“Determinants of nurse performance in accredited Indonesian private hospitals”

This study analyzes the effect of transformational leadership on nurse performance using intervening variables of social competence, self-efficacy, and burnout. The partial least square data analysis method with an explanatory research type is used. Primary data are obtained via a questionnaire. A nurse population of 160 from five private hospitals in Indonesia’s East Java Region was analyzed using proportional random sampling. Data analysis was performed using descriptive statistics and partial least squares (PLS). The result of this study proved that transformational leadership has no significant effect on nurse performance, however, it affects significantly on social competence, self-efficacy, and has significant negative effect on burnout. The low performance of nurse was caused by the main job that is providing service for patient and doing administration work for BPJS, which require plenty of time, that the inseparable part of a nurse life is burnout, regarding the high mobility in providing service for patient. Social competence has a significant positive effect on nurse performance, self-efficacy has a significant positive effect on burnout, self-efficacy has a significant positive effect on nurse performance, and burnout has a significant negative effect on nurse performance. Novelty of this study is self-efficacy that has a significant positive effect on social competence.


INTRODUCTION
Hospital nurses are at the spearhead of services, directly in contact with patients, 24 hrs. per day. Huseno (2007) portrayed nurses as a large population of workers providing nursing services both directly and indirectly to patients. Nurse performance is a key factor to be considered by all hospitals. The poor performance of East Java private hospital nurses is reflected in the low levels of services delivered and the low performance of the hospitals. We feel this is related to competence and behavior.
Based on the results of a preliminary survey of private hospitals in East Java, fluctuations were found in the levels of development of nurse performance. The development of nurse performance at private hospitals from 2011 until 2017: 96.0%, 94.0%, 95.0%, 81.0%, 85.8%, 76.3%, 67.0%, while at the government hospitals: 97.0%, 96,6%, 96.4%, 95.0%, 86.0%, 84.7%, 84.0%. Nurse performance in private hospitals tends to decrease more than the decrease of nurse performance in the government hospitals. Nurse performance in providing medical service depends on their owned skill.
Nursing practice standards established assessment criteria for nursing service quality. The Indonesian National Nurses Association (2005) set standards of performance across five stages: assessment, nursing diagnosis, planning, implementation, evaluation. A direct leader is required to provide an assessment, based on leadership style. The important factor determining employee performance, according to Locander et al. (2002), was leadership. Salanova et al. (2011) explained that transformational leadership could predict nurse performance through self-efficacy and work engagement. Research conducted by Saxe (2011) empirically demonstrated that transformational leadership had a positive effect on social and emotional competence. Astuti et al. (2014) showed that transformational leadership had a significant effect on nurses social competence at private hospitals in South Kalimantan. They also showed that the quality of transformational leadership was in line with the improvement of social competence.
Burnout cannot be separated from a nurse's working life, considering the high mobility of work serving patients. Burnout is a form of emotional exhaustion, where feelings flow personal accomplishment and depersonalization are commonly experienced. Burnout research on nurses was carried out by Swider and Zimmerman (2010) and Yagil (2006) who found that the overall empowerment construct had a significantly negative effect, including emotional exhaustion, depersonalization, and decreased personal achievements. Greco et al. (2006) showed that the overall constructs of empowerment had a significant positive effect on burnout. However, the proposition test conducted by Alam (2010) showed that the construct on empowerment had no significant effect.
Burnout is a personal problem that is relatively difficult to solve. The self-efficacy of every individual is supposed to decrease burnout. According to Baron (1991), self-efficacy is a personal evaluation of one's own ability to perform a task, to achieve goals, and to overcome obstacles. Similarly, self-efficacy affects one's effort and endurance when facing problems. An individual with a high self-efficacy will finish any difficult job by considering it as a challenge (Bandura, 1997). Research on the effects of self-efficacy on burnout was conducted by E. M. Skaalvik and S. Skaalvik (2007) and Aftab et al. (2012), who found that self-efficacy had a negative effect on burnout, including emotional fatigue and depersonalization. Meanwhile, Schaufeli and Buunk (2003), E. M. Skaalvik and S. Skaalvik (2010) showed that self-efficacy had a significant positive effect on burnout, considering emotional fatigue and depersonalization as the central element. Maharani (2011) showed that self-efficacy had a significant negative effect.
It can be concluded that gaps remain on this issue. Follow-up research is needed for the development of human resource science, especially those related to transformational leadership, burnout, selfefficacy, social competence, and nurse performance. The originality of past research can be seen in the relationships of their variables (e.g., transformational leadership and self-efficacy), between transformational leadership and burnout, between self-efficacy and social competence, and between self-efficacy and burnout. Additionally, this study reviews the problem holistically, rather than partially, like past studies. Focusing on private hospital nurses and theoretical and empirical studies, the purpose of this study is to analyze and discuss the effects of transformational leadership on social competence, self-efficacy, burnout, and nurse performance in East Java, Indonesia. Locander et al. (2002) wrote about transformational leadership's effects on social competence, stating that nurses' performance was determined by leadership. Burns (1978) parceled leadership into two styles: transactional and transformational. Leaders with transactional styles used the power of compensation, such as rewarding high productivity or offering no reward for a lack of productivity. Leaders with transformational leadership styles provided design and inspiration to followers to achieve goals beyond the limits of their own abilities. Yukl (2005)  Personal social competence, characterized by the ability to manage interpersonal relationships, can inspire good communication and interaction among fellow employees in an organization. Someone who tries to understand co-workers and superiors will create cohesiveness to impact the formation of good cooperation, either among peers and employees or between employees and managers. Good cooperation boosts the achievement of good work. Thus, an increase in employee social competence will positively impact performance. Astuti et al. (2014) showed that, for private hospital nurses in South Kalimantan, social competence had a significant effect on nurse performance. This supports the idea that social competence has a positive significant effect on nurse performance.

THEORY, EMPIRICAL AND HYPOTHESES
The social cognitive theory of self-efficacy explained the function of psychology in the context of personal internalized environmental events in the form of cognitive, affective, biological, and behavioral variables. These are related to human symbolization, advanced thinking, and learning, also known as observational self-theory (Bandura, 1977). Self-efficacy refers to beliefs about an individual's ability to mobilize motivation, cognitive resources, and actions needed to successfully carry out tasking particular context (Stajkovic, 1998). Social competence refers to the interaction of individuals at work and at other activities occurring at a workplace. This supports the idea that self-efficacy has a positive significant effect on social competence. Baron and Byrne (1991) stated that self-efficacy was a personal evaluation of ability or competency when pursuing goals and overcoming obstacles. Schaufeli and Buunk (2003) and E. M. Skaalvik and S. Skaalvik (2010) stated that self-efficacy had a positive effect on burnout. Maharani (2011) found that self-efficacy had a negative effect on burnout. Sani (2011) stated that burnout had a significant effect on emotional intelligence and performance. Therefore, self-efficacy has a negative effect on burnout.
Self-efficacy refers to an individual's belief in his/ her ability to execute the behaviors needed to produce a certain performance achievement (Bandura, 1977). Khurshid et al. (2012) found a positive and significant relationship between self-efficacy and performance. This is similar to empirical research conducted by Lai and Chen (2012) and Stajkovic (1998). This supports the idea that self-efficacy has a significant positive effect on nurse performance.
Maslach and Jackson (1981) described burnout model for emotional exhaustion, depersonalization, and feelings of decreased personal achievement. Cordes and Dougherty (1993) wrote about the humanity tendency of personalizing others, resulting in cynicism on the carrier and self-performance. This supports the idea that burnout has a significant negative effect on nurse performance.

RESEARCH METHODS
In summary, the nine hypotheses are written as follows: H1: Transformational leadership style has a positive significant effect on social competence.
H2: Transformational leadership has a positive significant effect on self-efficacy.
H3: Transformational leadership has a negative significant effect on burnout.
H4: Transformational leadership has a positive significant effect on nurse performance.
H5: Social competence has a positive significant effect on nurse performance. H6: Self-efficacy has a positive significant effect on social competence. H7: Self-efficacy has a negative effect on burnout.
H8: Self-efficacy has a significant positive effect on nurse performance.
H9: Burnout has a significant negative effect on nurse performance.
Nurses from private hospitals are accredited by the Hospital Accreditation Committee, including patient centers, academic medical centers, and standard organizations. The research designs explanatory explain in ginter-variable effects by testing hypotheses and explaining the relationship and effect of transformational leadership variables, social competence, self-efficacy, burnout, and nurse performance. The nurse study population of five private accredited hospitals in Jember, East Java, included Jember Klinik (44 nurses), Bina Sehat (39 nurses), Kaliwates (36 nurses), DKT (21 nurses), and Citra Husada (20 nurses). The sample size was 160 respondents. Samples were taken using a simple random method. The population was taken according to the percentage of the number of nurses at each hospital. Data analysis was performed using descriptive statistics and partial least squares (PLS).  20. A model accuracy of 90% explains that the model's ability to explain the structural relationship of the five variables was 90%. The rest is explained by other variables not involved in the model. Hypotheses testing from the SEM-PLS model targeted transformational leadership (TL), social competence (SC), self-efficacy (SE), burnout (BO), and performance (P), as shown in Figure 1.

ANALYSIS RESEARCH RESULT
Results of the hypotheses directly influenced testing are shown in Table 1. The interpretation of Table 1 and Figure 1 are explained next, showing that transformational leadership has a significant positive effect against SC, that it has a significant positive effect on SE, that it has a significant negative effect on burnout, that it has no significant positive effect on the nurse performance, that SC has a significant positive effect on nurse performance, that SE has a significant positive effect on SC, that SE has a significant negative effect on burnout, that SE has a significant positive effect on nurse performance, and that burnout has a significant negative effect on nurse performance.

Effect of transformational leadership on social competence
Transformational leadership has a significant positive effect on SC. The results showed that increasing transformational leadership would improve nurses' SC. Thus, the first hypothesis is supported. This study supports the research of Saxe (2011) who studied the relationship between transformational leadership on social competency. Leaders who understand others' thoughts, feelings and perspectives can encourage employees to work well. Leaders determine and consider employees' personalities, showing interest in their work. Via leadership style, they inspire employees to have enthusiasm and motivation at work. However, superiors who often feel displeased with employees' work reduce their enthusiasm and motivation. As people authorized to assess attitudes, leaders can stimulate employee work via several methods, such as empowerment. In terms of position, it is generally clear where the leaders and subordinates are. However, that does not mean that the leader is in control of everything. Therefore, the leader must demonstrate that each employee has advantages that can be utilized for organizational progress. Providing trust for completing tasks also helps employees feel appreciated. Through leaders' actions, giving confidence, nurses can increase their confidence to solve complex work problems requiring accuracy in clinical skills. Nurses will be encouraged to work optimally when the leader can show that the results are not only for the leader, but also for the hospital. Therefore, the leader should be trustworthy, supporting the common good. The leader will easily find competition among nurses when the nurses have a high provision of SE. Leaders can encourage employees to gain achievement as high as their colleagues and maintain high spirits of those having gained achievements to always improve their work. This discovery supports Parker (1994) and Jex et al. (2001) who suggested that those with high SE tended to take proactive approaches when dealing with stressful situations, carrying out their roles and responsibilities more broadly than those with low SE. Bandura (1999) states that influential leaders could improve SE by modeling attitudes and strategies to deal with problems and to provide resources.  (Miller, 1996). An East Java hospital envisioned to "be people's choice hospital which prioritize quality improvement and patient safety". This motivated nurses pretty well. However, in East Java, the leaders treated all nurses at the same level of competence without considering job training. Otherwise, those hospitals employ nurses as optimally as possible.

The effect of transformational leadership on burnout
According to the Nursing Law no. 36 of 2009, the implementation of nursing care is carried out to achieve the goals of health services in accordance with the duties and authority of nurses by fulfilling the ethics code provisions, professional standards, the rights of health service users, service standards, and standard operating procedures (Rahman, 2015). Briefly, nursing performance comprises actions and practices that are easily observed and assessed.
The demand for work beyond the limits of nurses' ability without adequate education and training is exploitation and causes depression. The results of interviews showed that the low performance of nurses was due to nurses' work on patient care services and administration (Social Security Administrator/ BPJS). A nurse's work on patient services causes boredom while the patient awaits the doctor's arrival. Specialist "poly" doctors tend to be late. BPJS administration requires separate mindsets; the BPJS files need plenty of time. Another reason for the low performance of nurses was that for hospital nurses, their number is inadequate compared to the number of patients. The patient chooses a doctor who will provide treatment. Thus, if there are many patients, there should also be many care services to affect nurses' income imbalance. The difficulty for nurses in completing work quickly is another cause for low performance. A quick and accurate completion of work encourages good performance. Therefore, the problem is training.
The findings of this study support the findings of previous researchers, such as Insan et al. (2013) and Astuti et al. (2014). Transformational leadership directly but insignificantly affects the performance of nurses at private hospitals in South Kalimantan. However, this study does not support the results of previous studies proposed by Thamrin (2012), where there was a significant influence of transformational leadership on employee performance. Shahhosseini et al. (2012) proved that there was a significant effect of transformational leadership on employee performance.

Effect of social competence on nurse performance
The analysis result stated that increasing SC would improve nurse performance. Thus, H5 is supported. The effect of SC shows that nurses who can meet their social needs will have an impact on their performance. The fulfillment of nurses' social needs, including acceptance, positive impressions, and control with colleagues, managers, and patients while carrying out work encourages morale, which ultimately improves their performance. Empirical support can explain the effects of SC on performance, as shown by Astuti et al. (2014). Research conducted on the Astuti on hospital nurses in South Kalimantan explained that SC had a significant effect on nurse performance. Increasing the nurse performance is characterized by the seriousness of nurses in carrying out their work, such as meeting specified services (i.e. data collection and data assessment), making an action plan to overcome problems and improve client health, implementing nursing-plan measures, evaluating client progress, and revising basic data and planning.

Effect of SE on SC
The analysis results showed that the increase in nurses' SE would improve nurses' SC. Thus, H6 is supported, indicating that the higher level of SE perceived had a significant effect on the level of SC experienced by nurses. Nurses have confidence of personal strength when performing tasks and serving patients. This is considered successful because of the nurses' hard work and self-motivation. Thus, SE and SC are two important inseparable ideas, used as tools to support the nursing profession. SE refers to individuals' beliefs about their ability to mobilize motivation, cognitive resources, and actions required to successfully carry out tasks in certain contexts (Stajkovic, 1998). Social competence refers to the interaction of individuals related to work and other activities that occur in the workplace.

Effect of SE on burnout
Self-efficacy has a significant negative effect on burnout, and it can be explained as follows.
Burnout is a phenomenon that cannot be separated from life activities affecting the human service profession. The field of humanitarian services always demands high emotional engagement. Nursing is a human service profession that provides comprehensive services. Additionally, nurses must deal with patients of various cultures, behaviors, and temperaments, which cause emotional stress. Perrewe et al. (2002) stated that burnout can occur as a result of emotional pressure, constant or repeated, owing to the complexity of the task, lack of time, interaction, and conflict.
Empirical evidence shows that private hospital nurses in East Java have very high subjective confidence in their abilities to carrying out work. However, the effect of the level of self-efficacy being high neither reduces nor increases the occurrence of burnout, especially for physical fatigue or emotional exhaustion. This condition differs from the theory of Ryckman (2013), who studied how to cope with burnout. It is not easy for someone without high self-efficacy. It does not support the self-efficacy theory of Baron and Byrne (1991), which was an evaluation of a person's ability to perform a task, achieve goals, and overcome obstacles. Nurses who have high self-efficacy tend to reduce burnout because of confidence. This opposes the opinion of Caputo (1991) who said that a professional that works full time is more at risk of experiencing burnout, compared to part-time professionals. Therefore, the circumstances of this study are different that Bandura's theory, which stated that individuals having high self-efficacy will try to achieve a predetermined goal and will try to adapt to various obstacles. The results of this study differ from the theory of Schaufeli and Buunk (2003) about several individual variables that affect the influence of pressure and tension experienced by individual one of the variables was self-efficacy.
The results of this study prove that self-efficacy has a significant negative effect on burnout. Thus, it confirms and expands the research of Aftab et al.
(2012) who wrote about the relationship of self-efficacy and burnout among physicians. Discoveries from those results show that self-efficacy has a significant negative effect on the dimensions of burnout, including physical exhaustion, emotions, and depersonalization. It has a positive effect on self-efficacy and other burnout dimensions, based on a decrease in personal performance. The outcome supports the findings of research conducted by Maharani (2011) who studied the effect of self-efficacy on the burnout of teachers in Bogor City. They clearly showed that there was a negative significant effect between self-efficacy and burnout. Thus, the burnout in private hospitals in East Java, caused by excessive or lack of competent nurses, leads to overlapped work that should be done by more nurses.

Effect of self-efficacy on the nurse performance
This study shows that self-efficacy is perceived highly by nurses, because it suits what they feel. This indicates that nurses have broad, skilled, and very experienced insight to providing services. The variable description of self-efficacy, individual performance, and empirical data about the working period support the effects of self-efficacy on positive performance. This is significant. Thus, the self-efficacy and performance of the nurse simply some very important things. These discoveries confirm and expand Bandura's theory about self-efficacy being an assessment by a nurse about his/her ability to organize and decide on the actions needed to achieve desired performance. Similarly, the results of this study confirm and extend the results of previous studies, including Khurshid et al. (2012). They concluded that there was a significant positive effect of self-efficacy on teacher performance in Rawalpindi and Islamabad secondary schools in India. Additionally, they found female teachers with longer teaching experience and higher levels of education having higher self-efficacy. In private hospitals in East Java, nurses had broad insight, were skilled, and were experienced in providing services to patients.

Effect of burnout on nurse performance
Based on empirical facts, it can be shown that the higher level of burnout perceived by respondents, the higher the individual performance produced. Thus, burnout and individual performance in the nurse profession are important things to notice. They do not have to be in line, and both influence quality of service.
The results of this study support research by Idrus et al. (2015), which states that burnout has a significant negative effect on individual performance and does not support the theory of Cordes and Dougherty (1993) and Osipow (1983), which states that depersonalization is the human tendency toward others and is the development of cynicism about career and self-performance. People who experience depersonalization feel that none of their activities are valuable or precious. This attitude has been shown through several behaviors, such as cynicism, insensitivity, and ignorance of others' interest. The results of this study also confirm and expand the opinions of Mangkunegara (2010) about the characteristics of someone with high performance, such as those having high personal responsibility, daring to take and bear the risks faced with realistic goals. They have a comprehensive work plan and strive to realize its goals. They utilize feedback in all work activities and seek opportunities to realize the programmed plan. The results of this study confirm and expand the descriptive and explorative research of Kounenou (2012)

Hypotheses summary
Based on the finding and the discussion above, we can summarize the hypothesis as follows: H1: Transformational leadership style has a positive significant effect on SC: supported.
H2: Transformational leadership has a positive significant effect on SE.
H3: Transformational leadership has a negative significant effect on burnout.
H4: Transformational leadership has a positive insignificant effect on nurse performance.
H5: Social competence has a positive significant effect on nurse performance.
H6: SE has a positive significant effect on social competence.
H7: SE has a negative effect on burnout.
H8: SE has a significant positive effect on nurse performance.
H9: Burnout has a significant negative effect on nurse performance.

CONCLUSION
This study can be concluded as follows. Nurse is the most needed position and the competency in performing nursing duties to boost the patient healing is continuously increased. The nurse ability in providing medical service depends on their performance. According to Locander et al. (2002), nurse performance is determined by leadership. This study examines the effect of transformational leadership on nurse performance as the mediation variable of self-efficacy, social competence, and burnout, which providing concept and model of the hospital nurse performance.
The result of this study stated that transformational leadership had an insignificant positive effect on nurse performance. The low performance of nurses was shown by the low service provided and the low achievement of the hospital. The low performance of nurses was caused by the additional job given such as doing the administration work of BPJS (Social Security Administrator), which required much time beside their main job in providing services for patient.
Leadership in this case is the leadership in the hospital, which covers hospital board, board of installation, board of paramedic and non-paramedic, and the board of hospital service. A good transformational leadership will decrease burnout on nurses. Nurse performance is inseparable from burnout regarding the high mobility in providing service for patients. Burnout has a significant negative effect on nurse performance, the increase of burnout will decrease nurse performance. Nurse who experiences burnout will gain mental fatigue, commitment loss, emotional fatigue, and decreased motivation as the time goes. Pines and Guendlman (1995) stated an individual who experiences continuous pressure at work will earn depersonalization, which is the humanity tendency on others, which is the development of cynical expression on career and individual performance. Overcoming burnout is not an easy thing for nurses, except for those who have self-efficacy. Baron and Byrne (1991) stated that self-efficacy is the personal evaluation on his/her ability or competency in performing task to achieve goals and overcome obstacles. The novelty of this study stated that self-efficacy had a positive significant effect on social competence; the increase of nurse's self-efficacy will increase the nurse's social competence. Self-efficacy refers to the personal trust on his/her own ability to mobilize the motivation, cognitive resource, and action needed to finish the task in a particular context successfully (Stajkovic & Luthans, 1998). Social competence of nurse clinical skill shall be able to be perceived and fulfilled in social life.
Transformational leadership has a significant effect on social competence with positive direction. This study supports the study of Saxe (2011) that there is a relation between transformational leadership on social competence, and the finding of Hairudinor et al. (2014) that transformational leadership has a significant effect on nurse social competence. Through his/her leadership style, the leader may give a spirit and motivation for the nurse at work, give them trust to complete the task, which will make them feel their skill are respected.
A nurse who is able to fulfill his/her social need will give an impact to the performance. If a nurse social needs has been fulfilled such as an acceptance of co-workers and leader, which will give a positive impression, and the nurse skill in self-control in any situation either with the fellow co-workers, leaders, or patients at work may lit the spirit of the nurse, which in the end will improve his/her performance. Empirical support which explained the effect of social competence on performance was from Hairudinor et al. (2014) that social competence has a significant effect on nurse performance.
Transformational leadership has a significant effect on self-efficacy with positive direction. This study supports the finding of Walumbwa et al. (2008) that transformational leadership has a positive relation with self-efficacy. A leader who has a nurse who has a strong belief on her skill in completing the task may give some supports that those belief can be realized to improve the work quality. Therefore, this finding means self-efficacy and individual performance on nurse are two important things and affect each other. This finding confirms and extends the theory of Bandura (1997) that self-efficacy is an individual appraisal or perception on his/her skill in organizing and deciding action needed to achieve the desired performance.
In the future, the writer was suggested to discuss the Organizational Citizenship Behavior (OCB) variable. OCB is an extra-role behavior as the behavior of nurse who has gone beyond the formal task and given contribution to the effectiveness of an organization.