Relationship of Nurse Caring Behaviour with Patient Satisfaction at the Emergency Department of Catholic Hospital of Budi Rahayu Blitar

One indicator of hospital services is patient satisfaction related to nurses caring behaviour. The caring behaviour of nurses who provide nursing services in the Emergency Department is expected to increase the satisfaction of nursing services. The purpose of this study was to study the relationship between nurses caring behaviour with patient satisfaction receiving nursing services at the Emergency Department of Catholic Hospital of Budi Rahayu Blitar. The research design was cross sectional. Sample sizes were 80 patients who received nursing services at the Emergency Department were selected by purposive sampling. The study variables were nurse caring behaviour and patient satisfaction. Data were collected using a questionnaire. Analysis using the Spearman rank test. The analysis results obtained p = 0.000 and r = 0.618, which means there is a strong positive relationship between nurses caring behaviour with patient satisfaction. Suggestion, nurses maintain and even increase caring behaviour, especially communication skills in the orientation phase.


INTRODUCTION
The globalization era promises new business opportunities and challenges for hospitals in Indonesia. However, there is fierce competition between domestic and foreign hospitals (Tjiptono & Gregorius, 2008). Hospitals that can compete are hospitals that provide quality services. Thus, hospitals are required to make improvements in the quality of service. A service is said to be of quality if the service indicator reaches or exceeds certain standards. One indicator used to assess hospital services is patient satisfaction (Nursalam, 2014).
Hospitals in Indonesia have not provided satisfactory services as expected by patients / consumers. The results of a 2010 Citizen Report Card (CRC) survey conducted by the Indonesian Corruption Watch (ICW) in 2010 with a sample of 738 inpatients in 23 Hospitals (Public and Private) found as many as 65.4% of patients complained of nurses' attitudes that were less friendly, less sympathetic, and rarely smile (Minar, 2016).
Emergency department is the start of hospital services, the philosophy used is time-saving so that fast handling is needed to save the lives of patients. Emergency department is the face of the hospital so that the dissatisfaction of service in this place will affect patient satisfaction in general. Nurse caring behaviour to patients is the essence of nursing that positively contributes to patient satisfaction while receiving nursing services. The research purpose was to study the relationship of nurses caring behaviour with patient satisfaction in the Emergency Department of Catholic Hospital of Budi Rahayu Blitar.

METHOD
The study design uses cross-sectional. Sample sizes were of 80 inpatients through the Emergency Department of the Catholic Hospital of Budi Rahayu Blitar on April 18 to May 7, 2017, was selected by purposive sampling. The measurement of caring behaviour used CBA (Caring Behaviour Assessment) which was modified by Lynn Kimble in 2003 and translated into Indonesian. The instrument contains 20 questions assessed on a 1-4 Likert scale, where: 1 = Strongly disagree if the situation is not in accordance with the conditions experienced, 2 = disagree if the condition does not match the conditions experienced, 3 = agree if conditions in accordance with the conditions experienced, and 4 = strongly agree if the conditions are very in accordance with the conditions experienced by the patient. The measurement of patient satisfaction variables uses a modification of the Satisfaction Instrument Based on Five Characteristics (RATER) with 25 question items. The measurement of this questionnaire uses a Likert scale of 1-4 where: 1 = Very dissatisfied, 2 = Not satisfied, 3 = Satisfied, and 4 = Very satisfied. Analysis used the Spearman rank test.

RESULT No
Characteristic f %

DISCUSSION
Nurse caring behaviour is an application of Watson's 10 carative factors including providing support, attention, respect, skill, health care, trusting relationships, being ready to help, providing support to patients for recovery, and maintaining patient privacy (Alligod, 2014;Watson, 2005;Watson, 2009). Nurse caring behaviour according to the patient's assessment was as much as 92.5% that the caring behaviour of the Emergency Department nurses at Catholic Hospital of Budi Rahayu Blitar was categorized as good, namely humanistic and altruistic, instilling trust and hope, and solving problems systematically. This nurse caring behaviour can support the nursing process (Potter, 2005;Potter & Perry, 2009).
The number of patients who rated nurses more women (62.5%) than men. This situation is similar to Ade's study (2012) that mentions the number of patients who rate equally between men and women. And, Suryani (2010) mentions the number of patients who rate more men than women. However, the results of the three studies obtained the same results, namely, the nurses caring behaviour is considered good by patients. These results illustrate that there is no significant effect between the sex of the patient on nurses caring behaviour.
Radwin in Ade (2012) states that the level of patient education affects perceptions while receiving quality nursing services. Patients with higher education tend to expect good nursing services because they are able to assess nurses caring behaviour. About 60% of patients who receive nursing services have senior high school and higher education, this situation illustrates that patients easily to receive information well.
Some factors that influence nurses caring behaviour are workload, knowledge of work environment, and training. As written by Suryani (2010) and Ade (2012) that a good work environment can create high caring behaviour for nurses and improve service quality. This is in accordance with a conducive working environment for emergency nurses at Catholic Hospital of Budi Rahayu Blitar. The results of observations during the study found that the relationship between nurses was good including the relationship between health workers or doctors. Thus, a comfortable environment makes health workers (nurses) behave positively which in turn can improve the quality of nursing services. This environment affects the nurse caring behaviour of good.
Catholic Hospital of Budi Rahayu Blitar has nurse development activities aimed at supporting nursing services. The activities carried out took the form of in-house training, namely Excellent Service Training, Seven Habits Training, and Effective Communication Training. This activity instils the value of caring nurses to provide services to patients, reflected in the hospital's motto that is Committed to LIFE (Love, Integrity, Friendship, Empathy). Thus, the value of caring in nursing such as empathy, love, and effective communication is not new for nurses although they have never received special training in caring behaviour.
Factors that can influence caring behavior are knowledge. Knowledge can be obtained through experience in certain fields for a long time (Ambar, 2016). As many as 54.5% of emergency department nurses at Catholic Hospital of Budi Rahayu Blitar have work experience of more than 10 years. In theory, written that caring does not grow on its own in a person but arises based on values and experiences in establishing relationships with others (Christopher, & Hedegus, 2000;Kimble, 2003;Rafii, & Nikravesh, 2006 (Johansson et al, 2002). Patient satisfaction is the level of one's feelings after comparing feeling after receiving service with expectations. If the service received is below expectations, the patient is disappointed, if the service received is as expected, the patient will be satisfied. Nursalam (2014) writes factors that affect patient satisfaction, namely: product or service quality, price, emotional, performance, aesthetics, product characteristics, service, location, facilities, communication, atmosphere, and visual design. Assessment of patient satisfaction is measured using five dimensions of service quality, namely RATER (Responsiveness, Assurance, Tangibles, Empathy, and Reliability) (Gerson, 2004;Kotler, 2003). All patients expressed satisfied and were very satisfied to receive nursing services. Patient satisfaction is influenced by the quality of nurse services. Factors affecting nursing services are nurses having more than ten years of experience and educated in nursing so that long experience of nurses influences nursing professional skills and improves communication skills. Thus, the ability of nurses to provide high nursing services affect patient satisfaction.
Patients who expression very satisfied aged 40-60 years (44 patients). there is a theory states that a person's age affects satisfaction, that ages 40-60 years as the ages where individuals are able to guide themselves optimally and are able to assess themselves. So that patients this age more quickly accept the situation than the young. The assumption is that young individuals have more demands and expectations on health services, tend to complain, criticize, impatient, and want to be served quickly (Monica, 2008;Pohan, 2007;Wiyono,1999). Older individuals are generally wiser, understand situations and conditions, are able to be patient, and do not have high demands or expectations of the service received.
Spearman rank test results obtained p = 0,000 and r = 0.618 which means there is a strong relationship with the direction of positive correlation so that the higher the caring behaviour of nurses, the higher the patient satisfaction. Nursalam (2014) writes that the factors that influence satisfaction are the quality of services, in this case, the nurse's behaviour and what is meant is caring behaviour. Nurse caring behaviour can have an emotional impact on patients, provide security, create a relationship of mutual trust, provide more energy to patients, and increase physical healing as well Anjaswarni & Keliat, 2002). Nurse caring behaviour that is felt fulfilling patient needs, nurses immediately approach the patient, nurses are able to communicate well, and able to explain the patient's condition. However, there were 6 patients (7.5%) stated nurses caring behaviour was lacking but were satisfied with nursing services. Patients assess nurses caring behaviour is lacking in affective behaviour that is not introducing themselves and not understanding patient feelings. However, patients highly value the nurse's cognitive behaviour, namely communication skills, taking action, and using medical equipment. This illustrates the patient's perception of nurse service satisfaction is more influenced by nurse cognitive behaviour meaning that patients are more satisfied if the nurse has service skills.

CONCLUSION
Based on the results of the study (1) the nurse caring behavior of well-categorized, (2) The level of patient satisfaction during receiving categorized nursing services was satisfied, and (3) there is a relationship of 0.618 (p=0.000) between nurses caring behavior with the patient satisfaction during receiving services at Catholic Hospital of Budi Rahayu Blitar.

SUGGESTION
It is expected that emergency department nurses continue to show caring behavior when providing services to patients even in conditions of high workload, especially in the orientation phase, namely by introducing themselves to patients so that a therapeutic relationship can be established between nurses and patients.