Analysis of Factors Affecting Nursing Services with Inpatient Satisfaction at Harapan / Pematangsiantar Hospital

Improving quality of nursing services became a major issue in health development both in national and global, because of growing demands on health services organization to give satisfaction with nursing services maximally by providing the best service to facilitate the ease of fulfilling the needs and realize the satisfaction. This study was a quantitative research design survey analytic used cross-sectional approach. It was conducted at Harapan Hospital Pematangsiantar. The population were 280 respondents and a sample obtained by 74 respondents. Data analysis of univariate, bivariate using chi square and multivariate using logistic regression at 95% confidence level (α = .05). The result showed that more respondents who gave a rating of good in the aspect of reliability, followed by the aspect of responsiveness, tangible, assurance, and empathy the influence aspects in this study were reliability (p=.002), assurance (p=.014), tangible (p=.011), empathy (p=.030), responsiveness (p=.024). The most influential aspects of this study was the reliability with Exp(B)/OR=20.667 that aspect of reliability that respondents perceived to have the opportunity 20.667 times to produce patient satisfaction. It is concluded that there was an influence of reliability, assurance, tangible, empathy, responsiveness to patient satisfaction in Harapan Hospital. It is recommended to hospital to further improve the quality of nursing service, to improve the welfare of nurse through provision of appropriate incentives hope the nurse, provide training, and installing CCTV in every room and monitoring of the level of patient satisfaction on a regular basis through a survey so that can improve the quality of hospital services as a whole.


Introduction
Nursing service as one of the main services in the hospital is an inseparable part. The quality of nursing services as an indicator of the quality of health services is one of the factors determining the image of health service institutions in the eyes of the community (Butar-butar et al., 2016).
Objectively, the measure of success is assessed through the clinical disease improvement process and there are no errors in the medical care process. Subjectively or objectively, the dimensions of health service quality are measured based on patient safety, efficiency, effectiveness, timeliness, patient-oriented (patiencenteredness) and fairness (Usman, 2017).
Hospitals as institutions that provide complete individual health services have a very strategic role to achieve the highest degree of health (Law of the Republic of Indonesia No.44 of 2009; Hospital service indicators are needed to determine the level of utilization, quality and efficiency of hospital services. In addition, in order for the available information to be meaningful, there must be a parameter value that will be used as a comparison value between the facts and the desired standard. One indicator of hospital services can be used to determine the level of utilization, quality and efficiency of hospital services. The indicator in question is BOR (Bed Occupancy Ratio = number of use of beds). BOR according to Huffman (1994) is "the ratio of patient service days to inpatient bed count days in a period of under consideration." Meanwhile, according to the Indonesian Ministry of Health (2005), BOR is the percentage of bed use in a certain time unit. This indicator provides an overview of the high and low level of utilization of hospital beds (Pematangsiantar, 2018).
The development of the number of beds has also increased from year to year which in turn will affect the number of BOR at Harapan Hospital. In 2002 the number of beds was 86 TT (beds) with a total BOR of 30.41% and in 2004 the BOR decreased to 28.73%. This shows that there are still a few people who use the Harapan Hospital as a means of providing health services for the community (Pematangsiantar, 2018).
Based on the results of interviews in the initial survey conducted on 10 (ten) inpatients at the Harapan Pematangsiantar Hospital, it was found that 6 (six) patients felt less satisfied with nursing services because nurses did not provide sufficient information about care, were less friendly. and less response when the patient asks or asks for help and there is an impression that the nurse is doing her job as forced and 4 (four) patients are satisfied with the nursing services at Harapan Pematangsiantar Hospital. This condition has an impact on the patient's lack of satisfaction with the hospital. Based on some of the descriptions above, the researcher wants to do research on "Analysis of Factors Affecting Nursing Services with Inpatient Satisfaction at Harapan Pematangsiantar Hospital".

Methods
The type of research used in this research is quantitative with analytic survey research design using a cross-sectional study approach. The research was conducted at the Harapan Pematangsiantar Hospital. The study population was 280 people and the sample was obtained 74 people. Data analysis was univariate, bivariate, using chi-square and multivariate using multiple logistic regression at the 95% confidence level (α = 0.05). The research instrument uses a questionnaire that has been carried out by testing the validity and reliability. The data used are primary and secondary data.

Respondent characteristics
Based on the results of the study showed that based on gender, the most respondents were male (66.2%) and female (33.8%). Respondents aged 46-65 years (58.1%) and aged 12-25 years (10.8%). Based on the education of 74 respondents, the education of the most respondents is SMA / SMK (50%) and the lowest distribution is SD (12.2%) and SMP (12.2%). Based on the work of 74 respondents, the largest occupation was farmers (27%) and the lowest distribution was teachers (1.4%). The quality of nursing services in terms of the reliability factor has a good category (91.9%) of respondents, and (8.1%) said the category of the reliability factor is not good. The quality of nursing services in terms of the Assurance factor is in a good category (66.2%), and (33.8%) says that the category of the Assurance factor is not good.
The quality of nursing services in terms of tangible factors (physical evidence) has a good category (67.6%) and (32.4%) says the Tangible factor category (physical evidence) is not good. The quality of nursing services in terms of the Empathy factor (attention) is in a good category (62.2%), and (37.8%) says that the Empathy factor category (attention) is not good. The quality of nursing services in terms of responsiveness factors (responsiveness) has a good category (79.7%), and (20.3%) said the category of responsiveness factors (responsiveness) is not good.

Multivariate
The result of multiple logistic regression test shows that the variable with the greatest influence in this study is the variable reliability which has a value of Exp (B) / OR = 20,667, which means that the reliability factor felt by the respondent has 20,667 times the opportunity to produce inpatient satisfaction. outpatient services in the Semarang Eye Center (SEC) Sultan Agung Islamic Hospital, Semarang, which states that the largest gender is female (58%) (Sriatmi et al., 2014).

Age
Based on the results of research from 74 respondents of inpatients, it was found that there were more respondents aged 46-65 years, namely 43 respondents (58.1%) compared to those aged 26-45 years of 13 respondents (17.6%), age> 65 years of 10 respondents (13.5%) and those who are at least 12-25 years old are 8 respondents (10.8%). This research is in line with research conducted by Irma Herliana. In his research entitled Gender Relations, the level of education with patient satisfaction in the Inpatient Room of Mitra Family Hospital was obtained from 84 respondents, there were the most aged respondents who were> 35 years old, namely 48 respondents 57.1% while the least age was age 17-25 years by 7 respondents 8.3% (Sihaloho & Herliana, 2017).

Education
The results of the study of 74 respondents of inpatients found that the education of the majority of respondents was SMA / SMK as many as 37 respondents, S1 was 19 respondents and the least was SD 9 respondents and primary school education was 9 respondents. This research is in line with the research conducted by Irma Herliana on 84 respondents at Mitra Keluarga Hospital, the results showed that there were 29 respondents (34.5%) who had a high school education and the least were those with junior high school education as many as 7 respondents (8.3%) (Sihaloho & Herliana, 2017) Bivariate Analysis

The effect of Reliability on the satisfaction of inpatients at Harapan Pematangsiantar Hospital
Reliability related to the ability of health service personnel to provide nursing services appropriately and accurately can be a positive thing for the quality of nursing services at Harapan Pematangsiantar Hospital so that patients who come for treatment have confidence in hospital services. In this case the level of patient satisfaction with aspects of reliability (reliability) is categorized as good and satisfied. The satisfaction felt by the patient is not something that happens by itself. Satisfaction occurs because the expectations that exist in patients are met in using hospital services through the quality of nursing services. This research is in line with research conducted by Butar-Butar et al (2016), arguing that service reliability will be provided if the customer can trust the service, which includes services that must be consistent, in addition to convoluted services and the length of the patient's waiting period can determine the quality. nursing services because it makes patients feel not served well so that this will lead to patient dissatisfaction. From the results of research that has been carried out, the researcher argues that in providing services with high knowledge, expertise, independence and mastery of professionalism, the work activities carried out produce high values and vice versa if the service provision has low knowledge, expertise and professionalism mastery skills, then the work activities that are carried out are high. done to produce a low value (Butar-butar et al., 2016). The demand for employee reliability in providing fast, precise, easy and smooth service is a prerequisite for assessing the people served in showing the actualization of employees' work in understanding the scope and job descriptions that are the attention and focus of each employee in providing their services. The essence of reliability service is that every employee has reliable abilities, knows about the ins and outs of work procedures, work mechanisms, corrects various deficiencies or deviations that are not in accordance with work procedures and is able to show, direct and provide correct directions to any form of service that has not been understood by community, so that it has a positive impact on these services, namely employees understand, master, are reliable, independent and professional in their job descriptions (Parasuraman, 2001: 101). The service dimension relationship reliability (reliability) is very important in the dynamics of an organization's work. Reliability is a form of characteristics or characteristics of employees who have high work performance. Reliability in providing services can be seen from the reliability in providing services according to the level of knowledge they have, reliability in being skilled in mastering the applied work field, reliability in mastering the work field according to the work experience demonstrated and reliability using work technology. Sunyoto (2004: 16) the reliability of an individual organization in providing services is very necessary to deal with the work dynamics that keep rolling, demanding high service quality according to individual employee reliability (Jayanti, 2016).

There is an effect of Assurance on the satisfaction of inpatients at Harapan Pematangsiantar Hospital
Based on the Chi-Square test, the value of pvalue = 0.014 (P value <0.05) was obtained, meaning that there was a significant influence between assurance and the quality of nursing services at Harapan Pematangsiantar Hospital. This research is in line with Herman Harun's research (2020) concerning the analysis of factors that affect the quality of health services on patient satisfaction at the Puskesmas inpatient in Pasaman Regency 2019, which shows that there is a relationship of assurance (guarantee) with inpatient satisfaction (Pvalue = 0.009). The number of respondents who stated that the quality of nursing services in terms of good assurance aspects tends to be satisfied and vice versa, the assurance from nurses is not good, so the patient feels dissatisfied. This can be obtained because patients feel they do not get special attention from nurses and they do not create familiarity with the nurses while they are being treated at the hospital (Harun, 2020). Assurance (guarantee) is the ability of an institution to convince customers that the services provided can be trusted / guaranteed. The aspects that build up this dimension are friendliness, competence, and security. The hospitality aspect can be assessed from the smile, intonation of speech, language and gesture while communicating and providing services to customers. Customers will also trust the institution if the service provider is a competent person. In addition, customers also need security guarantees. A patient will feel satisfied if served by health workers (doctors, nurses, nutritionists, pharmacists) who are able to provide friendly, competent and safe services (Wulandari, 2015).

There is a Tangible effect (physical evidence) on the satisfaction of inpatients at Harapan Pematangsiantar Hospital
Based on the results of Chi-Square analysis, tangible (physical evidence) with a value of p = 0.011 has a significant effect on the satisfaction of inpatients at Harapan Pematangsiantar Hospital. This research is in line with research conducted by Mitropoulus (2018) that tangibles (physical evidence) in the hospital environment have an influence on patient satisfaction. The emergence of patient dissatisfaction is due to the physical form (tangible) which is not accompanied by good responsiveness from the nurse. Even though the nurse has a clean and tidy appearance, but in terms of time the nurse does not arrive on time, the room is less ventilated, so physically the patient's view of the nurse is not good, meaning that the nurse is not ready to provide services to patients and lack of comfort inside. inpatient room (Mitropoulos,P.,Vasileiou,K.,& Mitropoulos, 2018). According to the researchers' assumptions, of the 50 respondents who answered both physical evidence in the quality of nursing services provided, the majority of respondents were satisfied as many as 47 respondents (63.5%). This means that the respondent is satisfied with the convenience of seeking treatment at the Harapan Pematangsiantar Hospital. Tangible is a customer assessment of what he can see. Even though in fact the service cannot be felt, smelled, or seen, in reality the customer will judge the service he receives based on the results of his sensing of many things in the form of perception. A patient will judge / perceive the services provided by the hospital to be satisfactory if the hospital building has a modern design, the environment (treatment room, waiting room, bathroom, etc.) is clean, looks luxurious, the equipment used is sophisticated, the uniform of the nurse / employee. Neat, clean and attractive model and others.
Based on the theory that the quality of nursing services in terms of tangible aspects (physical evidence) includes the condition of physical facilities such as buildings and waiting rooms, the availability of parking lots, cleanliness, tidiness, and comfort of the room, equipment, and appearance of officers. In addition to the reliability, responsiveness, assurance and attention given by the hospital, of course, to undergo patient care, the necessary facilities are needed, while the level of satisfaction with the facilities provided to patients varies greatly depending on the habits of the patient towards the facility. -ever felt physical facilities (Valarie A. Zeithml, 2004).

There is an influence of empathy (attention) on the satisfaction of inpatients at Harapan Pematangsiantar Hospital
Based on the results of the Chi-Square analysis (P value = 0.030), it shows that empathy (attention) has a significant effect on the satisfaction of inpatients at Harapan Pematangsiantar Hospital. Concern for patients in providing services can be in the form of providing motivation to patients or encouragement for patients to be enthusiastic and able to accept the situation they are experiencing. This is very important to increase patient satisfaction. This study is in line with research conducted by Herman Harun (2019) showing that there is an influence of empathy (attention) on inpatient satisfaction (Pvalue = 0.005, <0.05). Empathy (attention) can facilitate good communication relationships, personal attention and understanding patient needs. Respondents who stated that nurses' empathy was not good tended to be dissatisfied in terms of service. The feeling of dissatisfaction arises because of the lack of time to consult or the nurse giving too little explanation to the patient about the disease so that the patient feels worried about the illness they are experiencing (Harun, 2020).
Empathy is the nurse's ability to build relationships, care, and understand the patient's needs. Nursing services include improving therapeutic communication in greeting and speaking, patient participation in making treatment decisions, freedom for patients to choose a place of treatment and health personnel, and the ease with which inpatients get family visits (Valarie A. Zeithml, 2004).

There is an effect of responsiveness on the satisfaction of inpatients at Harapan Pematangsiantar Hospital
Based on the results of the Chi-Square analysis (P value = 0.024), it shows that there is an effect of responsiveness (responsiveness) with the satisfaction of inpatients at Harapan Pematangsiantar Hospital. This research is in line with research conducted by Like J. Mumu. et al (2015) show that responsiveness has an influence on patient satisfaction (Pvalue <0.05). This study is also in line with research conducted by Simbala et al. (2013) in a cross-sectional analytical survey study of 100 respondents who found that responsiveness was significantly associated with patient satisfaction (P = 0.002) (Mumu et al., 2015). This research is also in line with research conducted by Eka et al (2016) which states that there is an effect of responsiveness on patient satisfaction (Pvalue = 0.008 <0.05) (Eka M. dkk, 2016).
Responsiveness means the speed / responsiveness of service delivery. Along with the increase in the activity intensity of each individual, customer expectations of this dimension are increasing. Every customer is increasingly expecting shorter waiting times. In this aspect, a patient will feel satisfied if they get fast service without requiring a long waiting time (Fandy Tjiptono & Anastasia Diana, 2019).
The responsiveness dimension shows the willingness of service providers, especially their staff, to help and provide appropriate services according to consumer needs. This dimension emphasizes the attitude of service providers who are attentive and responsive in providing services, namely facing customer requests, questions, complaints and problems by delivering clear information (Kuntoro & Istiono, 2017).

There are variables that most influence the satisfaction of inpatients at Harapan Pematangsiantar Hospital
The multivariate analysis shows that of all the independent variables that affect the satisfaction of inpatients at Harapan Pematangsiantar Hospital, there is one variable that most influences the satisfaction of inpatients with Pvalue 0.039 <0.05, while the other independent variables (assurance, tangible, empathy, and responsiveness) obtained a value of Pvalue> 0.05 so that it was not among the most influential on the satisfaction of inpatients at Harapan Pematangsiantar Hospital. The largest OR value obtained is 20,667, which means that the reliability factor felt by the respondent has 20,667 times the opportunity to produce inpatient satisfaction, meaning that of the five factors of nursing service quality, the most dominant influence on inpatient satisfaction at Harapan Pematangsiantar Hospital is reliability.
This research is in line with research conducted by Mustika and Sari (2019) with the title patient satisfaction with inpatient services at Jagakarsa Hospital which states that reliability is the most dominant factor in the relationship with inpatient satisfaction. In this study it was found that of all respondents 83.3% of them were satisfied with Jagakarsa Hospital services. This shows a good thing where Jagakarsa Hospital continues to improve the quality of its services. From the results of this study, from the five dimensions there are four dimensions that significantly influence patient satisfaction. Thus, efforts to improve the quality of hospital services need to seek improvements in accordance with the criteria of each dimension by highlighting which dimensions are most influential from the results of the multivariate analysis, so it is necessary to make a priority scale for increasing all dimensions based on the number of effects (Mustika & Sari, 2019).

Conclusion
Based on the results of research on 74 patient respondents in the inpatient room of Harapan Pematangsiantar Hospital, it can be concluded that. There is an effect of reliability, assurance, tangible, empathy, responsiveness, on the satisfaction of inpatients at Harapan Pematangsiantar Hospital. The variable that most influences the satisfaction of inpatients is reliability, which has a value of Exp (B) / OR = 20,667, meaning that respondents who say reliability have 20,667 times the opportunity to produce inpatient satisfaction.