Leadership Style and Nurse Performance in the Inpatient Ward of Muhammadiyah Gresik Hospital: A Cross-sectional Study

Introduction: Nurses responsible to perform optimally, adhere to the standards set by the hospital to gain high quality of nursing care. The determining factor for the quality of nursing services is the performance. Leadership style of the head ward is one of the factors that influence the performance of nurses. The aim of this study is to analyze the relationship between the leadership style and the performance of nurses in the inpatient ward at Muhammadiyah Gresik Hospital. Method: The research design is correlational with a cross-sectional approach. The sampling technique in this study was total sampling with a total sample of 44 nurses. Data collection for leadership style using a questionnaire, while the nurse performance using a performance appraisal checklist. The statistical test in this study used the Rank Spearman test to determine the correlation between variables. Results: Most of the leadership style in the inpatient ward of the Muhammadiyah Gresik Hospital is a democratic leadership style (79.5%), most of the nurses have performance at the sufficient category (65.9%). There is a relationship between the leadership style of the head of the ward and the performance of nurses in the inpatient ward at Muhammadiyah Gresik Hospital (p=0,000). Conclusions : The democratic leadership style has a good influence on the nurse performance. Further study for improving nurse performance by optimizing leadership role is needed.


INTRODUCTION
Leaders play a very important role in the organizational life, they are very decisive in achieving of organizational goals (Artianingsih, 2016).It is said that the success or failure of an organization is largely determined by leadership (Anteja, 2014).Leadership is an ability to influence the behavior of other people or groups towards achieving organizational goals (Paul Hersley In The Situational Leader) in (Yuliastanti & Erpidawati, 2019).The leader has his own style to achieve the desired goal (Sagala & Syaiful, 2018).
Leadership in the scope of nursing is the ability and skills of a nurse in influencing other nurses under her supervision to carry out the duties and responsibilities of nurses in providing nursing services so that nursing goals are achieved (Simamora, 2018).Leadership style is one of the factors that influence nursing performance, while the determining factor for the quality of nursing work is nursing performance.Nurses will always be required to perform optimally and according to the standards set by the hospital (Trevia et al., 2019).
According to Rahayu, Wahyuni, & Sulasmini (2019), study in Gondanglegi Islamic Hospital in Malang Regency revealed that leadership style has a very close correlation with nurse performance with data on almost all participants as many as 15 participants (47%) in the category of democratic leadership style, and as many as 30 participants (94%) in the category of performance with a standard value.Research at Major General HA Thalib Kerinci Hospital by Trevia, et al. (2019) states that there is a significant relationship between democratic and autocratic leadership styles and nurse performance with the following data; the performance of the nursing staff was good at 67.3 percent and a strong democratic leadership style was achieved at 57.4 percent, weak autocracy at 63.8 percent, participatory, weak at 52.5 percent and laisez faire was weak at 69.3%.From interviews with the chief nurse in the inpatient ward of the Muhammadiyah Gresik Hospital, she stated that 4 out of 10 nurses whose performance still did not meet the criteria for the good category, the performance of nurses is still not optimal as a whole.Based on the above background, this study aimed to examine whether leadership influences nurses on their performance at Muhammadiyah Gresik Hospital.
Leadership is considered ideal when work goals and decisions are made together in groups.The most effective leaders have mutually supportive relationships with subordinates relying on individual decision making, and encouraging supervisors to set and achieve goals for high performance.For ward nurses, ward managers are managers who can motivate nurses to work well.An overview of the leadership of the ward manager is generated from his leadership role in carrying out the leadership role of managing, and directing nurses to be in charge and responsible for providing services.

Design
This research design is correlational analytic research with cross sectional approach.

Population, Sample, and Sampling
The population used in this study were all of the nurses at the patient ward in Muhammadiyah Gresik Hospital with a total of 44 nurses.The research sample were the nurses at the inpatient ward of Muhammadiyah Gresik Hospital with a total of 44 nurses.The sampling method used total Sampling.

Variable
The independent variable is leadership style of chief nurse and the dependent variable is the performance of nurses in the inpatient ward at Muhammadiyah Gresik Hospital.

Instruments
The research instrument was a questionnaire for leadership style taken from Trihastuti (2016) in Rumaisha (2019) using 12 item questions, with the assessment criteria Authoritarian = A, Democratic = B, Laissez-faire = C, while for nurse performance using a check list that has been set by Muhammadiyah Gresik Hospital consisting of 7 items with the number of questions were 28 questions.The questions used are closed or structured questionnaires where the participant only has to answer or select the column provided (participants only give a mark (√)).

Procedure
Starting from taking care of research permits, digging information related to the number of nurses and shift schedules to Muhammadiyah Gresik Hospital, researchers visited participants on each shift schedule.The researcher explained the benefits, objectives and research procedures to the participants.Participants filled out informed consent.Researchers distributed questionnaires to participants.
Participants filled out informed consent.Researchers distributed questionnaires to participants.The researcher explained the procedure for filling out the questionnaire to the participants.Researchers accompany participants when filling out.Furthermore, the data that has been obtained is collected and processed by the researcher.

Data Analysis
Bivariate analysis is an analysis carried out to determine whether there is a relationship between the independent and dependent variables using statistical tests (Notoatmodjo, 2012).
Univariate analysis aims to explain or describe the characteristics of each research variable (Notoatmodjo, 2012).In this study, univariate analysis was performed using frequency distribution tables for gender, age, marital status, length of service, and education level of nurses at Muhammadiyah Gresik Hospital.

Ethical Clearance
Ethical Approval number: 156/KET/II.3.UMG/ KEP/A/2022 from the research ethics commission of the Faculty of Health, University of Muhammadiyah Gresik.

Characteristics of Nurses Based on Gender, Age,
Last Education, Length of Service The demographic characteristics from the participants can be seen in table 1.Based on table 1, it shows that 33 (75%) of the female nurses are mostly aged 31-40 years, 27 (61.36%)nurses with Bachelor of Nursing education level, that is, there are 27 (61.36%)nurses, the length of service of the nurses in inpatient wards >6 as many as 25 (56.8%)nurses.

Leadership Style Frequency Distribution
Based on table 2, it shows that as many as 35 (79.5%) nurses think that the leadership style of the head of the ward in the inpatient ward at Muhammadiyah Gresik Hospital applies a democratic leadership style.

Nurse Performance Frequency Distribution
Based on table 3 it shows that as many as 29 (65.9%)nurses are included in the sufficient performance category.

The correlation between Leadership Style and
Nurse Performance in the Inpatient Ward of the Muhammadiyah Gresik Hospital   The results of the analysis obtained a p value of 0.000 < α 0.05, meaning that there is a relationship between the leadership style of the ward manager and the performance of nurses in the inpatient ward at Muhammadiyah Gresik Hospital.This study has a correlation coefficient of 0.526, which means that the level of correlation is moderate.

DISCUSSION
The results of the study in table 2 show that the total number of the participants were 44 nurses at Muhammadiyah Gresik Hospital.The number nurses who determine that the chief of nurse who have authoritarian leadership style were 7 nurses (15.9%), 35 nurses (79.55%) stated that the leadership style of nurse chief was a democratic leadership and 2 nurses (4.55%) stated that the leadership style of the chief nurse was a laisses-faire style.From the questionnaire about the leadership style distributed by the researcher, it was found that the description of the nursing unit manager leadership style of Muhammadiyah Gresik Hospital inpatient ward, they always interacts with the implementing nurse, and continues to ensure that all team members are aware of their responsibilities, and work with the team of nurses, and also jointly involved in problem solving, building good interpersonal by making its members feel important and involved in every decision making.
The results of research on leadership styles in the inpatient ward at Muhammadiyah Gresik Hospital are in line with Napitupulu, Putra, & Shalahuddin, (2019) which state that democratic leaders are determined from their style for leading, it has nothing to do with being democratically elected.This type of leadership is a type of leadership where leaders are always willing to appreciate suggestions, opinions and advice from staff and subordinates, through forum meetings or deliberations to reach a consensus.Democratic leadership is leadership that is active, dynamic, and also directed.Control activities are carried out in an orderly and responsible manner.The delegation of duties is accompanied by clear authority and responsibility, and allows each member to participate actively.
The results of the study also found that 7 nurses (15.9%) who rated their leaders as leaders with an authoritarian leadership style.Research findings regarding authoritarian leadership styles are in line with Napitupulu, et al. (2019), that absolute power or authority resides with the leader, a centralized authority system.Policies or decision are only decided by their self, subordinates are not involved into the decision-making process.Leadership orientation only focuses on increasing employee productivity with less attention to the subordinates feelings and welfare.
According to researchers, democratic leadership style is a leadership style that places humans as the main and most important factor in a group.While the authoritarian leadership style is a leadership style that is oriented towards the ego of a leader.The benefits of a democratic leadership style for the organization are that all members of the organization can develop because they are given the opportunity to think and innovate for development and some decision making so that the members of the organization who in this study are nurses feel very valued.
Table 3 show that the performance in the good category is 13 (29.5%)nurses, the performance in the sufficient category is 29 (65.9%)nurses, according to the performance assessment checklist carried out by researchers, the value is sufficient, namely between 156 to 177 of the 7 nurse performance assessment checklist indicators, and the performance of nurses with less performance was 2 (4.6%) nurses.
The results of research on nurse performance are in line with Suriana's theory (2014), that the work of nurses is professionals with good intellectual abilities, nurses are professionals with good intellectual, technical, interpersonal and moral abilities who are responsible and have the authority to perform nursing in health services in the framework of professionals who are most qualified and competent in planning tasks and implementing the goals of the target unit of the health organizational unit regardless of the circumstances and the time situation.
According to researchers, nurses with sufficient category is already a good achievement, although it is not perfect, so it is necessary to increase the planting of the importance of responsibility, so that the average score on the performance appraisal checklist achieves a good score, exceeding the number of nurses with sufficient scores The results of the analysis in table 4 illustrate that the authoritarian leadership style has 5 nurses (71.4%) with good performance, 2 nurses (28.6%) with sufficient performance, while the democratic leadership style has 8 nurses (22.9%) with good performance.good, 27 nurses (77.1%) with adequate performance, and with a laisses-faire leadership style there are 2 nurses (100%) with less performance, thus the results in table 5.7 conclude that democratic leadership style has more influence on nurse performance than with other leadership styles.
The results of the analysis obtained a p value of 0.000 < α 0.05, meaning that there is a relationship between the leadership style of the head of the ward and the performance of nurses in the inpatient ward at Muhammadiyah Gresik Hospital.This study has a correlation coefficient of 0.526, which means that the level of correlation is moderate.
From the discussion above, the correlation value of a variable shows how much the strength of the relationship between the two is, so that the greater the correlation coefficient, it means that democratic leadership style has a pretty good influence on nurse performance.This result are in line with research conducted by Lengkong, Nursalam, & Tungka, (2019) in the RUMKITAL inpatient ward Dr. Wahyu Slamet Bitung Hospital concluded that statistically there is a significant relationship between leadership style and the performance of nurses in the RUMKITAL inpatient ward Dr. Wahyu Slamet Bitung Hospital with the result p = 0.000 and r = 0.623.The results of this study are also in line with research conducted by Ahmad (2021) at a private hospital which concluded that there is a relationship between the leadership style of the head of the ward and the performance of the implementing nurses with a p-value of 0.000.
In this study it was proven that the nurses performance included in the sufficient category by applied the democratic leadership model, which means that the level of service from nurse to patients was good enough.

CONCLUSION
From the study can be concluded that as many as 33 nurses (79.5%) think that nursing unit manager in the Muhammadiyah Gresik Hospital inpatient ward applies a democratic leadership style.29 nurses (65.9%) in the inpatient ward at the Muhammadiyah Gresik Hospital have sufficient performance There is a correlation between leadership style and nurse performance at Muhammadiyah Gresik Hospital inpatient ward.Further study for improving nurse performance by optimalizing leadership role is needed.
Table 4 illustrate that authoritarian leadership style has 5 nurses (71.4%) with good performance, 2 nurses (28.6%) with sufficient performance, while Tabel 1. Frequency Distribution Based on Gender in Nurses in the Muhammadiyah Gresik Hospital Inpatient

Table 3
Frequency Distribution of Nurse Performance in the Inpatient Ward of Muhammadiyah Gresik

Table 4 .
Cross-tabulation of the correlation between Leadership and Performance of Nurses in the Inpatient Ward of Muhammadiyah Gresik Hospital