THE ANALYSIS OF NURSE PERFORMANCE DURING COVID-19 PANDEMIC: A CASE STUDY FROM PRIVATE HOSPITAL IN TANGERANG

The performance of nurses as the front line is crucial in handling covid 19. The purpose of the research was to determine the effect of employee training, employee engagement, and work motivation on nurse performance in the healthcare industry when the COVID-19 pandemic occurred. The object of this research is a nurse with a staff position and a coordinator who works at the AN-NISA hospital located in Tangerang with 140 respondents from February until March 2021. This research uses a quantitative approach which will use questionnaire measuring tools and employee performance data during 2020. Data analysis using path analysis. This research concluded that appropriate employee training, employee engagement, and work motivation had a significant effect on nurse performance. However, employee training and work motivation have no significant effect on nurse performance through employee engagement when the COVID-19 pandemic occurred.


INTRODUCTION LITERATURE REVIEW AND HYPOTHESES Performance
Management experts argue that the notion of performance is the work performance of the implementation and goals of the organization carried out by superiors and employees who work in the organization so that organizational goals are achieved. (Nugroho et al., 2020). In Siswoyo (2018), Robbins's view states that actual attitudes at work or performance are formed from several components consisting of evaluation aspects and strong feelings that can guide behavior. (Siswoyo et al., 2018).
The performance can serve as a benchmark for improving health services to maintain the quality of health services provided to healthy and sick patients (Glady et al., 2019). Nurses' performance needs to be evaluated to maintain quality and determine and plan important career development strategies and achieve organizational goals, especially in the era of the COVID-19 pandemic. (Darma Yanti et al., 2020).
Spencer and Spencer define that competence as the characteristics that underlie behavior that describes the motives, personal characteristics (characteristics), self-concept, values, knowledge, or skills brought by a superior performer in the workplace. (Suhartini, 2016). The assessment based on Spencer and Spencer has two dimensions: 1) core competencies and functional competencies.

Employee Training
Training is an aspect of developing human resource capabilities in every organization. Training is related to improving employee skills and knowledge, which ultimately aims to improve performance. Training is one way to increase individual productivity and quality. (Sendawula et al., 2018).
One of the efforts to deal with the COVID-19 pandemic is comprehensive support by health service providers, namely training programs (Opatha, 2020). The nursing training program requires knowledge and expertise related to handling infectious diseases so that the medical team is sufficiently prepared to handle public health emergencies due to COVID-19 (Huang et al., 2020). Nurbiyati (2017)stated in his research that training evaluation was adopted from the Kirkpatrick Model. Kirkpatrick's evaluation model, known as the Kirkpatrick Four Levels Evaluation Model,

Retna Yulianti
developed in 1998, includes four levels of evaluation (level 1 reaction, level 2 learning, level 3 return on investment, and level 4 result). This model reflects Kirkpatrick's opinion that development through training is not something that is expensive and only harms the financial side but is an investment. So that training is an accurate investment calculation of the benefits obtained after carrying out HR development (Nurbiyati, 2017).

Work Engagement
Work engagement focuses on positive psychology, characterized by how energetic and flexible employees are, how involved they are in their work, and how focused they are in carrying out their duties. (Sendawula et al., 2018).
The increasing workload on nurses in the COVID-19 pandemic reduces nurse engagement in reducing patient suffering related to health during the COVID-19 pandemic on an ongoing basis, which is in line with nurses' ethical obligations to society in a human-centered nursing model (Rosa et al., 2020).

Dimensions of work engagement (work engagement) can be measured with the Utrecht Work
Engagement Scale (UWES) to following per under Vigor (spirit), Dedication (dedication), and Absorption (absorbed in work) (Giménez-Espert et al., 2020) UWES describes a high attachment at work, has a deep focus on the organization, is sensitive to the small important things, is so engrossed in work that he loses time and reduces all kinds of distractions at work. (Kristiana et al., 2019) Maintenance factors include physical working conditions, remuneration, supervision, various kinds of allowances and. This need includes a variety of intrinsic conditions and job satisfaction, which will impact a strong level of motivation resulting in a good performance. The motivation Factor includes a series of intrinsic conditions, job satisfaction (job content) which will drive a strong level of motivation when present in the job, which can result in good job performance (Andriani and Widiawati, 2017).

Relationship between Nurse Training and Job Engagement
Research Allande-Cusso (2021)found a significant difference (p < 0.05) between the training and job engagement dimensions. Nurses during the COVID-19 pandemic are a difficult profession because they are at risk of exposure due to lack of knowledge, training in self-protection, and complex service restructuring will impact the mental health of nurses in carrying out their duties. Research Labrague (2020) found that there was a significant difference between the level of work engagement (p < 0.05) of nursing training in the COVID-19 pandemic era (Labrague and De Los Santos, 2020). Nurse managers must provide adequate organizational support by implementing a safe work environment, providing complete and quality PPE and equipment to prevent infection, providing accurate and timely information on illness, and implementing training relevant to COVID-19. This organizational practice is very important to support nurses in their nursing practice and improve nurse work engagement in the era of the COVID-19 pandemic(Labrague and De Los Santos, 2020). Based on the statement above, the proposed hypothesis is: H1: Appropriate nurse training will form high job engagement.

Relationship between Nurse Motivation and Job Engagement
The relationship between work engagement and extended working time among nurses; In other words, an excessive service load during the COVID-19 pandemic will affect mental health and decreased work engagement. However, working overtime voluntarily, motivated by personal development and fulfillment, promotes increased work engagement .
Efforts to ensure a stable work engagement of nurses during the COVID-19 epidemic are to increase the motivation of nurses. The increase in motivation is by recognizing the dedication of nurses as front lines and paying more attention to infection control and physical discomfort Retna Yulianti caused by PPE. Further interventions should increase confidence in treating patients with infectious diseases (Zhang et al., 2021). Based on the statement above, the proposed hypothesis is: H2: High motivation of nurses will form high work engagement.

Relationship between Nurse Training and Nurse Performance
Training activities generate benefits or positively impact the performance and growth of individuals, teams, and organizations. Many studies have identified three benefits that employees derive from participating in training, namely personal benefits, career benefits, and work-related benefits. Perceptions of the benefits of training are influenced by previous experience in training which is a key variable for learning in improving employee performance (Sendawula et al., 2018).
A previous study conducted by Elnaga and Imran (2013) stated that training is one of the most important labor-management practices and affects the quality of workers' skills and knowledge, resulting in higher employee performance. The results of employee training are substantial productivity and quality performance(Nugroho et al., 2020).
The COVID-19 outbreak has put tremendous pressure on health services and nurses as the front line facing the impact of COVID-19. In this case, health service providers must focus on psychological support and training for coping strategies to maintain optimal performance and maintain quality. (Huang et al., 2020). Based on the statement above, the proposed hypothesis is: H3: Appropriate nurse training will establish high nurse performance.

Relationship between Nurse Motivation and Nurse Performance
Work motivation is a competency factor that can change. For example, giving encouragement, appreciation, recognition, and individual attention to employee work can positively affect an employee's motivation so that it will have a positive impact on employee performance(Ma'ruf, 2014). Employee performance is directly affected by intrinsic motivation. Because when employees are intrinsically motivated, they know their performance and work hard to earn rewards (Deressa and Zeru, 2019).
Nurses face various difficulties in their work, especially in the era of the COVID-19 pandemic, for example, work overload, treatment errors, unstable nurse image, decreased work motivation, 153 and work discomfort. The motivational aspect and its factors are an effective way to improve the performance of nurses, especially in the COVID-19 pandemic situation (Yanti et al., 2020).
Based on this statement, the proposed hypothesis is: H4: High nurse motivation will form high nurse performance.

Engagement
Employees exhibit bonded or committed behavior when they dedicate their physical, cognitive, and emotional resources to a work role, by having high energy levels, being enthusiastic about their work, thoroughly enjoying work engagement, leading to high-performing work practices and performance better outcomes at work (Johnson et al., 2018).
Nugroho (2020) argues that committed employees are characterized by motivation, participation, success, enthusiasm, dedication, enthusiasm, and a positive state through positive activities such as improving the quality of human resources that increase employee productivity.
Employee engagement during the current COVID-19 pandemic is very important in influencing performance and commitment to organizational goals, namely to continue providing quality services. (Radhwan et al., 2020). Based on this statement, the proposed hypothesis is:

H5: High work engagement will form high nurse performance
Based on the above hypothetical framework, the research model can be described as follows: Picture 1. The sampling technique used in this study is Stratified sampling used to select respondents from each section or installation to ensure that the installation is represented. Simple random sampling was used to select the final respondents in each installation. The selection of respondents in the study was by predetermined inclusion criteria, which consisted of nurses who were employees of the AN-NISA Hospital Tangerang; nurses who did not undergo orientation for six months; nurses who are not on maternity leave; Nurses who are willing to be respondents.
Employee training research variables measured using the employee training evaluation questionnaire developed by Kirkpatrick (1998) and consist of 4 dimensions with eight indicators as follows: reaction dimension consists of two indicators; attitude and influence; learning consists of two indicators, namely knowledge and skills; results consist of two indicators, namely implementation and impact of the relationship; along with cost-effectiveness consists of two indicators, namely efficiency and work effectiveness (Nurbiyati, 2017).
Employee engagement research variables measured using the Utrecht Work Engagement Scale (UWES), which consists of 3 dimensions with ten indicators as follows: Vigor consists of three indicators, namely enthusiasm for work, willingness to try while working, surviving under challenging circumstances; dedication consists of four indicators, namely a sense of responsibility, a sense of pride in work, a feeling of being challenged in work, feeling useful for others); along with absorption consists of three indicators, namely it is difficult to get away from work, pleasure at work, concentration when carrying out tasks (Titien, 2017). Meanwhile, the nurse's performance research variable was measured by secondary data through a performance evaluation process arranged in the AN-NISA Hospital Performance Assessment Guide Tangerang. Performance appraisal adopted from Spencer and Spencer has two dimensions: 1) core competence and functional competence. The nurse performance category is divided into four categories: unsatisfactory with a score of <69, quite good with a score of 70-79, good with a score of 80-95, and extraordinary with a score of 96-100.
Before being applied to the actual research, the research instrument will be tested first. The trial was carried out to ensure that the instrument compiled was good because it would affect whether the data was correct or not. The value of validity and reliability describes the good or bad of the instrument to know its feasibility in research on nurses who work at the AN-NISA

RESULTS AND DISCUSSION
The results of the research from 140 nurse respondents who worked at the AN-NISA Hospital Tangerang showed that the majority of respondents were women by 83.6%, aged between 21 -30 years by 85.7%, with the last education of Bachelor (S1) at 100%, staff/executive nurses. By 93.6%, length of service from 1-5 years by 76.4%. This shows that nurses who work at the AN-NISA Hospital are young people with a fairly high education Bachelor (S1) with a position as an implementing nurse who starts their work from 1 to 5 years at AN-NISA Hospital Tangerang.  Intervening variable analysis of nurses' training and motivation on nurse performance through work engagement did not have a significant relationship or effect because the direct effect was greater than the indirect effect (0.215 > 0.02176 and 0.201 > 0.00945).

Discussion
Our results agree with findings from prior studies, especially Allande-Cussó (2021) and Larague (2020) stated that nursing during the COVID-19 pandemic was a difficult profession due to lack of knowledge, training in self-protection, and complex service restructuring, so that has an impact on work engagement and function as a nurse. Darma Yanti's research (2020)  Training and development can provide competent quality for nurses to adapt to the changing conditions due to the COVID-19 pandemic. Improving the quality of nurse competence will provide the best service for people with COVID-19, which naturally increases job satisfaction and nurses' engagement with their duties and functions. (Azmy, 2019).
The study results found that the motivation of nurses has a high effect on work engagement (H2).
The results of this study are in line with the research of Gómez-Salgado (2021) because the excessive service burden during the COVID-19 pandemic will affect the motivational factor according to Herzberg's theory which has an impact on work absenteeism. .

Jurnal Manajemen Teori dan Terapan Volume 14. No. 2, Agustus 2021
Work engagement is an important factor that nurses must maintain in the COVID-19 pandemic era because of awareness of the importance of the work that must be done. Many studies have identified that nurses can maintain work engagement with values of caring, attitude (optimism), shared beliefs (religion), professional skills in the context of the work environment, and available support). This fact can direct nurses who cultivate an element of motivation to the special impact of COVID-19 in their work (Giménez-Espert et al., 2020).
In this test, it has been stated that training does not affect the performance of nurses (H3). This states that appropriate training does not make nurses have high performance in the era of the COVID-19 pandemic. The results of this study are in line with the findings of Sperling (2021)that no significant correlation was found between education level, nurses' attitudes towards work, and training about the health system during the COVID-19 pandemic on nurses' performance. This fact is influenced by two factors: experience and perception of risk of exposure to COVID-19.
More experienced nurses were happier with their decision to work in the health system during the COVID-19 pandemic than less experienced nurses. In addition, the higher the nurse's perception of personal risk, the more unhappy they are about their decision to work in the current health system. The more worried they will be about the impact of the pandemic on their career so that the nurse's performance will be less than optimal.
This study has proven that there is a positive influence of high motivation on the performance of nurses in the era of the COVID-19 pandemic (H4). This result is because the motivation felt by respondents during the COVID-19 pandemic was the most important psychological factor at work in the form of personal rewards when work targets were achieved and basic needs that were needed continuously to support the quality of life and work.
These results are by the research of Darma Yanti (2020), which states that Factors that affect the providing complete quality PPE and equipment to prevent infection, providing accurate and timely information regarding the disease and the implementation of training relevant to COVID-19. This organizational practice is very important to support nurses in their nursing practice, increase motivation, and produce optimal nurse performance in the COVID-19 pandemic (Labrague and De Los Santos, 2020). The implications for policymakers in the health care industry are to improve the performance of nurses on duty in the COVID-19 room by providing rewards, conducting regular screening, and providing protection for nurses by providing personal protective equipment by following the standards recommended by WHO.
One of the efforts to ensure stable work engagement and performance of nurses during the COVID-19 pandemic is by increasing the motivation of nurses. The increase in motivation is by recognizing the dedication of nurses as front lines and paying more attention to infection control and physical discomfort caused by PPE. Further interventions should increase confidence, knowledge, and skills in caring for patients with infectious diseases (Zhang et al., 2021).
The implications of the research for researchers can be used as basic data to research with qualitative or mixed methods to find out the factors that most influence the performance of nurses, given that nurses are important human resources in dealing with the COVID-19 pandemic. The purpose of developing human resources by knowing the most influential factors is to improve the quality of professionalism and skills of nurses from carrying out their duties and functions as nurses so that they can further improve the performance of nurses.
The limitations of this study can be considered for further research. This study uses a questionnaire as a research instrument to save time and effort. However, this questionnaire has limitations in filling out questions. There is a possibility that the respondent did not answer the questionnaire in real or just answered filling out the answers to the questionnaire based on the expected ideal conditions and not the actual conditions that occurred. In addition, there are limitations in distributing questionnaires and performance assessments according to the guidelines that only apply and are carried out at the AN-NISA Hospital. Therefore, future research could examine the larger respondents or larger scope.
Further research can be carried out in all lines in one area at a specific time by involving nurses involved in COVID-19 care to improve the accuracy of data analysis. Add research variables such as psychological well being, job satisfaction, burnout, and so on so that the results of data and variables are more varied to be studied. The results of this study state that organizations cannot ignore appropriate and regular training needed by employees even in the COVID-19 pandemic era to maintain work engagement and motivation so that employee performance remains optimal.