THE EFFECT OF MOTIVATION, WORK ENVIRONMENT, AND TRANSFORMATIONAL LEADERSHIP ON NURSE PERFORMANCE (CASE IN S HOSPITAL)

DOI:10.31933/DIJMS Abstract: The purpose of this study was to determine the effect of motivation, work environment, and transformational leadership on the performance of nurses at S Hospital. This research was conducted in Denpasar, Bali, involving 55 nurses. Data collection was carried out by distributing questionnaires based on descriptive quantitative methods. Data were analyzed with the SmartPLS program. The results of this study stated that transformational leadership has a positive effect on nurse performance, motivation has a positive effect on nurse performance, work environment has a positive effect on nurse performance, transformational leadership has a positive effect on motivation, and transformational leadership has a positive effect on work environment.


INTRODUCTION
Hospital is a complex infrastructure that includes various assets that must be provided in accordance with the arrangements to support health professionals in serving the community. Good hospital performance depends on professional management guaranteed by competent and skilled members. The hospital consists of medical staff and support including nurses, pharmacy, hospital management, and non-medical staff. Among the hospital member structures, 40% are nurses (Moekijat, 2005). Nursing services are an important component that must be managed properly by hospital management (Anggraini, 2009).
Based on the results of the interview with the nurse manager, one of the biggest problems that often occurs at S Hospital is lateness. Below is supporting data obtained from each head of the room regarding the percentage of punctual attendance of nurses in the last five months, namely:  (2019) Maintaining and increasing the percentage of attendance is a difficult thing in the organization because many factors affect (Hasibuan, 2011). Leaders have a direct influence on employee attitudes and behavior (Sutrisno, 2010). Motivation is important for employees. Motivated employees have a high desire to come to work (Wijaya and Andreani, 2015). Work environment influences job satisfaction. Conducive work environment will give good work productivity (Mangkunegara, 2013). The level of attendance affects employee performance. Developing a high-quality, performanceoriented nursing workforce has become a necessity today and every nurse leader strives to inspire members to create a team that is committed and enthusiastic about working outside of the job requirements.

Relationship of Transformational Leadership with Nurse Performance
Transformational leadership is an important change that is valued and has a positive impact on its members (Gousy, 2015). Transformational leadership is effective in a variety of situations. Transformational leaders have the ability to unite members and can change members' goals and philosophies. This type of leadership results in higher levels of achievement and performance among individuals. Transformational leadership has a positive impact on employee performance, so employees will give maximum effort to their work (Muenjohn and Armstrong, 2015). Based on research conducted by Afzal, Waqas, Kousar, Perveen, and Hussain. (2016) found that transformational leadership has a positive influence on nurse performance. Similarly, research conducted by Murtiningsih (2015) found that transformational leadership has a positive effect on nurse performance.
Ha 1 : Transformational leadership has a positive effect on nurse performance.

Relationship of Motivation with Nurse Performance
Motivation at work is considered as a force that drives employees to achieve organizational goals. The only way for employees to work hard is to have high motivation. Every individual in organization is motivated in different ways. Through motivation, the willingness of employees to work can be built so that human resources can be fully utilized (Grant, 2008). In health service organizations, work motivation is a benchmark for health workers' responses to increase health challenges and demands. Nurse's work motivation has an impact on well-being, organizational performance, satisfaction, retention, involvement and commitment (Toode, Routasalo, & Suominen, 2011). Referring to the results of research conducted by Al-Absi (2015), there is a positive influence between motivation and nurse performance. Research conducted by Lingga (2012) and Setiyaningsih, Sukesi, and Kusuma (2013) also found that there is a positive influence between motivation and nurse performance.
Ha 2 : Motivation has a positive effect on nurse performance

Relationship of Work Environment with Nurse Performance
Work environment are aspects that exist around workers who have a direct influence on employees in carrying out their duties (Nitisemito, 2011). Work environment is important for producing positive employees. The quality of work environment is said to provide a major influence on the level of performance and employee motivation (Chandrasekar, 2011). Research conducted by Rahman (2015), and Rahalulu (2018) also states that the work environment has a positive influence on nurse performance.
Ha 3 : The work environment has a positive effect on nurse performance

D. Relationship of Transformational Leadership with Motivation
Given that leaders have the means and strength to run an organization, their impact on employees is very important and their leadership style plays a major role in shaping employee attitudes towards creativity, performance, and job satisfaction. Transformational leadership increases employee motivation and increases their commitment to the organization (Bushra, Usman, and Naveed, 2011).
Research conducted by Sundi (2013) shows that transformational leadership has a positive influence on employee motivation. Research conducted by Aunjum, Abbas, and Sajid (2017) found that transformational leadership has a positive effect on motivation.
Ha 4 : Transformational leadership has a positive effect on motivation

E. Relationship of Transformational Leadership with the Work Environment
To support the performance of employee members, leaders in each organization will try to pay attention to their work environment. With the implementation of transformational leadership methods a good work environment will arise and encourages employees to work optimally and have a positive attitude in carrying out their work. Work environment of an organization creates a work relationship that binds its employees, therefore work environment must be good and conducive. A good and conducive work environment makes employees feel comfortable being in the room, so that there is a feeling of excitement and enthusiasm every time they carry out a given task (Moekijat, 2013). The results of research conducted by Coleman (2017) and Pourbarkhordari, Zhou, and Pourkarimi (2016) found that the results of transformational leadership have a positive influence on the work environment.
Ha 5 : Transformational leadership has a positive effect on work environment

RESEARCH METHODS
This study aims to determine the effect of motivation, work environment and transformational leadership on the performance of nurses at S Hospital. The independent variable in this study is transformational leadership, while the dependent variable is nurse performance. Motivation and work environment are intervening variables in this study. Target population is all nurses at S Hospital, amounting to 55 people. All members of the population are used as data sources so this study uses census studies. The survey method was used to obtain data through the distribution of questionnaires to all nurses at S Hospital. The data obtained were analyzed with SmartPls 3.0. The measurement of construct items uses a 5-point Likert scale namely (1) strongly disagree, (2) disagree, (3) neutral, (4) agree, and (5) strongly agree. Testing the measurement model (outer model) and structural model (inner model) were done in this study. The measurement model (outer model) is evaluated based on convergent validity, discriminant validity, composite reliability, and average variance extracted (AVE). The instrument is declared valid if the value of AVE> 0.5, loading factor> 0.7, and discriminant analysis must meet the Fornel-Larcker criteria (square root value of AVE must be greater than the correlation value between variables). Then, the reliability test by calculating the value of composite reliability which must be greater than 0.7. The structural model is evaluated if the data meets the requirements in the measurement model (outer model). Evaluation was carried out using Rsquare (Ghozali & Latan 2015;Hair, Black, Babin, Black, and Anderson, 2014).

FINDINGS AND DISCUSSION
The respondent profile shows the proportion of female respondents is greater than male respondents, namely 40% female respondents and 15% male respondents. The educational background of the respondents was dominated by diploma of nursing by 60%, while the remaining 40% with bachelor of nursing. Respondents were mostly <30 years old with a percentage of 51%, followed by 30-40 years of age by 47%, and 41-50 years with 2%. The working period of respondents is dominated by respondents working> 2 years with a percentage of 74%, followed by 3 months-1 year and 1-2 years respectively 13%. Complete respondent data can be seen in table 2.

Outer Model
This study conducted by showing convergent validity, discriminant validity, and composite reliability. Validity test is a benchmark for assessing an indicator accurately measuring data objects collected by researchers (Ghozali, 2015). The Rule of Thumb is used to assess convergent validity, the loading factor value must be more than 0.7. A value of 0.4-0.7 can still be accepted if the Average Variance Exracted (AVE) value> 0.5 (Hair et, al., 2014).    Table 5 shows the results of the discriminant validity test using the Fornell-Larcker criteria where the value of the square root AVE must be greater than the value of the relationship between variables (Hair et al, 2014).  Table 6 is the result of the reliability test conducted by measuring the value of composite reliability. A variable is stated to have good reliability if the value of composite reliability is above 0.7 (Ghozali & Latan, 2015). In this study, all constructs have composite reliability values> 0.7, so that all constructs are declared reliable.

Inner Mode
In this study, testing is done by looking at the value of Variance Inflation Factor (VIF) which aims to find out whether there is any collinity in the independent variables. VIF value must be less than 5. If the VIF value> 5 then the research model experiences multicollinearity problems (Hair et al., 2014). Structural model testing can also be done by evaluating the R-square value to explain the extent to which the independent variable explains the dependent variable. Table 7 shows that the independent variable has a VIF value <5, so it can be concluded that there is no multicollinearity.  (2019) Hypothesis testing in this study is done by paying attention to the path coefficient. If the path coefficients are the same, then the hypothesis is proven to have a positive effect (Hair, Black, Babin, Black, & Anderson, 2010).

DISCUSSION
The results of the first hypothesis, namely transformational leadership has a positive effect on nurse performance is supported. This finding is in line with the statement from Muenjohn and Armstrong(2015) regarding transformational leadership has a positive impact on employee performance, so that employees will give maximum effort to their work. The results of this study are also consistent with previous studies conducted by Afzal et al. (2016) and Murtiningsih (2015) which states that transformational leadership has a positive influence on nurse performance. Therefore, if the transformational leadership method is increasingly applied, the better the nurse's performance will be.
The results of the second hypothesis state that motivation has a positive effect on nurse performance supported. This result is in line with the theory by Toode, Routasalo, and Suominen (2011) which states that work motivation is an important measure of the response of health professionals to the challenges and demands that are currently increasing. Nurse's work motivation has an impact on well-being, organizational performance, satisfaction, retention, involvement and commitment. The results of this study are in line with previous studies conducted by Al-Absi (2015), Lingga (2012), and Setiyaningsih, Sukesi, and Kusuma (2013) which states that there is a positive influence between motivation and nurse performance. In conclusion, if the nurse has higher motivation, the nurse's performance will also increase.
The results of the third hypothesis states that the work environment has a positive effect on nurse performance. This is consistent with Nitisemito (2011) which states that the work environment is anything that exists around the work that can influence workers in carrying out the tasks assigned. This result is in line with research conducted by Rahman (2015), and Rahalulu (2018) which states that the work environment has a positive influence on nurse performance. So, if the hospital work environment is conducive, the better the nurse's performance will be. The results of the fourth hypothesis, namely transformational leadership has a positive effect on motivation is supported. The results of this test are in accordance with the theories of Bushra et al. (2011) which states that transformational leadership styles increase employee motivation and commitment to the organization. The efficiency of a leader is the main determinant of organizational success or failure. This result is also consistent with research conducted by Sundi (2013) and Aunjum, Abbas, and Sajid (2017) who state that transformational leadership has a positive influence on motivation. So it can be concluded that the main statement regarding the theory of transformational leadership appropriate.
The results of the fifth hypothesis prove that transformational leadership has a positive effect on the work environment supported. The results obtained are in accordance with the theory by Moekijat (2013) which states that with the implementation of transformational leadership methods, a good working environment will arise and encourages employees to work better and be positive. The results of this test are also in accordance with research conducted by Coleman (2007) and Pourbarkhordari, Zhou, Pourkarimi (2016) who state that transformational leadership has a positive influence on the work environment. So, for work results to be achieved well, the leadership style must be in accordance with the work environment.

CONCLUSION AND SUGESTION
Based on the results of data analysis and discussion, it can be concluded that: 1. Transformational leadership has a positive effect on nurse performance. 2. Motivation has a positive effect on nurse performance. 3. The work environment has a positive effect on nurse performance. 4. Transformational leadership has a positive effect on motivation. 5. Transformational leadership has a positive effect on the work environment.
This study has limitations, including a small number of samples in the study so that the initial validity assessment only uses face validity, which is the lowest validity test because it contains subjective elements. Furthermore, this research was conducted with respondents whose work was homogeneous. In addition, this study did not include all the variables that affect nurse performance. Variables that can be added in this study are work discipline, work stress, workload, and organizational culture. Therefore, it is expected that further research can take a larger sample so that the results obtained are better. It is also hoped that in future studies a heterogeneous sample can be used. Samples can be developed into doctors, midwives and nurses, so that comparisons can also be made.