ANALYSIS OF NURSE WORKLOAD ON IMPLEMENTATION OF PATIENT SAFETY AND TEAMWORK WITH CARING BEHAVIOR AS MEDIATION

Abstract


Introduction
The central issue currently developing for Indonesian nurses is the era of globalization competition in it, especially in increasing the role of caring as a basis for improving the quality of nursing services and patient safety. The basic problem in the Indonesian nursing profession is that nurses still have not carried out the caring role professionally in providing nursing care to clients.
Caring is the essence of nursing that distinguishes it from other professions and dominates, unites, and animates the act of caring nursing as the core of nursing science known as "human science and human care" (Watson, 2012). Caring is a force in improving the quality of service and patient safety. Caring behavior that is expected in nursing is a behavior based on several aspects including: 1) human altruistic (prioritizing values in human relations); 2) faith-hope (instilling elements of trust and hope); 3) sensitivity (developing sensitivity to oneself and others);4) helping-trust (relationship of mutual trust and mutual assistance);5) expression of positive feelings and negative feelings;6) systematic problem solving;7) interpersonal teaching and learning process; 8) supportive environment; 9) fulfillment of basic human needs, and 10) existentialphenomenological (Watson, 2012).
Caring is one of the education that nurses are required to know well to implement and optimize patient safety as caring education itself has a strong influence in giving nurses awareness according to.
Patient safety is a system that makes patient care safer, including risk assessment, patient risk identification, and management, incident reporting and analysis, the ability to learn from incidents and their follow-up, as well as implementing solutions to minimize risks . Patient safety requires strategic action in its application in hospitals.
Ineffective patient safety implementation can occur in patient identification, communication errors, operating point errors, medication errors, hospital infections, and patient falls. Potential errors commonly occur in patient identification, incorrect patient name, communication during discharge planning is incomplete, and lack of patient control causing the patient to fall. The most common mistakes in implementing patient safety are ineffective communication. (Eklof & Ahlborg Jr, 2016). Identification of risks from the stage of service and the patient's condition must be carried out to determine risk reduction actions. Risk control is a form of applying patient safety according to standards that can improve the quality of nursing care.
Nurse workload is all activities or activities carried out by nurses during their duties in a nursing service unit (Tubbs-Cooley et al., 2015). The nursing workload in a unit can be estimated by taking into account the components, namely the number of patients treated per day, per month, and year, the condition of the patient, the average number of patients treated, direct and indirect actions needed by the patient, the frequency of each action taken. required and the average time required to act (Simeulu et al., 2013).
The workload is closely related to the productivity of health workers, of which 53.2% of the truly productive time is used by direct health services and the remaining 39.9% is used for supporting activities (Ullatifa, 2017). Assessment of the workload of nurses can be seen from 3 aspects, namely physical, psychological/mental, and the use of time. The physical aspect relates to the main tasks, additional tasks, and the number of patients being treated. Psychological aspects are related to interpersonal relationships between nurses and other nurses, the head of the room, and the patient. The aspect of working time is related to the allocation of time used to perform their duties every day. The workload of nurses is an issue that is always interesting to discuss in both government and private health services because the workload has different characteristics between service units and between hospitals (Hart & Warren, 2015).
In carrying out nursing duties together, nurses are required to cooperate and support each other with one. The performance of an effective nursing team will result in the achievement of maximum service quality. The factors that influence the emergence of service quality are quite complex and intertwined with each other. One of the factors that affect the quality of service is teamwork. Teamwork is The ability of individuals to form and manage teams. Human behavior in various work situations concludes that human relationships among team members are more important in determining productivity than changes in working conditions The results of a preliminary study conducted by researchers in January 2020 with a sample of 8 inpatient nurses, showed the nursing workload (direct and indirect nursing care activities), namely 77.14% indicating nursing activities and 22.85% indicating non-nursing activities. (preparing forms, explanations about filling out questionnaires, handling complaints, photocopies of files for guarantees, nursing still gets task delegation from pharmacy and laboratories for taking venous blood samples outside of sampling hours, looking for doctors on duty to write prescriptions, taking medicines to the pharmacy, delivering sample and take drug test results) The results of the survey data on the application of caring by nurses were conducted by sampling in the inpatient nurse's room to patients who have received treatment for more than three days (Cho et al., 2015), the number of samples is 20 inpatients distributing a question form consisting of ten question items, the results obtained are 91, 8% of nurses caring for patients and 9.8% of nurses not caring for patients.
Reports of incidents at Metro Hospitals Cikupa that were reported in 2019 were potential injury events (KPC) there were 56 incident reports, near-injury events (KNC) were 47 incident reports, non-injury events (KTC) had 19 incident reports and 5 unexpected incidents, from all incident reports that occurred the most cause was a communication that was not well established and did not identify properly and correctly by officers.
Based on interview data from customer service, there are many complaints received from inpatient nurses, including the nurses being sloppy, not smiling, and taking a long time to come when called by the patient.
The performance of this effective nursing team has not been realized by The results of interviews with several nurses, staff, employees, and patients at the Metro Hospitals Cikupa Hospital provide information that reveals problems that cause the service provided by the hospital to be less than optimal. The attitude of not caring, the lack of desire and awareness to resolve conflicts, and the lack of awareness of nurses on the importance of cooperation and communication often cause conflict, and the relationship between nurses that is felt to be less than harmonious which hinders the establishment of cooperation is a problem that is faced by the hospital.
Based on these problems, the researchers wanted to study further the workload of nurses, caring for nurses, and the quality of service at Metro Hospitals Cikupa, so a study was carried out with the title "Analysis of the relationship between nurse workloads on the application of patient safety goals and teamwork and caring behavior as an intervening variable in hospitalization. inpatients and polyclinics of Metro Hospitals Cikupa in 2020".

Research Methods
The methodology of this research will use the Path Analysis model to analyze the pattern of variable relationships. The type of data used in this research is quantitative data. The variables in this path analysis consist of exogenous variables (the dependent variable is (X) and endogenous independent/ intervening variables Z and Y. The dependent variable is the Nurse Workload (X), the independent variable (Y) is the application of patient safety goals, the intervening variable (Z1) is the Caring Behavior of nurses, and (Z2) is Teamwork.
The population and sample in this study were inpatient and polyclinic nurses at XYZ Hospital who had worked for at least 1 month totaling 60 nurses. Data collection techniques in this study used a questionnaire with a Likert scale (4 scales) and a daily log form. The data analysis method in this research is using the Path Analysis data analysis method or path analysis Results And Discussion 1.
Result A.

C haracteristics of respondents
Based on the characteristics of 60 respondents who are nurses at XYZ Hospital, it can be seen that 47 people (78.3%) are 30 years old and 13 people (21.7%) are > 30 years old. From these results, most of the respondents were 30 years old. Frequency distribution of respondents based on education, 49 people (81.7%) have a diploma and 11 people (18.3%) have a bachelor's degree. The frequency distribution of respondents based on gender obtained 60 people (100.0%) of the sex female. The frequency distribution of respondents based on marital status was obtained 38 people (63.3%) are not married and 22 people (36.7%) are married. From these results, most of the respondents are not married. The frequency distribution of respondents based on room/unit is spread from 6 rooms/unit, where most of them come from polyclinic, sapphire, and topaz.

B. Test validity and reliability
The validity test according to (Lampert et al., 2013) shows the degree of accuracy between the data that occurs on the object and the data collected by the researcher. Validity shows the extent to which a measuring instrument measures what it wants to measure. In this case, the researcher uses a questionnaire in data collection, the questionnaire that he has compiled must measure what he wants to measure. The validity test that is often used is Pearson's product moment.

Nurse Caring Behavior Variable Validity Test
The validity test of the nurse caring behavior variable consisted of 25 statements. Based on data processing using the SPSS program, the results of the questionnaire validity test above the entire value of r count (r product moment) has a value above r table (0.444), so it can be concluded that all statements on the Nurse Caring Behavior variable are declared valid.

Teamwork Variable Validity Test
The test of the validity of the teamwork variable consists of 11 statements. Based on data processing using the SPSS program, the results of the questionnaire validity test above the entire value of r count (r product moment) have a value above r

c. Nurse Workload
This variable shows a minimum value of 1,000 and a maximum value of 4,000. The average value of the nurse's workload is 3.317, this shows that the nurse's workload is at the light workload.

d. Nurse Caring Behavior
This variable shows a minimum value of 2.360 and a maximum value of 4,000. The average value of nurse caring behavior is 3.397, this shows that nurses' caring behavior is often carried out.

e. Teamwork
This variable shows a minimum value of 2,820 and a maximum value of 4,000. The average value of teamwork is 3.722, this shows that teamwork is almost always done.

f. Implementation of Patient Safety Goals
This variable shows a minimum value of 2.270 and a maximum value of 4,000. The average value of the application of patient safety goals is 3.503, this shows that the application of patient safety goals is often carried out.

D. Analysis three-box method
a. The results of the description of respondents' answers about caring behavior are as follows  Based on the table above, it is known that the average value of the respondent's response tendency on the variable of implementing patient safety goals is per indicator, the highest average indicator is IPSG2 and the lowest average indicator is IPSG3.

E. Variable Workload
After collecting the workload questionnaire, the results of the answers and analysis of the answer score index on the nurse's workload variable are as follows: Tabel 7 The results of the answers and analysis of the answer score index on the nurse's workload variable The table shows the results of respondents' responses to the nurse's workload from the results of the questionnaire with the daily log form on the light answer (4), namely 50.0%, meaning that the excess working time is <60 minutes, the moderate answer (3), which is 33.3%, meaning that the hours are overtime. 61-90 minutes of work, heavy answer (2) means 91-180 minutes of extra work time, very heavy answer (1) 1.7% means over 181 minutes of working hours. where the average value of the workload is the excess of working time, mostly under 60 minutes, meaning that the nurses implementing inpatient and polyclinic duties per shift on average are more than 1 hour from the nurse's service time.

Classic assumption test 1) Normality Test
The normality test is used to test whether the relevant data is normally distributed or not. The regression model is normally distributed if the critical ratio (cr) value of each variable is less than 2.58. Based on the results of SEM -AMOS, the results of the normality test can be seen in the following It can be seen from the calculation above that the covariance matrix value is 0.001, which means that there is no correlation between independent variables or all variables in the model so it shows that there is no multicollinearity problem.

3) Hypothesis Test
Hypothesis testing is statistical proof of all that has been hypothesized in theory-based research. To test the hypothesis that has been proposed and to detect the effect of the mediating variable (intervening variable) in mediating the independent variable on the dependent variable, descriptive statistical analysis methods, three box methods, path analysis, simultaneous testing (f test) and partial testing (t-test) are used. ). There are 3 paths in the path analysis of the structural equation model (Structural Equation Model) with the following description.

4) Model Fit Test (Simultaneous Test)
The results of the Hypothesis 1 test on the AMOS program are as follows: Minimum was achieved 890 Degrees of freedom = 1 Probability level = .0711 Hypothesis 1 is accepted because the Chi-square count shows a value of 0.00 which is smaller than the Chi-square table value. The results of this very small Chi-square value indicate that there is no difference between the theory and the empirical data environment so hypothesis 1 is accepted. This means that the nurse workload variable has a significant effect on teamwork and caring behavior and patient safety goals because the arithmetic value has a very small value compared to the chi-square table value.

5) Coefficient of Determination (R2)
The coefficient of determination shows the value of how much simultaneous influence the independent and intervening variables have on the dependent variable. The value of the influence of nurse workload, teamwork, and caring behavior on patient safety goals, in the hospital, is shown in the table below.
The value of the influence of workload on caring behavior is 0.155 or 15.5%. The effect of workload on teamwork is 0.072 or 7.2% and the effect of workload on patient safety goals is 0.508 or 50.8%. In this case, the nurse's workload as the independent variable has a small effect on the intervening variable of teamwork and caring behavior, while the nurse's workload has a large influence on the dependent variable of patient safety goals.

1.
Hypothesis 1: Workload simultaneously affects teamwork, caring behavior, and the application of patient safety goals The results showed that the workload simultaneously affects teamwork behavior, caring, and the application of patient safety goals, meaning that the lighter the nurse's workload, the more team cooperation and caring behavior of applying patient safety goals will be better too. This is different from the results of previous research by (Kansong et al., 2022) regarding the relationship between the workload of nurses and the application of patient safety in the inpatient room at RSUD Dokter Soedarso Pontianak to the data on the workload of nurses in the heavy category and the application of patient safety in the less category means the heavier the burden. The work carried out by nurses has an impact on decreasing the application of patient safety goals.
A previous study by (Hartawan et al., 2018) regarding the relationship between nurse workload and caring behavior in inpatient surgical installations, shows that there is no relationship between nurse workload and nurse caring behavior in inpatient installations in hospital operating rooms because it is not forever. The heavy workload of nurses shows poor caring behavior because there are also nurses who have a light workload but their caring behavior is not good. . This is not in line with this study because the workload is light so caring behavior, teamwork, and achieving patient safety goals are high.
Previous research by (Manuho et al., 2015) on the relationship between workload and nurse performance in providing nursing care in inpatient installations at Prof DR.R.D Kandou Hospital Manado that there is a relationship between workload and caring behavior is high, the application of patient safety goals must still be high (Jha et al., 2013).
The six goals of managing patient safety according to the Joint Commission International include: identifying patients correctly, improving effective communication, increasing the safety of high-alert medications, ensuring the right place, right procedure, and correct patient surgery, reducing the risk of infection from health workers, reducing the risk of a worse error occurs in patients. Six patient safety goals, Patient safety goals (IPSG) in Indonesia refer to the International Patient Safety Goals (IPSG).

5.
Hypothesis 5 is accepted because from the results of this study the workload variable has a significant positive effect on patient safety goals.
This means that the workload is high, and the teamwork will also increase. West (2008:97) stipulates the indicators of cooperation as a measuring tool as follows: 1) The joint responsibility to complete the work, namely by giving responsibilities can create good cooperation; 2) Contributing to each other, namely by contributing to each other, both energy and thought, will create cooperation; 3) Maximum deployment of capabilities, namely by mobilizing the abilities of each team member to the maximum, cooperation will be stronger and of higher quality.
In this study, it is not in line with previous research by (Yosiana et al., 2020) it was found that the effect of workload and organizational commitment on nurse performance and the role of teamwork as a mediating variable obtained the effect of workload on teamwork, obtained workload in high category and teamwork variable are in the very high category so that the results of the hypothesis test indicate that there is no significant relationship.
The results of this study showed that the nurse's workload had a significant effect on the Teamwork variable. This means that the workload of nurses is light, and teamwork will be good.

Conclusion
Workload has a simultaneous effect on the variables of teamwork, caring behavior, and patient safety goals at Metro Hospitals Cikupa because the workload of hospital nurses is in a low category so that nurses can carry out teamwork, caring behavior, and safety goals well.
The workload of nurses has a positive effect on the variables of implementing patient safety goals at Metro Hospitals Cikupa. This means that the nurse's workload is light, medium, heavy, and very heavy, the application of patient safety goals must be carried out by nurses to patients properly. In the results of this study, it was found that the workload of nurses at Cikupa Metro Hospitals was low so that the implementation of safety goals could be carried out properly.
The nurse's workload variable has a positive effect on the variable of the application of caring behavior at the Cikupa Metro Hospital. This means that the nurse's workload is light, medium, heavy, and very heavy, caring behavior of nurses must be carried out properly for patients. From the results of this study, it was found that the workload of nurses at Metro Hospitals Cikupa was light so the