Relationship Between Leadership Style And Motivation With Nurse Performance In Hospitals

Background: Performance is the quantity and quality of task achievement. Good leadership can motivate employees to improve performance. This study aims to determine the relationship between leadership style and motivation on the performance of nurses in hospitals. Methods: This study is a systematic review and meta-analysis. Article searches were carried out using search engines, including Google Scholar, PubMed, Sciendirect, BMJ, and Garuda Portal. The keywords used were “leadership style” OR motivation AND performance AND nurses AND “crosssectional”, performance AND nurses. Determination of the eligibility of articles using PRISMA. Results from the entire literature were selected using inclusion and exclusion criteria. Measurement of effect size using RevMan 5.3 program. Results: All research obtained using a cross sectional research design. Good leadership style increased nurse performance by 3.19 times compared to poor leadership style and was statistically significant (OR= 3.19; 95% CI= 1.76 to 5.79; p<0.001). The sample of leadership style variables is 1290 nurses. Good motivation can improve nurse performance by 3.65 times compared to poor motivation and is statistically significant (OR= 3.65; 95% CI= 1.95 to 6.82; p< 0.001). Conclusion: Leadership style and motivation as factors in improving nurse performance. The leadership style of the head must be adapted to the needs of each room and must be flexible. With the right leadership style, nursing services in the room can be aligned with hospital goals. ARTICLE HISTORY Received : June 27 th , 2021 Accepted : July 14 th , 2021


INTRODUCTION
Human resources for nursing staff have an important role that absolutely must be analyzed and developed so that their time, energy and abilities can really be used optimally in supporting the performance of health service organizations. Nurses as one of the health workers in hospitals play an important role in achieving health development goals. The success of health services depends on the participation of nurses in providing quality nursing care to patients (Potter, PA Perry, 2005). This is related to the presence of nurses on duty 24 hours to serve patients, as well as the number of nurses who dominate health workers in hospitals ranging from 40-60%, therefore hospitals must have nurses who perform well to support them. Hospital performance so that customer or patient satisfaction can be achieved (Swanburg, 2000in Suroso, 2011. Nurse performance is closely related to the quality of nursing services provided. The Directorate of Nursing Services of the Ministry of Health in collaboration with WHO (World Health Organization) in 2004 which examined several provinces in Indonesia consisting of the provinces of East Kalimantan, North Sumatra, North Sulawesi, West Java and DKI Jakarta, the results showed that during the last 3 years as many as 70, 9% of nurses have never attended training, 39.8% of nurses in hospitals perform non-nursing tasks, 47.4% of nurses do not have clear and written job descriptions, there is no monitoring and evaluation of the performance of nurses in particular. In dealing with certain situations and conditions, a leader must make efforts to change character. This is because the change in character is a strategy to solve the problems at hand. Without a strong character of integrity, endurance to face difficulties and challenges, a clear vision and mission, one will never become a leader (Thoha, 2013).
The leadership style used by America is very common in leadership practices in Asian countries, including Indonesia, which applies a pattern of direction and command. The participatory leadership style in Asia involves closer equal collaboration with leaders and colleagues, and this applies more generally in the European region. Based on careful observations, there are nine key qualities of a successful leader in increasing employee motivation, of course without ignoring cultural factors, namely: enthusiasm, assertiveness, self-confidence, integrity, adaptation, emotional toughness, emotional resonance, self-knowledge and humility (Affif, 2013).
According to Mangkunegara's theory in Yuliawan (2011), employee performance itself is influenced by internal factors which include intelligence, skills, emotional stability, nature, attitude, motivation, age, gender, education, work experience, cultural background and other personal variables. While external factors that affect performance are those from the environment, including labor regulations, customer desires, competitors, economic conditions, organizational policies, leadership, actions of colleagues, types of training and supervision, wage systems and social environment (Mangkunegara, 2014).
Leadership has an important role in the organization, the leader is in charge of supervising and controlling the running of an organization. So that the role of leaders in the organizational environment is very vital and ensures the organization runs well and achieves the goals that have been set. The use of appropriate leadership from superiors is one of the factors that can move, direct, guide and motivate employees to excel at work (Mangkunegara, 2014). One of the important internal factors that affect the performance of nurses is motivation. According to Afandi in Ulfah (2019) Motivation is a desire from within the individual, where the individual will be encouraged to do work with pleasure so as to get quality results. According to research conducted by Terok et al (2015), that there is a relationship between motivation and the performance of nurses at the Tuminting Health Center with p= 0.001. This study aims to determine the relationship between leadership style and motivation with the performance of nurses in hospitals.

MATERIALS AND METHOD
This research is a systematic research and meta-analysis. Research data was searched from a systematic and comprehensive electronic database of several indexes. The databases used include: Google Scholar, PubMed, BMJ, ScienceDirect, and Portal Garuda. The keywords used in the journal collection were "leadership style" OR motivation AND performance AND nurses AND "cross-sectional", performance AND nurses.
Articles are searched taking into account the feasibility of using SPIDER. The population of this study were nurses in hospitals with interventions in the form of leadership style and motivation and the results in the form of nurse performance. The inclusion criteria of this study used a cross-sectional research design with a measure of the Odds Ratio (OR) relationship, CI and p value. The research subjects are nurses who work in hospitals. Articles used from 2015 to 2020. The exclusion criteria in this study were primary research conducted with an experimental design. Articles published other than English and Indonesian.
Qualitative data analysis using the Critical Appraisal Checklist for Cross-sectional Study (Barend, 2015) and quantitative analysis using Review Manager (RevMan) 5.3 program.

RESULTS
Research related to the relationship between leadership style and motivation with nurse performance consists of 21 articles, of which 19 articles are from Indonesia, 1 article from East Africa, and 1 article from Switzerland. Of the 21 articles obtained, there are 9 research articles that fall into the leadership style variable and 14 research articles that fall into the motivation variable. Based on Figure 2 shows the results of the analysis of the relationship between leadership style and nurse performance. The value of I 2 = 76% so that the analysis uses a fixed effect model. We can see the interpretation of the results of the meta-analysis process through the forest plots.
The results of the forest plot show that a good leadership style can improve nurse performance by 3.19 times compared to a poor leadership style and is statistically significant (OR= 3.19; 95% CI= 1.76 to 5.79; p<0.001). Based on Figure 3, it can be seen that there is a publication bias which is indicated by the symmetry of the right and left plots where there are 3 plots on the left and 6 plots on the right. The plot on the left of the graph has a standard error of between 0.8 and 0.4 and the plot on the right of the graph has a standard error of between 0.8 and 0. Publication bias can be seen from the balance of the distance between the studies on the two charts. right and left sides of the funnel plot.  Figure 4, it can be seen the results of the analysis of the relationship between motivation and nurse performance. The value of I 2 = 86% so that the analysis uses a random effect model. We can see the interpretation of the results of the metaanalysis process through the forest plot. The results of the forest plot show that high motivation can improve nurse performance by 3.65 times compared to low motivation and is statistically significant (OR= 3.65; 95% CI= 1.95 to 6.82; p<0.001). Figure 3 shows the absence of publication bias as indicated by the symmetry of the right and left plots where there are 7 plots on the left and 7 plots on the right. The plot on the left of the graph has a standard error of between 1.5 and 0 and the plot on the right of the graph has a standard error of between 2 and 0.5. Publication bias can be seen from the balance of distances between studies on both the right and left sides of the funnel plot.
http://jurnalinterest.com/index.php/int | 96    There is a relationship between leadership style and nurse performance because the head of the room is the leader who directly supervises the implementing nurse and the implementation of the nurse's duties in the inpatient room is a process in hospital management. The head of the room acts as a manager as well as a leader. The head of the room has the responsibility to move the implementing nurse. Therefore, the head of the installation also has the task of evaluating the performance of nurses. Work motivation greatly affects the performance of nurses, because it is driven from within a nurse, the work displayed will not be optimal. There is a relationship between motivation and the performance of nurses, this is due to the motivation to seek ways to optimize the potential of employees to be able to work well, willing to support to encourage the improvement of employee performance, so that they succeed in achieving and realizing the goals that have been determined. There is an influence of motivation on the performance of nurses because motivation is one of the efforts to achieve success, good cooperation, and mutual support of fellow nurses so that they can complete the job well. The results of the analysis of the relationship between work motivation and nurse performance, especially nurses who have high motivation will have a better chance of performance. work motivation and nurse performance, indicate that nurses who have high work motivation will have good performance. Nurses with good performance tend to encourage a strong drive to achieve goals, this is because they will try to achieve a position. the good one. they dream of, nurses who perform well will have a positive mental attitude that creates a high level of trust. The results showed that there was an influence between motivation on performance.Motivatio n is needed because of motivation, employees will be more enthusiastic and responsible for the work so that their performance can be better. There is a significant relationship between motivation and the performance of nurses in hospitals.This means that if the motivation of a nurse is increased, the performance of the nurse will also increase. Based on the assessment of study quality using the Critical Appraisal Checklist for Cross-sectional Study (Barend, 2015), A total of 21 articles included in the quantitative meta-analysis synthesis meet the articles that are categorized as good. Found 9 articles about the relationship of leadership style with nurse performance. There were 14 articles on the relationship between motivation and nurse performance.

DISCUSSION
Relationship between leadership style and nurse performance, the results of journal searches from various sources contained 9 research articles from 2016 to 2020 which could be analyzed quantitatively using RevMan 5.3 as a source of meta-analysis of the relationship between leadership style and nurse performance. All research studies obtained used a cross-sectional study design. The sample of the leadership style variable is 1363 nurses. The results of the forest plot show that a good leadership style can improve nurse performance by 3.19 times compared to a poor leadership style and is statistically significant (OR= 3.19; 95% CI= 1.76 to 5.79; p<0.001).
Overall, the articles included in the meta-analysis have the same research results, namely the relationship between leadership style and nurse performance. This metaanalysis provides evidence to support leadership style as a factor in improving nurse performance. These results are in line with research conducted by Hasibuan et al., (2021) that there is an influence of the leadership style of the head of the room on the performance of nurses in the inpatient room of RSUD Rokan Hulu where a good leadership style has the opportunity to improve the performance of nurses to be good 3.673 times greater than the head of the room with a leadership style that is not good after being controlled by the variable period of service (POR = 3.673 ; 95% CI = 1.364 to 10.024). The head of the room is a leader who directly supervises the nurse and carries out the duties of the nurse in the inpatient room. The head of the room has the responsibility to mobilize nurses and evaluate nurses' performance.
Not only the head of the room, the performance of nurses is also influenced by the leadership style of the existing doctors. Research conducted by Sudiarto et al., (2021), shows that doctors with good leadership styles have a 6.073 times greater chance to improve the performance of nurses than doctors with bad leadership styles (OR= 6.073; p= 0.008). The success of nursing services and services is largely determined by the performance of nurses in providing nursing care. The leadership style applied by the head of the room will determine how the role of the head of the room in improving the performance of nurses. For this reason, the leadership style of the head of the room must be adapted to the needs of each room and must be flexible, the head of the room must be able to read the situation of the room, make an analysis and decide when to be appointed.
Democratic or authoritarian. With the right leadership style, nursing services in the room can be aligned with hospital goals (Sudiarto et al., 2021). The relationship between motivation and nurse performance, the results of journal searches from various sources contained 14 research articles from 2015 to 2020 which could be analyzed quantitatively using RevMan 5.3 as a source of meta-analysis of the relationship between motivation and nurse performance. All research studies obtained used a crosssectional study design. The sample of the motivation variable is 1290 nurses. The results of the forest plot show that high motivation can improve nurse performance by 3.65 times compared to low motivation and is statistically significant (OR= 3.65; 95% CI= 1.95 to 6.82; p<0.001).
Overall, articles merged into meta-analysis has the same research results, namely the relationship of motivation to nurse performance. This meta-analysis provides evidence to support motivation as a factor in improving nurse performance.
The results of this meta-analysis are in line with research conducted by Sovia et al., (2019), where nurses with high motivation had 4.1 times the chance to show good performance compared to nurses with low motivation after being controlled by attitude and personality (aOR = 4.083; 95% CI = 1.672 to 9.972; p = 0.002). The involvement of nurses will positively affect their self-efficacy and leadership motivation, which in turn will positively affect their career aspirations. According to research conducted by Hee et al., (2016), intrinsic motivation is positively related to the improvement of nurse performance (β= 0,557; p<0,050).
Any increase in intrinsic motivation will improve the performance of nurses. This means that nurses who have intrinsic motivation will work better in carrying out their duties. So nurses need to keep intrinsic motivations maintained because intrinsic motivation produces integrity of goals, both organizational goals and individual goals where both can be satisfied

CONCLUSIONS
This meta-analysis showed that, Good leadership style and high motivation can improve nurse performance. The leadership style of the head must be adapted to the needs of each room and must be flexible, the head must be able to read the situation of the room, make analysis and decide when to be democratic or authoritarian. With the right leadership style, nursing services in the room can be aligned with hospital goals.