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The Leadership and Performance of Nurses in The Hospital

Method: the design of the study was descriptive correlational with a cross-sectional approach. The sample size of 205 respondents who were selected through simple random sampling technique. The inclusion criteria for respondents were nurse who were implementing nurse, working more than one year, and providing nursing care. The independent variable was the leadership, and the dependent variable was the performance of nurses. The instruments used were the situational leadership questionnaire questionnaire for leadership and the observation sheet: nursing documentation questionnaire for performance of nurse’s questionnaire. The data analysed using descriptive analysis and logistic regression test with a significance value of p ≤ 0.05.


INTRODUCTION
Nurses are the largest number of health workers in hospitals so they have an important role in determining the quality of health services through the performance of nurses (Nursalam et al, 2018). The performance of nurses determines the quality of health services, because the work scope of nurses is directly involved in interacting with other people and the environment (Pujiyanto et al., 2016). Some nurses are still found to have less than optimal performance in providing nursing care, due to factors that come from the nurses themselves, leaders and organizations (Wisuda & Putri, 2019). The performance of nurses in health services is influenced by organizational culture, as well as the application of leadership styles (Winasih et al., 2015;Due et al., 2020). Previously, there was no research on the most influential leadership on the performance of nurses in health services. So that, the relationship between leadership and nurse performance still requires identification.
The results of research in America in 2016, explained that 134 of 399 American nurses had poor performance on a scale of 33.8% (Dyrbye et al., 2019). Research in Turkey in 2017, explained that the performance of nurses had a value of 3.90 with a standard deviation of 0.58 (Özer et al., 2019). Research at the Manado hospital in 2015, explained that 45% of the total respondents were 40 nurses are still incomplete in documenting nursing care (Hia, 2019). Meanwhile, in 2018 research on the performance of nurses at one of the Madura Hospitals, explained that the majority of nurses had good performance, namely 41.5% with 44 nurses from 106 respondents and the assessment was lacking in nursing care documentation with the highest number shown in the assessment aspect (Nursalam et al., 2018).
The preliminary study on January 12-13, 2021, was carried out at RSUD dr. Soedono Madiun by looking at the staffing performance data, it was found that the average performance score of nurses in 2019 was 86.8% above the specified standard (≥80.00) using the employee work target system (SKP). The head of the room having their own and different ways of solving problems for each room.
Nurse performance can be improved through organizational characteristics such as leadership (Noor et al., 2020). This is because leadership can create an effective work environment for nurses to carry out nursing care by influencing, directing and motivating (Suratno et al., 2018). The implementation of a positive and effective leadership style will improve nurse performance (Due et al., 2020). Nurse performance is also maintained through the competence and motivation of nurses from QNWL (Nursalam et al., 2018). The poor performance of nurses will have an impact on the quality and satisfaction of services in the hospital (Winasih et al., 2015).
The results of this study can be used as a consideration for hospital management in making policies. Kopelman's theory in (Nursalam, 2015) explains organizational determinants, namely leadership affects individual or organizational performance, while other organizational determinants affect individual or organizational performance through knowledge, skills, and abilities. In addition, performance is also influenced by organizational characteristics, nurse characteristics, and job characteristics (Nursalam, 2020). Previous research on nurse performance has been carried out, but most have only focused on the individual characteristics of nurses. Therefore, this study examines other characteristic factors that are related to the performance of nurses in the hospital. The study aimed to analyze the relationship between leadership with the performance of nurses in hospital.

Research Design
The study was a descriptive correlational with a cross-sectional approach. The study was conducted during March-April 2021 in RSUD dr. Soedono Madiun. The measurement of the relationship between leadership and the performance of nurses was only done at one time and without any follow up.

Population, Sample, and Sampling
The population in this study were all nurses in RSUD dr. Soedono Madiun with a total of 439 people. The sample size of this study was 205 respondents with the following criteria inclusion: 1) implementing nurses, 2) working more than one year, and 3) providing nursing care. The sampling technique used is simple random sampling. Simple random sampling by writing the names of all nurses in the population on paper then placed in a box and taken at random.

Research Variables
The independent variable of this study is leadership, while the dependent variable of this study is the perfomance of nurses.

Research Instrument
The data were collected using an instrument in the form of a questionnaire consisting of 3 questionnaires, namely demographic data questionnaire, an leadership questionnaire, and an the perfomance of nurses questionnaire. The leadership is measured using the situational leadership questionnaire which consists of 12 questions (Nursalam, 2020). The leadership questionnaire contains questions that reflect authoritarian, democratic, participatory, and followfree leadership styles. The performance of nurses is measured using observation sheet: nursing documentation questionnaire which of 30 questions contains the nursing care carried out by the implementing nurse at the hospital (Nursalam, 2020).

Procedure
The research procedure begins with asking permission at the research location, then conducting a research ethics test. At the time of data collection, the researcher will provide an explanation of the objectives of the research to be carried out to the respondents. Data was collected by asking respondents to fill out the answers to the questionnaire according to their perceived conditions. During data collection, researchers implemented health protocols and were assisted by the head of the room to provide assistance, so that if there were questions that were not directly accessible.

Data Analysis
The data analysis used was descriptive and inferential analysis. Descriptive analysis is used to group data according to category and frequency. Inferential analysis used logistic regression test with a significance value of p ≤ 0.05.

RESULTS
The respondents of this research were mostly aged 31-40 years (40.5%), and dominated by female respondents (71.1%). In addition, the majority of respondents stated that they were married (78%). The education level of respondents was dominated by graduates from D3 (53.7%) with the majority of the length of work for 1-7 years (34.6%). Most of the respondents had employment status as civil servants (59.0%) and had the most career paths as clinic I nurses (39.5%). (Table 1).
In this study most of the nurse leadership has a democratic leadership style. (Table 2). The study showed that most of the performance of nurses was dominated good category in all of the components nursing care documentation. (Table 3). The research shows that the performance of nurses with good categories is mostly led by the head of the room with democratic leadership style. The performance of nurses with the less majority category is led by the head of the room with a follow-free leadership style. (Table 4). The logistic regression test result showed that leadership has a significant relationship with the perfomance of nurses (p = 0.000). (Table 5).

DISCUSSION
The leadership has a significant relationship with the performance of nurses in hospitals. The positive leadership style of the head of the room will tend to cause the performance of the implementing nurse to be higher. The performance of nurses with good categories is mostly led by the head of the room with democratic leadership style.
The leadership style is a leader's way of influencing others or his subordinates in achieving goals (Tinambunan & Tampubolon, 2018). Gillies theory in (Nursalam, 2015) explains that the leadership style based on authority and power is divided into authoritarian, democratic, participatory, and free of action. The application of a positive and efficient leadership style in nursing will improve the performance of nurses in health services (Due et al., 2020). The leadership style will motivate nurses to work, thereby improving the quality of hospital services (Yunarsih et al., 2020). The most influential leadership style on the performance of good nurses is the democratic leadership style, while the performance of nurses who are lacking is the most influenced by the free-of-action leadership style (Rahayu et al., 2019). The democratic leadership style influences others to work together to achieve goals by respecting the nature and abilities of the staff. Meanwhile, the follow-free leadership style is centered on the leader and allows the staff to work independently according to their own will (Deniati & Putri, 2019).
Nurse means leadership that combines listening, professionalism, calmness, experience, structural ability, effectiveness, encouragement, empathy, social competence, support, information and objectivity. The leadership that is suitable for nurses to apply in hospitals is democratic leadership. Democratic leadership in the hospital will organize well and provide relevant information (Holmgren et al., 2019).
The positive leadership style of the head of the room will have an impact on the performance of good nurses in health services. Each situation the head of nursing has a choice of action with the right nursing style depending on the conditions and circumstances of the team. In this study, most of the nurses who had good performance stated that the head of the room had a democratic leadership style. The head of the room uses a way to influence the implementing nurse by respecting the nature and abilities, encouraging staff to develop, and involving staff in decision making. This causes the implementing nurses to be motivated in carrying out performance, so that the quality of hospital services can increase. Meanwhile, an act-free leadership style will leave the staff as they wish. This action causes staff to work freely without being directed and motivated in a structured manner, so that it can have an impact on service quality. The limitation of this research is that there is indirect data collection or entrusted to the head of the room, so that

CONCLUSION
The leadership of the head of the room with a democratic style can improve the performance of implementing nurses in hospitals. The head of the room uses a way to influence the implementing nurse by respecting her nature and abilities, encouraging staff to develop, and involving staff in decision making. So that, the implementing nurse becomes motivated in carrying out performance.