Determinant of Nurse Performance in the Era of the COVID-19 Pandemic in Bali

During the COVID-19 pandemic, medical personnel have received much heavier workload than normal. On top of it, stigma and low appreciation of the community for medical personnel leads to increase of both physical and psychological pressure. The purpose of this study is to analyze the effect of leadership, workload, and work environment on nurse satisfaction and performance. The sample in this study were 246 nurses who worked at Bali Mandara Hospital. Data was collected through questionnaire distributed online using google form platform and the data was processed using SmartPLS 3.2.1. The results of the study found that: (1) leadership, workload, and work environment had a positive and significant effect on nurses' job satisfaction; (2) leadership and nurse satisfaction have a positive and significant effect on nurse performance, workload has a negative and significant effect on nurse performance, and work environment has no effect on nurse performance; and (3) nurse job satisfaction mediates the influence of leadership, work load, and work environment on nurse performance. Keyword: workload, work environment, job satisfaction, performance, the COVID-19 pandemic Pemicu Kinerja Perawat di Era Pandemi COVID-19 Di Bali ABSTRAK Selama pandemi COVID-19, tenaga medis menerima beban kerja yang jauh lebih berat dari biasanya. Selain itu, stigma dan rendahnya apresiasi masyarakat terhadap tenaga medis menyebabkan meningkatnya tekanan baik fisik maupun psikis. Tujuan penelitian ini adalah menganalisis pengaruh kepemimpinan, beban kerja, dan lingkungan kerja terhadap kepuasan dan kinerja perawat. Sampel dalam penelitian ini adalah 246 perawat yang bekerja di RS Bali Mandara. Pengumpulan data dilakukan melalui kuesioner yang disebar secara online menggunakan platform google form dan diolah menggunakan SmartPLS 3.2.1. Hasil penelitian menemukan bahwa: (1) kepemimpinan, beban kerja, dan lingkungan kerja berpengaruh positif dan signifikan terhadap kepuasan kerja perawat; (2) kepemimpinan dan kepuasan perawat berpengaruh positif dan signifikan terhadap kinerja perawat, beban kerja berpengaruh negatif dan signifikan terhadap kinerja perawat, dan lingkungan kerja tidak berpengaruh terhadap kinerja perawat; dan (3) kepuasan kerja perawat memediasi pengaruh kepemimpinan, beban kerja, dan lingkungan kerja terhadap kinerja perawat. Kata kunci: beban kerja; lingkungan kerja; kepuasan kerja; kinerja; pandemi COVID-19


INTRODUCTION
The vision, mission, and goal of health development are contained in the Long Term Development Plan for Health (Rencana Pembangunan Jangka Panjang Bidang Kesehatan) 2005-2025. The current strategic objectives of the Ministry of Health are the elaboration of the third Mid-Term Development Plan for Health (2015)(2016)(2017)(2018)(2019), which is compiled every 5 years. The vision of National Health Development is to create a healthy nation of Indonesia by 2020, namely that the people evenly have the capability to afford quality healthcare and have the highest quality of health throughout the Republic of Indonesia (Depkes RI, 2015). The National Long-Term Development Plan (Rencana Pembangunan Jangka Panjang Nasional) is an elaboration of the formation of the Republic of Indonesia as stated in the Preamble to the 1945 Constitution, namely to: 1) protect the entire nation of Indonesia and all Indonesian; 2) promote public welfare; 3) educating the nation's life; and 4) participate in creating world order based on independence, eternal peace and social justice (Depkes RI, 2020).
The Ministry of Health of the Republic of Indonesia has outlined that General Hospitals have the task of implementing effective health efforts by prioritizing curative and rehabilitative efforts which are carried out in an integrated manner with promotive and preventive efforts as well as implementing referral efforts. Hospitals are an integral part of the entire health service system that serves patients with various types of services (Laksono, 2018:47-52,131). In facing the current era of globalization and decentralization, various challenges and changes must be taken seriously, hospital managers need to pay close attention to environmental dynamics. The thinking used is the hospital model as a service organization that processes input and produces services. Management needs to make changes in order to anticipate the effects of rapid environmental changes that are sure to come, both affecting external customers (patients, suppliers) and internal customers (nurses, doctors, employees) in order to survive and develop. The hospital management paradigm must be changed to be effective and efficient and able to accommodate changes (Laksono, 2018:200-215). Bali Mandara Regional Hospital, which in its development has been able to achieve type B accreditation, is expected to be able to provide quality health services in accordance with applicable rules. Bali Mandara Hospital has 28 doctors, 66 midwives, 246 nurses, and 15 medical personnel. According to (Luthans et al., 2015:110-121) organizational performance is influenced by individual performance, while individual performance is influenced by individual job satisfaction, so that individual nurse job satisfaction has a big effect on hospital performance. The nurse's performance will be high if at the time the nurse feels satisfied with their job.
Workload is closely related to job satisfaction, and in the end will affect the performance of an individual. Workload can be perceived subjectively, depending on a person's cognitive, affective, and psychomotor skills and character. The task of a manager is to find effective ways to manage human resources so that the existing workload can be processed properly and wisely by human resources (Barahama et al., 2019). The work environment is also closely related to job satisfaction. A good work environment has factors such as a large enough space, comfortable, clean, safe and quiet, adequate equipment, and so on. The theory of human relationships uses factors of work environment conditions as one of the motivating variables. The management assumption used is that people want to work in a safe and pleasant work environment with a fair and understanding boss. Happy individuals will work harder because of increased job satisfaction (Sayles, 2017: 200-231). Leadership is another factor that affects job satisfaction. A leader is tasked with empowering and mobilizing available human resources to achieve a goal. In doing this, there are many things that affect the success of a leader such as the type of leadership, the quality of leadership, and the character of the leader. Good leadership will directly increase the job satisfaction of the human resources led (Abdulkarem et al., 2019;Luthans et al., 2015:121-125).
Workload that is processed properly will affect the satisfaction of workers. Responses can be in the form of positive values such as a sense of achievement, as well as negative responses such as fatigue and frustration both physiologically and psychologically, which in turn will affect the effectiveness of one's performance (Wolo et al., 2015). Therefore, to support effective performance so that the organization can function optimally, managers need to pay attention to workload regulation and worker satisfaction. This is even more so for professions that have high pressure and workloads, but also demand a constant focus on the same such as the paramedic or nursing profession. This is especially interesting to note at the time of the COVID-19 pandemic, where medical personnel received a workload that was much heavier than normal plus the stigma and low appreciation of the Indonesian people for medical personnel which led to increased pressure both physically and psychologically.
Human resources in the nursing profession are the most important factor in hospital services, because in most countries up to 80% of health services are provided by nurses (Farid et al., 2020). Golmoradi and Ardabili (2016) stated that 40% -60% of human resources in hospitals are nursing personnel. According to the Indonesian Ministry of Health, in 2017 as many as 40% of health service providers in Indonesia are nursing personnel. Therefore, nursing service is the biggest indicator in all medical personnel. Nursing paramedics in medical institutions are the spearhead in the process of treating patients, so special attention is needed in their management, especially during a pandemic which adds to physical and psychological pressure for paramedics (Depkes RI, 2018). The COVID-19 pandemic has created a stressful situation with a real risk of exposure to dangerous diseases, resulting in a new workload that is far different from the conditions before the pandemic (Golmoradi & Ardabili, 2016). Therefore, it is necessary to reassess the level of job satisfaction of nurses compared to the new workload.
Pandemic is a term used to define a condition where there is a global epidemic of a disease covering various countries and even continents. The COVID-19 pandemic started in Wuhan with an extremely rapid spread. Within 2 weeks of the appearance of the first case there was an increase of up to 1000 cases and continued to increase sharply from day to day. As of May 25, 2020, the World Health Organization (WHO) stated that the COVID-19 pandemic has infected 216 countries and caused more than 340,000 deaths. Data from the Ministry of Health of the Republic of Indonesia until 25 May 2020 itself continues to show a graph of the number of cases that tends to increase. On the other hand other countries in general have experienced a decline in the graph, including neighboring countries in ASEAN such as Singapore, Thailand, Malaysia, Vietnam, and others. This and the public's ignorance of the efforts to prevent COVID-19 caused disappointment and frustration for medical personnel. The phenomenon that occurs in Indonesia is the emergence of the hashtag "IndonesiaTerserah" which is enlivened by medical personnel in Indonesia due to the fact that the community continues to gather and does not carry out social restrictions, is dishonest in stating medical history so that it endangers medical personnel, and the community's low appreciation of medical personnel. This phenomenon has been documented by various mass media, including BBC News, Kompas, and various news programs on television. This is in accordance with previous studies which found that the COVID-19 pandemic in general adds to the mental burden for medical workers even in developed countries such as the UK and Singapore (Greenberg et al., 2020;Rana et al., 2020;Tan et al., 2020). This shows that the COVID-19 pandemic has a risk of causing stress and an increase in workload on medical personnel, and its impact on job satisfaction which in turn will affect the performance of medical personnel, especially nurses.
Based on data from the Denpasar City Communication and Informatics Office, it was found that in Bali alone the highest number of reported cases of COVID-19 was found in Denpasar, especially in the Sanur area, with 131 reported cases. On the other hand, the Balinese, especially those in Sanur, are still less obedient in responding to calls from medical personnel. For example, on May 1, 2020 the COVID-19 Task Force Team for the City of Denpasar even had to forcibly pick up 4 Sanur residents who had been declared infected with COVID-19 without symptoms but were still active outside the home. This shows that people in Bali still do not care and lack empathy, which creates a psychological burden for medical personnel working against the COVID-19 pandemic. In addition, the low level of public awareness causes the case graph to continue to tend to increase, which also creates a physical burden for medical personnel, especially nurses. In connection with this, the hospital that is used as a COVID-19 referral hospital in Sanur is the Bali Mandara Hospital. Therefore, researchers want to examine how the influence of leadership, workload, and work environment on nurse satisfaction and performance during the COVID-19 pandemic at Bali Mandara Hospital.

RESEARCH METHODS
The population in this study were nurses who served in Bali Mandara Hospital. The sampling technique used was based on Slovin's formula (N / (1+(Ne 2 )), according to the data there were 246 nurses on duty at the Bali Mandara Regional Hospital. Thus, required minimum sample is 153 respondents. In this study the data were obtained from a questionnaire survey that was distributed to nurses at the Bali Mandara Regional Hospital through the google form platform. Questionnaires were distributed from 28 October to 7 November 2020. The research variables consisted of exogenous variables including leadership (X1), workload (X2), and work environment (X3) variables; endogenous variables, namely Nurse Performance (Y2); and the Intervening variable, namely Nurse Job Satisfaction (Y1).
To ensure the quality of the data obtained, the validity and reliability of the instrument were tested. Furthermore, the data is processed with SmartPLS 3.2.1. The PLS evaluation model is carried out by assessing the measurement model (outer model) and structural model (inner model). Outer model evaluation is done to assess the validity and reliability of the model. The outer model was evaluated through convergent and discriminant validity of the latent construct-forming indicators and composite reliability and Cronbach alpha for the indicator block. Inner model evaluation to predict the relationship between latent variables. The inner model is evaluated by looking at the percentage variance described by looking at the R-Square value for endogenous latent constructs (Ghozali & Latan, 2015:77-78).

Research Result
Convergent validity relates to the principle that the manifest variables of a construct should be highly correlated. The results of the convergent validity test for the reflexive indicators in Table 1 show that the loading factor value for each construct indicator is greater than 0.7, except for the Y2.5 indicator with a loading factor value of 0.627. According to Chin (1998) in Ghozali & Latan (2015:81-83), the loading factor value between 0.6-0.7 is still acceptable. Thus all construct indicators can be declared valid.  (2020) Furthermore, discriminant validity relates to the principle that the manifest variables of different constructs should not be highly correlated. The results of the discriminant validity test with reflexive indicators in Table 2 show that the cross loading value for each variable is greater than the other constructs. So that all latent constructs with reflexive indicators have met the conditions for discriminant validity. The reliability test was conducted to prove the accuracy, consistency and accuracy of the instrument in measuring constructs. Table 3 shows the composite reliability and Cronbach alpha values of all constructs greater than 0.7. Thus all indicators of reflexive constructs are reliable or meet the reliability test.  (2020) Evaluation of the inner model in Table 4 for each endogenous latent variable can be seen at the R-Squares value as the predictive strength of the structural model. The R-Squares value of the nurse satisfaction variable and nurse performance is greater than 0.75 so it is included in the strong category.  (2020) The size of the fit indexes can be seen from the Goodness of Fit (GoF) Index calculated by the AVE average root formula (Table 3) and R-Squares (Table 4). Based on the calculation, it is known that the GoF value is 0.741, so it can be concluded that the overall model has predictive power in the large category. The evaluation results of the outer model, inner model and GoF index have met the PLS requirements so that the data can be processed for hypothesis testing. The results of hypothesis testing can be seen in Figure 1 and Table 5. The results of the analysis of the direct influence of leadership, workload, and work environment on nurse satisfaction in Table 5 show that the coefficient of leadership, workload and work environment is 0.229, 0.414, and respectively. 0.337, with a p-value smaller than 0.05. This indicates that leadership, workload, and work environment have a positive and significant effect on nurse satisfaction or the first hypothesis is accepted. The highest coefficient value is indicated by the workload variable so that the workload variable is the dominant variable affecting nurse satisfaction. Furthermore, the direct influence of leadership, workload, work environment and nurse satisfaction on nurse performance shows that leadership and nurse satisfaction have a positive and significant effect on nurse performance. While the workload has a negative and significant effect on the performance of nurses, and the work environment has no effect on the performance of nurses because the p-value of work environment is 0.196> 0.05 thus the second hypothesis is rejected. Nurse satisfaction variable has a dominant influence on nurse performance because it has the highest coefficient of 0.794. The indirect effect of leadership, workload, and work environment on nurse performance through nurse satisfaction in Table 5 shows that nurse satisfaction mediates the influence of leadership, workload, and work environment on nurse performance thus the third hypothesis is accepted.

The effect of leadership, workload, and work environment on nurses' job satisfaction
Testing the first hypothesis proves that leadership, workload, and work environment have a positive and significant effect on nurses' job satisfaction. This shows that good leadership, workload, and work environment can increase nurses' job satisfaction. Leadership that is able to increase nurse job satisfaction is a leader model who always fosters cooperation and good relations with subordinates in a professional manner, is always on time at work, upholds the principle of deliberation and respects the opinions of members in solving problems and is able to allocate task loads to members appropriately and effectively during pandemic period. In line with the research results of (Fallatah & Laschinger, 2016) that there is a significant relationship between leadership and job satisfaction of new nurses. Workloads that can increase nurse job satisfaction are workloads that have clear descriptions, scope and work procedures, have definite and consistent working hours, and the amount of work completed is proportional to the length of time available during the pandemic. Another previous research in Egypt also shows that medical workers experience high levels of stress due to heavy workloads, thereby reducing job satisfaction (Elshaer et al., 2017). A work environment that can increase nurse job satisfaction is a work environment that has good lighting and air circulation, is clean, establishes relevant work safety measures to maintain worker safety, has facilities that are in accordance with job needs, have a harmonious relationship with fellow workers, and have a work environment. which provides fair career advancement opportunities based on the merits of each employee. The results of this study is in accordance with the previous research by Abdulkarem et al. (2019) who found that a conducive work environment increases job satisfaction of nurses.

The effect of leadership, workload, work environment, and job satisfaction of nurses on nurse performance
The second hypothesis testing proves that leadership and nurse satisfaction have a positive and significant effect on nurse performance. While the workload has a negative and significant effect on the performance of nurses, and the work environment has no effect on the performance of nurses. This indicates that the better the leadership and satisfaction of nurses the better the performance of nurses, while a lighter workload will also increase performance, and a good work environment does not have an influence on nurse performance. Leadership that is able to improve performance is conducted by a leader who always fosters cooperation and good relations with subordinates in a professional manner, is always on time at work, upholds the principle of deliberation and respects members' opinions in solving problems and is able to allocate taskloads to members appropriately and effectively during the pandemic. The results of this study support previous researches which found that leadership factors have a significant effect on nurse performance. The form of job satisfaction of nurses that is able to improve the performance of nurses is being stable in their current job so that they do not have the thought of switching professions, they feel that the current job has provided space to develop themselves and increase their knowledge, the salary received is in accordance with the workload and the hospital has provided appropriate non-material appreciation for the dedication done (Lee et al., 2017;Manges et al., 2017). Another research has also shown that job satisfaction is the most significant factor affecting nurses' performance (Kim, 2017). During the pandemic, the workload of nurses was felt to be heavier, thus reducing their performance. A pandemic period creates a new workload that is much different from prepandemic conditions, namely a stressful situation with a real risk of exposure to dangerous diseases. A previous research has shown significant relations between workload, fatigue, and sleep quality towards nurses' performance, in which excessive workload would cause a decrease in performance in nurses. An increased workload will reduce the focus it can put on each job, resulting in decreased performance (Qureshi et al., 2019;Song et al., 2020). Conversely, a lighter workload will increase the performance of nurses. It is in line with the research of Qureshi et al. (2019) that a sudden / unplanned event can reduce the performance of nurses due to an increase in workload. A good work environment has not been able to improve performance during this pandemic, even though the existing work environment has good lighting and air circulation, is clean, establishes relevant work safety measures to maintain worker safety, has facilities in accordance with work needs, fellow workers have a relationship. harmonious, and a work environment that provides fair career advancement opportunities based on individual employee performance. The work environment during a pandemic is certainly different from normal conditions, such as the facilities needed to provide health services during a pandemic are not yet available in hospitals. Previous research has shown that work environment has a significant effect on job satisfaction, but there is no direct significant effect on performance, so it is concluded that the work environment is not always the main factor for improving performance (Suharno et al., 2017).

Nurse's job satisfaction mediates the effect of leadership, workload, and work environment on nurse performance
The second hypothesis testing proves that the job satisfaction of nurses mediates the influence of leadership, workload, and work environment on nurse performance. This indicates that good leadership, workload, and work environment can increase nurse job satisfaction, and with an increase in nurse job satisfaction will also improve nurse performance. With a leader who always fosters cooperation and good relations with subordinates in a professional manner, is always on time at work, upholds the principle of deliberation and respects members' opinions in solving problems and is able to allocate taskloads to members appropriately and effectively during a pandemic, of course the nurses are not having thoughts of changing professions or leaving the current workplace will always defend even if someone is badmouthing their workplace. The results of this study are in line with the results of previous research which found that the type of leadership of nurse managers has a direct impact on job satisfaction, which in turn has an impact on the performance of the nurse (Morsiani et al., 2017). A workload that has a clear description, scope and work procedure, has definite and consistent working hours, and the amount of work completed is proportional to the length of time available during the pandemic, will certainly provide room for self-development and broaden the knowledge of the nurse. The nurse has an assessment that the salary received is in accordance with the existing workload and the non-material appreciation given by the hospital is also in accordance with the service that has been done so far. A lighter workload will also increase job satisfaction and also the performance of nurses (Qureshi et al., 2019), as well as a proper work environment which will indirectly affect performance through various pathways, including job satisfaction (Abdulkarem et al., 2019).

CONCLUSION
The results of this study concluded that: (1) leadership, workload, and work environment had a positive effect on nurses' job satisfaction; (2) leadership and nurse satisfaction have a positive effect on nurse performance, workload has a negative effect on nurse performance, and work environment has no effect on nurse performance; and (3) nurse job satisfaction mediates the influence of leadership, workload, and work environment on nurse performance.
For hospitals, based on the results of the study, it can be concluded that leadership, workload, and job satisfaction are still important factors to maximize the performance of nurses. This is in accordance with previous research outside the pandemic period. Adopting the right kind of leadership will help direct the nurse in a structured and clear manner. Efficient workload regulation can reduce stress and improve performance. Although the work environment does not directly affect performance, it is mediated through job satisfaction, so it remains an important factor in nursing resource management. Nurses who are satisfied with their jobs will work harder to achieve the goals of the existing hospital.
For the government, the results of this study can be used as a basis for forming hospital guidelines in dealing with COVID-19 by taking into account the factors that affect nursing resources working in hospitals.