Analysis of Factors Affecting the Performance of Emergency Nurses in Bhayangkara Tebing Tinggi Public Hospital

Emergency Room (IGD) as one of the first entry points for patients to the hospital, will indirectly provide an overview of hospital services as a whole. Data on emergency visits of patients at Bhayangkara Tebing Tinggi Hospital in the January May 2020 period were 2,685 patients and experienced a significant decrease every month. The research objective was to analyze the factors that influence the performance of emergency room nurses at the Tebing Tinggi Bhayangkara General Hospital in 2020. The research design used a descriptive analytic method with a cross-sectional approach. The population in the study were all nurses who served in the IGD at the Bhayangkara Tebing Tinggi Hospital in 2020 totaling 32 people. The sample uses the otal population. Data analysis used univariate, bivariate and multivariate analysis using logistic regression tests.The results of the study using logistic regression showed the sig. each variable, namely the variable ability (0.578), skills (0.011), motivation (0.129), reward (0.013), infrastructure (0.855) and the value of Exp (B) the largest = 26.633 in the variable reward. The conclusion of this study is that there is a significant effect of skills and rewards on the performance of nurses in the IGD at the Bhayangkara Tebing Tinggi Hospital and the variables that have no significant effect are ability, motivation and infrastructure.


Introduction
Health is a basic right so that every community has the right to obtain fair, equitable and quality health services that reach all Indonesians. In this regard, the Government is trying to improve public health services by providing health service facilities, including hospitals. One of the basic necessities of life which is the responsibility of the government is health. In Law No. 36 of 2009 on Health, it is emphasized that everyone has the same rights in obtaining health access and obtaining safe, quality and affordable health services. This means that in this case the government is obliged to make efforts to provide health services in accordance with the criteria of the law.
The hospital as a health facility that provides health services to the community has a very strategic role in accelerating the improvement of public health status. Therefore, hospitals are required to provide quality services according to established standards and can reach all levels of society. According to the Law of the Republic of Indonesia Number 44 of 2009 concerning Hospitals in Article 1, it is stated that a hospital is a health service institution that The hospital is an agency or organization that must have good management in order to provide services to patients. One of the most important parts of the hospital is the Emergency Room (IGD). The emergency department is the main door for all patients with both emergency and non-emergency conditions. IGD is a part of the hospital that performs actions based on triage of the patient's condition. Triage distribution to patients is very important in order to prevent disability and death in patients. Therefore, emergency room officers, especially doctors and nurses, must have more speed, skills and alertness than medical workers in other rooms.
Emergency services in emergencies start with the response time process and the implementation of patient triage. This is useful to assist officers in identifying patients who must be prioritized for early treatment. In performing their duties, emergency health workers must be based on standards. It is hoped that the existing nursing standards in the hospital can be used to determine the qualifications and types of services in the hospital. The philosophy of emergency handling is time saving life saving, meaning that every action taken to help patients must be effective and efficient. Stopping breathing for 2 -3 minutes can remove cells which will lead to tissue death (Sudiharto & Sartono, 2011).
The speed and accuracy of assistance provided to Emergency patients must be in accordance with the competence and service standards so that the handling given is based on a fast response time and appropriate action. Health workers' understanding of the concept of response time in emergencies requires continuous evaluation and refresher. Every year an audit of response time is required, especially in emergency cases. because response time measures are the quality of the emergency room service.
The results of Yuwono's (2015) research on government hospitals stated that the response time which is still far from standard is due to the lack of knowledge and attitudes of nurses regarding the importance of response time in true emergency patients. The results showed that 60% of nurses had a slow response time, namely 11-15 minutes, where through further study, it was found that 55% of nurses lacked knowledge in understanding the importance of response time and 45% were due to the attitudes of nurses who had motivation to let it slow down but safe. The results of this study conclude that there is need for direction, guidance and understanding to nurses in order to change attitudes, be able to increase knowledge in order to improve service quality in emergencies.
The factors that make services in hospitals, especially in the ER, are less than optimal, namely: incomplete medical equipment, inadequate action space and less skilled health personnel. So that this condition does not occur, all hospitals are required to apply the standard Emergency Room. Hospital emergency standards are currently regulated in the Republic of Indonesia's Minister of Health Decree No.856 / Menkes / SK / IX / 2009 concerning Hospital Emergency Room Standards, hereinafter referred to as Hospital Emergency Standards, so that all hospitals are expected to meet IGD standards with the expectation that the quality of service becomes increase (Susatyo, 2016).
In Tebing Tinggi City, there are 5 (five) hospitals that provide health services to the community, one of which is the Tebing Tinggi Bhayangkara Hospital. This hospital is a hospital belonging to the Indonesian National Police, which is classified as a Type C Hospital, which provides specialist and subspecialistic services with a capacity of 135 beds.
The main task of the Tebing Tinggi Bhayangkara Hospital is to carry out health functions including promotional, preventive, curative and medical rehabilitation activities for Republic of Indonesia Police (POLRI) personnel, Civil Servant and their families as well as the general public in the Kota Tebing Tinggi area and the stipulation of the MOU on Transfer of health service programs and joint use health facilities are expected to provide better health services than the previous program.
Emergency services at Bhayangkara Tebing Tinggi Hospital are carried out by competent health workers, including specialist doctors, general practitioners and nursing staff. Triage carried out at Bhayangkara Tebing Tinggi Hospital uses a combination of color categories and the Patient Acuity Categoryy Scale (PACS) in accordance with the Minister of Health Regulation No. 19 of 2016 concerning the Integrated Emergency Management System, which consists of four categories, namely the red category or P1 (emergency) with a response time of 0 -5 minutes, the yellow category or P2 (non-emergency / non-emergency) with a response time of 6 -10 minutes, green category or P3 (not serious and not emergency) with a response time of 15-30 minutes, black category or P0 (died before arriving at an emergency department or Death on Arrival (DOA) with a response time of 30-60 minutes. Especially for patients in the red category or P1 (emergency department) triage can be done while the patient is still in the vehicle or at the door of the emergency room.
According to the Regulation of the Minister of Health of the Republic of Indonesia Number 47 of 2018 concerning Emergency Services, Emergency Services in Hospitals must have a Doctor in Charge of Services (DPJP). The clinical competence of doctors who work in Emergency Services is adjusted to the competence of doctors based on their education level. According to the Decree of the Minister of Health Number 129 of 2008 concerning Hospital Minimum Service Standards (SPM-RS), the response time for doctor services in an emergency department has dimensions of quality of safety and effectiveness. The speed of doctor service in an emergency department is the speed at which the patient is served from the time the patient arrives until he gets doctor's service (minutes). The response time has a standard maximum of 5 minutes in each case. Service response time needs to be taken into account in order to provide services that are fast, responsive and able to save emergency patients. Nurses who work in the Emergency Services unit are nurses who have emergency competence obtained through standardized emergency training in accordance with the provisions of laws and regulations.
Based on the table of the number of patient visits at the Bhayangkara Tebing Tinggi Hospital for the 2017-2019 period, it is known that the number of patients visiting the Bhayangkara Tebing Tinggi Hospital has fluctuated in 2018, namely 45,014 outpatients and 21,342 inpatients compared to visits in 2017, namely as many as 50,908 outpatients and 24,994 inpatients. The number of patient visits in 2019 has again decreased, namely as many as 38,995 outpatients and 9,899 inpatients. Meanwhile, for emergency services, it is known that the number of visits was 29,698 visits.
Nursing services are an integral part of health services in hospitals, both in outpatient installations, inpatient installations and emergency departments. Emergency Room (IGD) as one of the first entry points for patients to the hospital, will indirectly provide an overview of hospital services as a whole. Increasing the performance of nurses can be improved through education and training in handling emergency patients, the existence of clear rewards and punishments and remuneration.
According to Nursalam, indicators of the quality of health services in the hospital can be reflected in patient satisfaction with the health services they have received. Patient satisfaction with service quality is a comprehensive assessment of the excellence of a service or service. Satisfaction is someone's happy feeling that comes from a comparison between pleasure in activities and a service received with expectations. Satisfaction is the feeling of being happy or disappointed by someone who comes after comparing their perceptions or impressions of the performance or results of a product and their expectations (Nursalam, 2014).
Patients will feel satisfied if the health service performance they get is in accordance with their expectations. Therefore patient satisfaction is a level of patient feeling that arises due to the results of comparing the performance of the health services it receives with what is expected (Pohan, 2007).
One of the quality indicators to measure the performance of the Emergency Room (IGD) according to the Minister of Health Regulation No. 19 of 2016 concerning the Integrated Emergency Management System, is the response time for patient services in the ER, namely the speed of patient handling is calculated from the time the patient arrives until he gets treatment in less than 5 minutes. Other indicators of quality of emergency services include the failure rate for infusion> 2x, the error rate for patient transfer, the error rate for blood draw and the error rate for administering drugs. According to the Ministry of Health 2011 regarding Standards for Emergency Nursing Services in Hospital, that the performance of a nurse will show the performance of a hospital, specifically the performance of a nurse in the ER in the standard of emergency nursing services in hospitals can be assessed from the speed of response time in serving patients , patient satisfaction rate> 70% and mortality rate in the ER <24 hours.
The factors that most support a person in doing a job from individual factors are the abilities and skills related to the tasks being carried out, abilities and skills can be obtained from the education and training of an employee. The organizational factor that most strongly influences one's performance is reward. Rewards is a statement of appreciation for the achievement of goals. Rewards consist of two things, namely intrinsic rewards and extrinsic rewards. Intrinsic rewards are rewards that arise from within the employees themselves, such as task completion, achievement and growth. While extrinsic rewards or external rewards consist of financial rewards, interpersonal relationships and promotions (Nursalam, 2014).
Based on a preliminary study conducted at the Bhayangkara Tebing Tinggi Hospital, data on the number of patient visits who entered the emergency room in the January -May 2020 period were 2,685 patients. According to the data in the preliminary study, the emergency room visits have decreased significantly every month with the number of patients as many as 813 patients in January 2020 and the following month decreased to 572 patients in February 2020, 416 patients in March 2020, 496 patients in April 2020 and the lowest was 388 patients in May 2020.
In the patient satisfaction data carried out by the customer service department of the Bhayangkara Tebing Tinggi Hospital in 2019, there were still many patient complaints related to services both from the registration, emergency department, outpatient care, pharmacy, inpatient and supporting services in terms of doctor response time and slow nurses, lack of clarity and openness of information, convoluted administrative procedures of BPJS, less friendly staff, uncomfortable waiting rooms and inadequate inpatient facilities. This allows for a decrease in the number of patient visits in 2020, coupled with the Covid 19 pandemic which has an impact on all sectors of public life including the economic sector.
Nurses as servants and those on duty in the emergency room at the hospital must carry out their duties and functions as much as possible based on the work standards set by the Health Service or the Bhayangkara Tebing Tinggi Hospital to provide the best possible service to patients so that patients are satisfied. The number of nurses who served in the IGD Bhayangkara Tebing Tinggi room was 32 people with the lowest education level was D3 Nursing and the highest education level was S1 Ners. The triage system used is a color triage system. The results of interviews with several IGD officers showed that the implementation of triage had been running according to the existing triage but had not conducted an evaluation regarding the response time of nurses. Without evaluation it will be difficult to assess the performance and quality of service, therefore it is necessary to evaluate the performance of the emergency room nurses. Where not all IGD nurses have First Aid certificates in Emergency (PPGD), Advanced Cardio Life Support (ACLS), Advanced Trauma Life Support (ATLS), nursing emergency, nurses who serve in the ER must have these certificates.
From the description of the problem identification above, the researcher is interested in conducting a research entitled "Analysis of Factors Affecting the Performance of Emergency Room Nurses at the Bhayangkara Tebing Tinggi General Hospital in 2020". The general purpose of this study is to analyze the factors that affect the performance of emergency room nurses at the Tebing Tinggi Bhayangkara General Hospital in 2020.

Methods
The research design used a descriptive analytic method with a cross-sectional approach, where researchers conducted research that emphasized measurement time, observed data on independent and dependent variables only once at a time and there was no follow-up.
This research was conducted at the Bhayangkara Tebing Tinggi Hospital. The population in this study were all nurses who served in the IGD at the Bhayangkara Tebing Tinggi Hospital in 2020 totaling 32 people. The sampling technique used an accidental sampling system, namely taking samples that happened to be available or available until a sample of 32 nurses who served in the emergency room at the Bhayangkara Tebing Tinggi Hospital was obtained. The data analysis used in this study was univariate, bivariate and multivariate analysis with logistic regression.

Respondent Characteristics
Based on the results of data collection on the characteristics that the age of nurses is grouped by age category, namely 19 respondents aged 31-40 years (59.4%). Respondents based on sex were more women as many as 19 people (59.4%), based on the education of the majority of the respondents had a D3 Nursing education as many as 26 people (81.3%) and based on the category of length of work the majority of respondents worked with a length of work> 10 years as many as 17 people (53.1%). The results of the measurement of ability were more capable categories, namely 18 people (56.2%), the rest were less well off as many as 14 people (43.8%). The results of the measurement of skills were more skilled, namely 21 people (65.6%), the rest were less skilled as many as 11 people (34.4%). The measurement results regarding motivation were higher, namely 20 people (62.5%), the rest were low as many as 12 people (37.5%). The results of the measurement of the more rewards were 23 people (71.9%), the rest were less than 9 people (28.1%). The results of the measurement of infrastructure are less supportive, namely 16 people (50.0%) and 16 people (50.0%) in the supporting category. The measurement results regarding the performance of nurses were better, namely 18 people (56.3%), the rest were less than 14 people (43.7%).

Bivariate Analysis
Based on the research results, it is known that from 26 respondents with a D3 education, it is known that there are 12 nurses with less performance (37.5%) while those with good performance are 14 people (43.8%). Of the 6 respondents who had an undergraduate degree, it was found that there were 2 nurses whose performance was less than 2 people (6.2%) while those with good performance were 4 people (12.5%). The results of the chi-square statistical test obtained p value 0.460> 0.05. This means that there is no relationship between education Based on the results of the study, it is known that from 14 respondents with the underprivileged category, it is known that nurses whose performance is less are 9 people (28.1%) while those with good performance are 5 people (15.6%). Of the 18 respondents in the capable category, it was found that there were 5 nurses whose performance was less (15.7%) while those with good performance were 13 people (40.7%). The results of the chisquare statistical test obtained p value 0.044 <0.05. This means that there is a relationship between ability and performance of nurses in the IGD at the Bhayangkara Tebing Tinggi Hospital in 2020.
Based on the results of the study, it is known that from 11 respondents with the less skilled category, it is known that nurses whose performance are less than 9 people (28.1%) while those with good performance are 2 people (6.3%). Of the 21 respondents in the skilled category, it was found that there were 5 nurses with less performance (15.7%) while 16 people (50.0%) had good performance. The results of the chi-square statistical test obtained p value 0.003 <0.05. This means that there is a relationship between skills and the performance of nurses in the IGD at the Bhayangkara Tebing Tinggi Hospital in 2020.
Based on the research results, it is known that from 12 respondents with low motivation category, it is known that there are 9 nurses whose performance is less (28.1%) while those with good performance are 3 people (9.4%). Of the 20 respondents with high motivation, it was found that there were 5 nurses with less performance (15.6%) while 15 people with good performance (46.9%). The results of the chi-square statistical test obtained p value 0.008 <0.05. This means that there is a relationship between motivation and the performance of nurses in the IGD at the Bhayangkara Tebing Tinggi Hospital in 2020 Based on the results of the study, it is known that from 9 respondents with the category of reward less known nurses whose performance is less than 8 people (25.0%) while those with good performance are 1 person (3.1%). Of the 23 respondents with good rewards, it was found that there were 6 nurses with less performance (18.7%) while 17 people had good performance (56.3%). The results of the chi-square statistical test obtained p value 0.002 <0.05. This means that there is a relationship between rewards and the performance of nurses at the Emergency Installation (IGD) of the Bhayangkara Tebing Tinggi Hospital in 2020.
Based on the results of the study, it is known that from 16 respondents with the category of infrastructure that is less supportive, it is known that there are 10 nurses with less performance (31.3%) while 6 people (18.8%) whose performance is good. Of the 16 respondents with supporting infrastructure, it was found that there were 4 nurses with less performance (12.4%) while 12 people with good performance (37.5%). The results of the chisquare statistical test obtained p value 0.037 <0.05. This means that there is a relationship between infrastructure and the performance of nurses at the Emergency Installation (IGD) at the Bhayangkara Tebing Tinggi Hospital in 2020.

Multivariate Analysis
Based on the results of the Phase I logistic regression test, it is known that there are three variables with a p-value> 0.05, namely the ability with a p-value of 0.578, the motivation variable with a p-value of 0.129 and the infrastructure variable with a p-value of 0.129. 0.855, it can be said that the variables of ability, motivation and infrastructure do not significantly affect the performance of nurses, so they must be excluded from the model for the multivariate.
Based on the results of the Phase II logistic regression test, it is known that there are 2 independent variables which significantly affect the performance of nurses because each of these variables has a significance value that is smaller than a = 5%. These variables are the skill variable (sig. = 0.011) and the reward variable (sig. = 0.013).

The Influence of Education on Nurse Performance in the Emergency Installation (IGD) at Bhayangkara Tebing Tinggi Hospital in 2020
The results of the chi square test showed that there was no significant relationship between education and the performance of nurses in the emergency room at the Bhayangkara Tebing According to researchers, there is no difference in performance between nurses with D3 and S1 Nurse graduates, because nurses with D3 graduates who work in the IGD have worked more than 3 years, which means they have a lot of work experience so that it affects their performance. In addition, all nurses in the IGD are equipped with emergency training regardless of the background of the nurse's education level. So it can be concluded that there is no significant influence on the level of education of a nurse with the performance of nurses.

The Effect of Ability on Nurse Performance in the Emergency Installation (IGD) at Bhayangkara Tebing Tinggi Hospital in 2020
The results of the chi square test show that there is a significant relationship between ability and performance of nurses in the emergency room at the Bhayangkara Tebing Tinggi Hospital in 2020 with a p value = 0.044 <0.05. This is indicated by the number of respondents, 14 respondents who are less well-performing as many as 64.3% underperforming and 35.7% with good performance. The results of multivariate analysis with logistic regression showed the sig value. 0.578> 0.05, it can be said that there is no significant effect on the ability of nurses in the IGD at the Bhayangkara Tebing Tinggi Hospital in 2020.
The results of this study are also inconsistent with Gibson's (1997) theory which states that the higher a person's ability level, the higher his / her ability to complete work. Ability is a trait (innate or learning) that allows someone to do something mentally or physically, while skills are the factors that most support a person in doing a job (Notoatmodjo, 2014). A person will be able to complete his job if supported by sufficient knowledge about the job, ability greatly determines the quality of one's work (Darodjat, 2015). In his research, Nikpeyma (2014) revealed several components that can improve nurse performance, one of which is the training process which will affect the improvement of nurses' abilities (Nikpeyma et al, 2014).
The findings of the researchers showed that there was no significant influence between the level of ability and the performance of nurses because the average nurse who worked in the

The Effect of Skills on Nurse Performance in the Emergency Room at the Bhayangkara Tebing Tinggi Hospital in 2020
The results of the chi square test show that there is a significant relationship between skills and performance of nurses in the emergency room at the Bhayangkara Tebing Tinggi Hospital in 2020 with a p value = 0.003 <0.05. This is indicated by the number of respondents, 11 respondents who are less skilled as much as 81.8% underperforming and 18.2% with good performance. The results of multivariate analysis with logistic regression showed the sig value. 0.011 <0.05, it can be said that there is a significant effect of skills on the performance of nurses in the IGD at the Bhayangkara Tebing Tinggi Hospital in 2020.
Nurses' triage skills are key in patient decision making. The role of the triage nurse is very important for the ER because the conditions of the ER are routinely unpredictable, limited resources, thus emphasizing the need for timely and accurate triage decisions which ultimately support the provision of optimal health services (Rankin et al, 2013).
According to Simanjuntak (2005) a person's performance can be influenced by three factors, namely individual competence, organizational support and management support. Individual competence is the ability and skills to do work. The ability and job skills of a person can be obtained through education, training and years of service. The longer a person spends education and training, the higher the ability and competence to do the job, thus the higher the performance (Simanjuntak, 2005). According to researchers, although Diploma III graduates are also referred to as novice professional nurses who already have sufficient professional attitudes to master nursing knowledge and professional skills which include technical, intellectual, and interpersonal skills and are expected to be able to carry out professional nursing care based on nursing care standards and nursing ethics.

The Influence of Motivation on Nurse Performance in the Emergency Installation (IGD) at Bhayangkara Tebing Tinggi Hospital in 2020
The results of the chi square test show that there is a significant relationship between motivation and the performance of nurses in the emergency room at the Bhayangkara Tebing Tinggi Hospital in 2020 with a p value = 0.008 <0.05. This is indicated by the number of respondents, 12 respondents with low motivation as much as 75.0% underperforming and 25.0% with good performance. The results of multivariate analysis with logistic regression showed the sig value. 0.129> 0.05, it can be said that there is no significant effect of motivation on the performance of nurses in the IGD at Bhayangkara Tebing Tinggi Hospital in 2020. This is not in line with Gibson's (1997) performance theory which hypotheszes that the factors that influence the performance of psychological factors are perception, attitude, personality and motivation and the one that most plays a role in a person's behavior and performance is motivation. Motivation is a human psychological characteristic that contributes to a person's level of commitment. Motivation has three main elements, namely needs, encouragement and goals. Needs occur when there is an imbalance between what is owned and what is expected, while impulse is a mental strength that is oriented towards achieving goals. The drive to achieve goals is the essence of motivation (Nursalam, 2014).
Research conducted by Sakit (2013) found that work motivation (achievement, experience, responsibility, development, salary, working conditions, interpersonal relationships, supervision) had an effect on the work of nurses Stella Maris Makassar (Sakit, 2013).
Tebing Tinggi Hospital in 2020 with a p value = 0.037 <0.05. This is indicated by the number of respondents, 16 respondents who stated that the infrastructure was not supportive, as many as 62.5% had poor performance and 37.5% had good performance. The results of multivariate analysis with logistic regression showed the sig value. 0.855> 0.05, it can be said that there is no significant effect of infrastructure on the performance of nurses in the IGD at the Bhayangkara Tebing Tinggi Hospital in 2020.
This research is in line with the theory put forward by Moenir (2016) that the existing work infrastructure must be maintained in accordance with the standards, procedures, and methods as well as their readiness. If the infrastructure is in accordance with hospital standards, the nurse's performance can improve.
The results of this study are in line with Moenir's (1998) theory that in an advanced society with sophisticated equipment, activities in human life increasingly depend on the presence of equipment, even if only partially. Realizing this, the existing work facilities must always be maintained in accordance with the standards, procedures and methods and their readiness is maintained (ready for use), otherwise disruption to work facilities can affect the implementation of work and consequently can hinder the service process to the community (Moenir, 1998).
The results of this study are also in line with Andoko & Putri (2020) study showing that the majority of respondents stated that the work facility factors were supportive (44.1 %) and a minority of respondents stated that the work facilities were not supportive (55.9%) based on the answers from 59 respondents. The existing work infrastructure must be maintained in accordance with the standards, procedures and methods as well as their readiness. If the infrastructure is in accordance with hospital standards, the nurse's performance can improve. Good performance can be caused by the high level of awareness of nurses to carry out work in accordance with existing standards, so that even though the infrastructure does not support the work produced is good, by utilizing the available infrastructure.

Conclusion
Based on research that has been carried out with logistic regression, it can be concluded that there is no significant effect of the variable ability, motivation and infrastructure on the performance of nurses in the IGD at Bhayangkara Tebing Tinggi Hospital in 2020 with a sig> 0.05. There is a significant effect of skill and reward variables on the performance of nurses in the IGD at the Bhayangkara Tebing Tinggi Hospital in 2020 with a sig <0.05. The results of the researcher's test of all independent variables, the variable that most significantly affected the performance of nurses in the IGD at the Bhayangkara Tebing Tinggi Hospital in 2020 was the reward variable with the largest Exp (B) value (26,633). The suggestions that the author can convey related to the results of this research are the Bhayangkara Tebing Tinggi Hospital to conduct training in the form of on the job training and workshops that are directly related to improving nurse performance and building a patient and nurse satisfaction survey system that can always be updated on what is become a customer need to become a reference in improvement and enhancement of nurse performance.