The Relationship between Workload and Social Support with Nurse Job Satisfaction in Hospital Inpatient Room

Introduction: concern for good psychological condition of nurse regarding workload and social support in every job they do is an effective strategy to increase nurse job satisfaction. Nurse job satisfaction is important for the creation of better nurse performance. The purpose of the study was to explain the relationship between workload and social support with nurse job satisfaction in the inpatient room of RSUD Dr. Harjono Ponorogo.


INTRODUCTION
To improve the quality of nursing services, it is necessary to pay attention to the performance and nurse job satisfactions, because nurse job satisfaction is very important for the creation of better nurse performance (Usastiawaty et al, 2018). Nurses who work continuously or without support from the people around them tend to have an impact on decreasing the physical and psychological conditions of nurses (Sari, 2016). This condition will have an impact on the nurse job satisfactions. Nurse job satisfaction affects the performance of nurses in the room (Nursalam, 2015).
Due to work pressure, excessive workload and lack of social support, nurses in inpatient rooms are vulnerable to job dissatisfaction (Elizar et al., 2020). Nurses are faced with various problems with patient complaints, relationships with colleagues and superiors that are not well established, and a heavy workload (Atiqoh, 2016). So far, nurses in inpatient rooms have decreased performance due to lack of rewards from the hospital, resulting in a lack of job satisfaction (Diniyah, 2020). However, research that explains the relationship between workload and social support with nurse job satisfactions in inpatient rooms is still very limited, especially in the research hospitals. Based on the preliminary study, the nurse job satisfactions in the inpatient ward of RSUD Dr. Harjono Ponorogo is in the good category with a score range of 61-100. However, in the item answers to questions, some nurses claimed to be dissatisfied with their work due to the incentives given not being commensurate with the existing workload and the lack of relationships between employees and work groups. However, in the item answers to questions, some nurses claimed to be dissatisfied with their work due to the incentives given not being commensurate with the existing workload and the lack of relationships between employees and work groups. Preliminary study in the inpatient room of RSUD Dr. Harjono Ponorogo about the ratio of the number of nurses and patient beds, the data obtained on the number of nurses in the inpatient room is 164 people while the number of beds available is 366 patient beds. So the ratio of the number of nurses and patient beds in the inpatient room is 164 : 366, so it can be said that 1 nurse in the inpatient room handles 2 to 3 patients. The unbalanced number of nurses and the number of patients treated can increase the nurse's workload. So it can be concluded that this has an impact on the job satisfaction of nurses in the inpatient ward of Dr. Hospital. Harjono Ponorogo.
The nurse's dissatisfaction has an impact on nurses, namely stress, poor nurse performance results in providing nursing services to patients, and increasing turnover intensity in nurses (Bautista et al., 2020). Nurse job satisfaction is influenced by several factors including supervision, salary and benefits, opportunities to get promotions and promotions, working conditions (workload), experience with skills, fair and not detrimental work assessments, good social relations in work (include social support), fast settlement of employees. complaints and good treatment from the leadership towards employees (Barahama et al., 2019).
Excessive workloads are often caused by the number of nurses being insufficient and not commensurate with the demands of the existing tasks (Haryanti et al., 2016). Meanwhile, social relations (social support) that are not well established between colleagues will lead to a lack of job satisfaction for nurses (Purdini et al., 2016). This study aims to explain the relationship between workload and social support with nurse job satisfactions in the inpatient ward of RSUD Dr. Harjono Ponorogo.

Research Design
The research design used was descriptive correlational with a cross sectional approach. The study was conducted in January 2021 -April 2021. Measurement of the relationship between workload and social support with nurse job satisfactions in all inpatient rooms of RSUD Dr. Harjono Ponorogo was only carried out at one time and without any followup.

Population, Sample, and Sampling
The population in this study were inpatient room nurses at RSUD Dr. Harjono Ponorogo of 164 people. The sample size in this study were 116 nurses with the following inclusion criteria: 1) Nurses who served in the inpatient room of Dr. Harjono Ponorogo and 2) Implementing nurse who has worked for more than 1 year and has a career path (minimum Clinical Nurse I). The sampling technique used is cluster random sampling or a sampling technique that is applied when the population finds groups that look uniform but internally remain different.

Research Variables
The independent variables in this study were workload and social support, while the dependent variable was nurse job satisfaction.

Research Instrument
Data collection using an instrument in the form of a questionnaire consisting of 3 questionnaires, namely the workload questionnaire, social support questionnaire, and nurse job satisfaction questionnaire. The workload questionnaire uses a questionnaire from Nursalam (2017) which consists of 13 questions with the answer choices "Heavy Workload" with a value of 1, "Moderate Workload" with a value of 2, "Light Workload" with a value of 3, and "Not a Workload" with a value of 4. Social support questionnaire adapted from Wardhana's (2018) questionnaire which consists of 16 questions with the answer choices "Strongly Disagree" with a value of 1, "Disagree" with a value of 2, "Quite Agree" with a value of 3, "Agree" with a value of 4, and "Strongly Agree" with a value of 5. The nurse job satisfaction questionnaire uses a questionnaire from Nursalam (2013) which consists of 20 questions with the answer choices "Very Dissatisfied" with a value of 1, "Not Satisfied" with value of 2, "Quite Satisfied" with a value of 3, "Satisfied" with a value of 4, and "Very Satisfied" with a value of 5.
The instrument used in this study has been tested for the validity and reliability of the SPSS version 25.0 application. The results of the validity test of the workload instrument obtained the pearson correlation value in the range of 0.870-0.982 (r > 0.632) at a significance value of 5%. The results of the social support questionnaire validity test showed the pearson correlation value in the range of 0.869-0.989 (r > 0.632) at a significance value of 5%. And the nurse job satisfaction questionnaire shows the pearson correlation value in the range of 0.752-0.998 (r > 0.632) at a significance value of 5%. Therefore, it can be concluded that all the question items in this research questionnaire are valid, so they can be used as research instruments. The results of the reliability test obtained that the cronbach alpha value for the workload variable was 0.785, the social support variable was 0.779, and the nurse job satisfaction variable was 0.773. Based on these values, it can be concluded that the questionnaire in this study is reliable (cronbach alpha 0.61 to 0.80) so that it can be used as a research instrument.

Research Procedures
The research procedure was started by asking permission to conduct research at RSUD Dr. Harjono Ponorogo. Next is to test research ethics and test the validity and reliability of the questionnaire that will be used. At the time of data collection the researcher will provide an explanation of the purpose of the research to be carried out, nurses who are willing to become research respondents are asked to sign an informed consent first. Data was collected by asking respondents to fill out the answers to the questionnaire according to their perceived conditions. During data collection, the researcher was assisted by the head of the inpatient room to provide assistance, so that if there were questions that were not understood, they could be asked directly. Questionnaires certainly not interrupt the respondent, because the questionnaire can be filled at any time when respondents are not currently in conducting nursing services.

Data Analysis
The data analysis used is descriptive analysis and inferential analysis. This data analysis was selected based on research needs namely correlational research, descriptive analysis was used to provide a description of the independent variables (workload, social support) and the dependent variable (nurse job satisfaction). While inferential analysis is used to determine the effect of independent variables (workload, social support) on the dependent variable (nurse job satisfaction). In descriptive analysis, data are grouped by category and frequency. While the inferential analysis used logistic regression test with a significance value of p ≤ 0.05. Data analysis in this study used the SPSS version 25.0 application.

RESULTS
The study was conducted on 116 respondents of nurses who served in the inpatient room of RSUD Dr. Harjono Ponorogo. Hospital Dr. Harjono Ponorogo is a place of reference for the Ponorogo area and its surroundings.
Based on the demographic characteristics data, it is known that the majority of respondents are in the 35-40 year age group as many as 34 respondents (29.3%). Most of the respondents were female, amounting to 84 respondents (72.4%) with marital status having been married, amounting to 102 respondents (87.9%). Most respondents have an education level of S.Kep.Ns. as many as 59 respondents (50.9%) and most of the working period in the hospital is more than 10 years as many as 50 respondents (43.1%). The highest employment status is civil servants with 62 respondents (53.4%) and the highest career path is clinical nurse I as implementing nurse as many as 49 respondents (42.2%) ( Table 1). In the analysis of research variables, it was found that the percentage of nurses' workload in the inpatient room of Dr. RSUD. Harjono Ponorogo was mostly in the moderate workload category as many as 54 respondents (46.6%). Nurses with heavy workload categories were 40 respondents (34.5%) and nurses with light workload categories were 22 respondents (19.0%). In the workload parameter, it was found that in the physical aspect the majority of respondents in the heavy workload category were 50 respondents (43.1%) and in the psychological aspect (43.1%) and in the psychological aspect the most were in the moderate workload category as many as 41 respondents (35.3%). While on the social support variable, the majority of nurses in the inpatient room of RSUD Dr. Harjono Ponorogo has good social support with a total of 93 respondents (80.2%). While nurses who have less social support amounted to 23 respondents (19.8%). On the parameters of social support, it was found that in the aspect of instrumental support the majority of respondents were in the good category as many as 74 respondents (63.8%) and the less category as many as 42 respondents (36.2%). In the aspect of informational support, the results obtained were 73 respondents (62.9%) in the good category and 43 respondents (37.1%) in the poor category. The majority of nurse respondents in this study had emotional support aspects in the good category as many as 80 respondents (69.0%) and in the less category as many as 36 respondents (31.0%). Meanwhile, in the aspect  Table 2). The results of the logistic regression test showed that the workload had a significant value of p 0.05 (0.000) and social support had a significant value of p 0.05 (0.003) (Table 3), which means that workload and social support were positively related to nurse job satisfaction. The positive workload and social support have an influence on the nurse job satisfactions.

DISCUSSION
Workload has a significant relationship with nurse job satisfactions in hospitals. A heavy workload will reduce nurse job satisfaction. Nurse workload is a condition where nurses are weak, both physically and non-physically in completing health service work (Romadhoni & Pudjirahardjo, 2018). The workload of nurses is divided into physical aspects and psychological aspects. The physical aspect is the workload that arises due to physical activity carried out by nurses. The study was conducted by researchers in the inpatient room of RSUD Dr. Harjono Ponorogo, the physical aspects found include observing patients during working hours, for example checking the patient's vital signs (blood pressure, respiratory rate, pulse, patient temperature), many and various jobs that must be done for patient safety, for example helping lift the patient while doing activities sitting/standing/walking and helping the patient to the bathroom, the nurse has direct contact with the patient in the inpatient room continuously, the nursing staff in the inpatient room is less than the patient, the knowledge and skills of nurses are sometimes not balanced with work that must be done, so that nurses feel burdened with existing physical activities. While the psychological aspect is the workload that arises and can be seen from the work carried out by nurses, the workload of the psychological aspect is formed cognitively from the minds of nurses (Lado, 2018). For example, the family for patient safety, the nurse's sense of responsibility in carrying out patient care while in the inpatient room, and the nurse's relationship with her superior, as well as the nurse and her family. The level of the nurse's workload depends on the number of patients being treated, the things that are done, and also by the number of nurses who carry out activities for the patients (Barahama et al., 2019). The number of patients and nurses who are not balanced will affect the workload of nurses, the workload of nurses will affect the nurse job satisfactions in the inpatient room.
Based on the research, the results showed that job satisfaction was both heavy on the physical aspect and heavy psychological aspects. This phenomenon occurs because of factors other than workload and social support that affect nurse job satisfaction, which consists of 5 indicators according to Abraham Maslow, namely physiological needs, security needs, social needs, esteem needs, and self-actualization needs. Physiological needs include the amount of salary received, the need for security (available equipment and facilities that support work), social needs (relationships between employees), esteem needs (the treatment of others towards us, freedom to do their own method of doing work), and the need for self-actualization (opportunities to improve employability through additional training or education).
The workload, which is optimally regulated and managed by the manager of hospitals, can be a light workload or a heavy workload for nurses. The light workload is a balance between the number of nurses and the number of patients in the room and a heavy workload because nurses have to do jobs outside of their main duties as nurses. This is also because the ratio of the number of nurses to the BOR (Bed Occupancy Ratio) or the number of beds filled in a certain period is not balanced, will greatly affect the nurse job satisfactions and have an impact on the quality of service.
Nurse social support consists of four parameters, namely instrumental support, informational support, emotional support, and reward support which have a positive relationship with nurse job satisfaction. social support is a major antecedent of job satisfaction in 1000 (Orgambídez & Almeida, 2020). Deep social support is supported by trust, business recognition, mutual respect and mutual assistance (Staempfli & Lamarche, 2020). This is achieved so that it can provide social capital for nurses, meaning that this support is a source that can bring back future motivation for nurses, and this social capital can significantly increase nurse job satisfaction.
The theory (House & Smet, 1994) in (Hastinda, Inge, 2016) explains that social support consists of instrumental support, informational support, emotional support, and reward support. Nurses with good instrumental support tend to have good job satisfaction. According to (House & Smet, 1994) instrumental support is assistance given directly from the hospital, including facilities or materials, for example providing the necessary facilities, lending goods, or other assistance. This study is in line with previous research, that the completeness of facilities can help nurses complete their work well due to good job satisfaction for nurses (Barahama et al., 2019). Based on the results of good job satisfaction research on lack of instrumental support, this is because there are other factors that affect nurse job satisfaction besides instrumental support, namely in accordance with Abraham Maslow's hierarchy of needs theory, including FAKHA (Physiological needs, security, social, appreciation, self-actualization). Physiological needs to the highest needs, namely self-actualization are met can increase the nurse job satisfactions in hospitals.
Nurses who have good informational support tend to have good job satisfaction. Informational support is to provide an explanation of the situation related to the problem being faced by the nurse, including advice, instructions, input or explanation (House & Smet, 1994). This study is in line with research that when nurses have clear and precise information about their duties, functions and responsibilities, and know the behavior expected for their position, they evaluate their work more positively and feel more satisfied in their workplace (Orgambídez & Almeida, 2020). Nurses with good emotional support tend to have good job satisfaction. According to (House & Smet, 1994) emotional support is an expression of empathy for example listening, being open, showing understanding, affection and attention. This study is in line with research that high emotional support increases the effect of social support on job satisfaction while reducing the effect of lack of organizational justice on nurse job satisfaction (Soto-Rubio et al., 2020). Good nurse job satisfaction is influenced by good reward support. Appreciation support is the provision of support by looking at the positive aspects that exist in the individual compared to others (House & Smet, 1994). This research is in line with research of Mousazadeh (2019) that requires nurse appreciation, nurses are not accepted and valued experience higher levels of depression and lower self-esteem, stress, anxiety, and increased job dissatisfaction (Mousazadeh et al., 2019).
Overall research shows that there is a significant relationship between workload and social support: instrumental support, informational support, emotional support, reward support and nurse job satisfaction. In this study it can be concluded that in order to achieve good job satisfaction, nurses must consider the workload and social support for nurses, so that professional nursing services can be created.

CONCLUSION
The workload felt by nurses is light, the better the nurse job satisfactions. Because a light workload is a sign of a balance between the number of nurses and the BOR (Bed Occupancy Ratio) or the number of beds filled in a certain period in the room, so that the number of nurses is balanced with the demands of the task at hand and nurses can fulfill their responsibilities to patients properly and maximally. Social support in the form of instrumental support, informational support, emotional support, and appreciation support felt by good nurses will also provide good job satisfaction for nurses. Because nurses feel cared for and appreciated by co-workers, superiors and families which can increase nurse job satisfaction. So that the performance of nurses increases and creates professional nursing services.