptive Variable Data Answers
Descriptive statistics are statistics that are useful for describing the object under study through sample or population data as they are (Sugiyono, 2014).

Description of Perception About Professionalism
Summary of respondents' responses is proposed to measure the nurse's perception of professionalism through 6 indicators or statements.Based on the description of each item on the perception variable about professionalism, it can be said that the majority of respondents agree (44.9%) about the items that construct the perception variable about nursing professionalism.

Description of Perception About Knowledge
Recapitulation of respondents' responses is proposed to measure the knowledge variable through 6 indicators or statement items.Based on description of each item on the knowledge variable it can be said that the majority of respondents agree (45.6%) about the items that build the knowledge variable about patient safety.

Description of Perception About Motivation
The recapitulation of respondents' responses is proposed to measure patient safety motivation variables through 6 indicators or statement items.Based on the description of each item on the variable perception of motivation it can be said that the majority of respondents agree (47.2%) about the items that build motivation variables about patient safety

Description of Perceptions About Program Implementation
Summary of respondents' responses is proposed to measure the variable implementation of the patient safety program through 6 indicators or statement items.Based on the description of each item on the variable perception of the implementation of the program it can be said that the majority of respondents agree (42.9%) about the items that build the patient safety program.

Evaluate SEM Assumptions
The process of data analysis and research results will explain the steps of analysis used in this study.
The normality test is carried out using the criteria c.r ± 2.58 at a significance level of 0.01 or 1%. The results of the normality test data from this study can be seen in Table 4.10.
295 From Table 4.11 it is known that the observation data has the biggest d-squared dob squared value that is 44.279 at the 26th observation and also the d-squared dh Squared value of 36.813 at the 45th observation. This value is greater ꭓ 2 (24;0,05) =44,99. . Both observations are outliers. However, the number of outliers that are quite small or only around 1.67% can be ignored or still be involved in the model. Meanwhile, other observations have a d-squared mahalanobis value smaller than ꭓ2¬¬¬ (24; 0.05) so it can be said that the majority of the data does not contain outliers.

Goodness of fit test
The purpose of the test model fit or Goodness of fit is to find out how precisely these indicators can explain the latent variables that exist. The results of the Goodness of fit test can be seen in

SEM Analysis
To analyze the relationship between knowledge, perception and motivation variables on the implementation of patient safety, it can be seen in the following table.. Based on table 4.13 above we can explain the direct influence relationship betwen variables as follows.

Relationship of Knowledge to Program Implementation
The standardized estimate is 0.223; this shows that the influence of patient safety knowledge on the implementation of patient safety programs is positive. This means that the better the patient safety knowledge of nurses will increase the patient safety implementation program. A p-value of 0.045 or smaller than the 0.05 significance level indicates that the patient safety knowledge of nurses significantly influences the implementation of patient safety programs. SEM analysis results show that nurses 'knowledge about patient safety has a positive and significant effect on the implementation of patient safety programs, so the hypothesis that nurses' knowledge about patient safety has a positive and significant effect partially on the implementation of patient safety programs in the Inpatient Room of the RSUD X Regional Hospital Semarang supported.
This finding is in line with Notoatmodjo's (2014) theory that knowledge about patient safety is the result of tofu and this happens after people have sensed a certain object. So after the nurse knows about patient safety, he will then understand and then apply and evaluate what he knows.

Relationship of Professional Perception to Program Implementation
The standardized estimate is 0.377; this shows that the effect of perceptions about nursing professionalism on the implementation of patient safety programs is positive. It means that the better perception of nursing professionalism 297 will improve the implementation of patient safety programs. A p-value of *** or smaller than the 0.05 significance level indicates that perceptions of nursing professionalism significantly influence the implementation of patient safety programs. SEM analysis results show that the perception of nursing professionalism has a positive and significant effect on the implementation of the patient safety program, so the hypothesis that the perception of nursing professionalism has a positive and significant effect partially on the implementation of the patient safety program in the Inpatient Room of RSUD X Regional Hospital Semarang is supported.
This finding is in line with research by Kim I, Park M.J, Park M.Y, Yoo H, Choi J., (2013) who found that positive perceptions indicate improved patient safety efforts. The same thing was also stated by Blais (2015) that professional health workers have special abilities and expertise in their fields so that they are able to carry out their duties and functions as health workers to the maximum or in other words, professional health workers are welleducated and well-trained people in carrying out their duties.

Relationship of Motivation to Program Implementation
The standardized estimate is 0.266; this shows that the motivation of patient safety nurses towards the implementation of patient safety programs is positive. This means that the better motivation of patient safety nurses will increase the implementation of patient safety programs. A p-value of 0.025 or smaller than the 0.05 significance level indicates that the patient safety motivation of nurses significantly affected the implementation of patient safety programs.
Based on table 4.13 above, it can be seen that the variable perception of nursing professionalism (0.377) has the most positive and direct influence on patient safety implementation programs compared to the direct influence of patient safety knowledge (0.223) and patient safety motivation (0.266) patient safety implementation programs. This means that the increased implementation of patient safety programs is greatly influenced by the role of perception of nursing professionalism.SEM analysis results show that patient safety motivation has a positive and significant effect on the implementation of patient safety programs, so the hypothesis that patient safety motivation has a positive and partially significant effect on the implementation of patient safety programs in the Inpatient Room of RSUD X Regional Hospital Semarang supported.
This finding is in line with the research of Sudarsono's theory (2014) which states that nurses work motivation as a broad term, used in psychology, which includes internal conditions or conditions that activate or give strength to the organism, and direct the organism's behavior toward the goal . The same thing also stated Siagian (2015) that nurse work motivation is a driving force for someone to contribute as much as possible for the success of the organization to achieve its goals so that the achievement of organizational goals means also achieved the personal goals of the members of the organization concerned.

Conclusion:-
Based on the results of the analysis and discussion in the previous chapter it can be concluded that socially demographically, the majority of nurses working in the Inpatient Room of RSUD X Hospital Semarang can be categorized as young nurses but overall have received training on patient safety. Perceptions of professionalism have a positive and significant effect on the implementation of patient safety programs in the Inpatient Room of RSUD X Regional Hospital Semarang. Patient safety knowledge has a positive and significant effect on the implementation of patient safety programs in the Inpatient Room of RSUD X Regional Hospital in Semarang. Motivation of patient safety has a positive and significant effect on the implementation of patient safety programs in the Inpatient Room RSUD X Regional Hospital Semarang

Suggestion
Based on the conclusions above, the advice that can be given from this research is important for the hospital to continue to assist and provide guidance for nurses, especially young nurses to continue to improve work knowledge and motivation with full professionalism so that the implementation of patient safety programs can continue continuously. is expected to foster a climate of good professionalism perceptions of health workers, especially nurses who are the largest component of health service personnel in hospitals by providing management procedures for patient services that support patient safety programs. Hospitals must facilitate their health personnel by conducting training and workshops to improve knowledge specifically about patient safety in order to improve the implementation of the patient safety program. Hospitals are expected to increase the motivation of health workers in conducting nursing care through care reward as a result of the annual performance evaluation at the hospital. For