Doctor's Leadership Style and Nurse Performance in Inpatient Room

Sudiarto, Ermi Girsang*, Ali Napiah Nasution

Faculty of Medicine, Prima Indonesia University

Keywords: Doctor's leadership style, executive nurse performance.

Abstract: The relationship between doctors and nurses in providing health care to patients is a more binding

partnership where there should be harmonization of tasks, roles and responsibilities and an open system. To

manage the implementation of health services, especially nursing, of course it takes a doctor's leadership

factor which in its application can have an impact on nurses' performance. The fact that in the application of

nursing care the role of doctors as clinical leaders is less assertive which has an impact on the performance

of nurses that is not yet optimal. This study analyzes the influence of the doctor's leadership style on nurses'

performance in the inpatient room. This type of quantitative research is analytic descriptive approach. The

number of samples were 38 nurses. Data collection is carried out through questionnaires and documentation

studies. The questionnaires were conducted in face-to-face with the participants in order to maintain the

validity of the research. Data were analyzed bivariately using chi square test and multivariate using multiple

logistic regression tests. The results of the study show that democratic leadership style, participatory,

authoritarian and Laissez-faire leadership style significantly influence the performance of the nurses. The

independent leadership style variable is the most dominant influencing the performance of the implementing

nurse. The results of this study are expected to be useful information and suggestions for hospital

management by involving the larger functions of doctors in governance and management. It is hoped that

the improvement of doctors' leadership abilities will have a direct impact on improving the performance of

nurses.

1 INTRODUCTION

Health and care professionals not only require

clinical experts but also have competence in

leadership and management skills that enable them

to be more actively involved in the planning,

delivery and transformation of services for patients.

To make a change that actually takes place in

achieving its goals, leadership is needed. There are

many examples of bad practice and system failure in

health care due to lack of leadership at the

individual, group and organizational level (Salim,

2016).

Greater doctor participation at the level of

strategic decision making has the potential to benefit

various hospitals. Greater doctor involvement is

beneficial for the decision-making process in the

hospital and has important implications for policy

and practice (Sarto and Veronesi, 2016).

The competence of doctors as leaders in health

services in hospitals, often referred to as clinical

leaders. For health care workers, especially doctors,

the leadership factor is needed in carrying out daily

tasks. The main task of the doctor is to lead the

health care technical team and in every medical

treatment certainly involves many parties ranging

from nurses, nutrition installations, medical records,

the availability of facilities and infrastructure and

doctors. Clinical leadership is a driver of efforts to

develop a vision of clinical services in hospitals. The

creation of a world-class clinical vision and

achievement strategy is a practical example of

clinical leadership in hospitals. But being a clinician

may not necessarily have clinical leadership

abilities. Given the large variety of professions in

hospitals and the complexity of hospital organization

management, this situation will prevent clinicians

from developing leadership abilities. The situation

will become even more difficult due to autonomy in

each profession, a hierarchy of competencies, and a

high workload (Trisnantoro et al., 2011).

In the case of health workers, of course the

highest number of personalities and the most

frequently dealing with patients served are nurses.

Data from the Ministry of Health showed the largest

number of nurses in 2016 among other health

Sudiarto, ., Girsang, E. and Nasution, A.

Doctor’s Leadership Style and Nurse Performance in Inpatient Room.

DOI: 10.5220/0010293302210228

In Proceedings of the International Conference on Health Informatics, Medical, Biological Engineering, and Pharmaceutical (HIMBEP 2020), pages 221-228

ISBN: 978-989-758-500-5

221

professions, 345,276 people or 30.19% of the total

recapitulation of health professionals in Indonesia,

namely 1,143,494 people. To manage the

implementation of health services, especially

nursing, of course it takes leadership factors from

doctors who in their application can have an impact

on nurse performance. Therefore, this research is

conducted on nurses because they are closely related

to doctors and patients and they also provide

services according to the doctors’ suggestions and

nursing intakes. The good performance of nurses is a

bridge in answering quality assurance of health

services provided to both sick and healthy patients,

health service facilities including hospitals (Ministry

of Health, 2018; Turnip, 2020; Wijaya, 2019).

The relationship between doctors and nurses in

providing health care to patients is a more binding

partnership where there should be harmonization of

tasks, roles and responsibilities and an open system.

According to the AMA, if collaboration between

doctors and nurses goes as determined it will have a

direct impact on patients, because many positive

aspects can be generated. In fact, in practice there

are various obstacles to collaboration between

doctors and nurses so that collaboration is difficult

to be created, among others, the dominance of

power, differences in the level of knowledge /

education, communication and perspective

(Rahaminta and Sulisno, 2012).

The main key in improving the quality of health

services is nurses who have high performance.

However, it is not uncommon to find complaints

related to the quality of health services which

originates from the performance of nurses. Even

criticism of nurses' performance in providing

services is often complained of and has often been

published in the mass media. It was reported that

there were nurses in the hospital saying harshly to

patients when serving health checks, nurses were not

responsive in providing services, and nurses were

less friendly to patients (Nurjannah, 2016).

Criticism or complaints regarding nurses'

performance can be minimized by taking into

account the factors that can influence them.

According to Ilyas, the factors that influence works

behavior and performance are individual,

organizational, and psychological variables. The

individual variables consist of abilities, skills,

background and demographics. The organizational

variables consist of resources, leadership, rewards,

structure and job design. The psychological

variables consist of perception, attitude, personality,

learning and motivation (Ilyas, 2016). One factor

related to the performance of organizational

variables is leadership. In this study limited to

clinical leadership of doctors (clinical leadership).

National Health Service (NHS) highlights the

importance of effective leadership in the system

especially the need to involve more doctors in the

leadership. Health and care professionals not only

require clinical experts but also have competence in

terms of leadership and management skills that

enable them to be more actively involved in

planning, delivering and transforming services for

patients and to make a change that actually happens,

requires leadership . There are many examples of

bad practice and system failure in health care due to

lack of leadership at the individual, group and

organizational level (NHS Leadership Academy,

2012).

Including leadership and management aspects in

the health service system on a team, department,

hospital or government scale in the health sector is

not an option, but an obligation for all clinicians.

This leadership is manifested through various types

of leadership styles. Leadership style is a way of

working and behaving leaders in guiding their

subordinates to do something (Kartono, 2014).

Given global trends, such as an aging population

and rapid adoption of new technologies, the way in

which health care is delivered has changed

substantially in the past 10 years, which in turn

brings the need for new ways to lead the health care

team. For this reason, a leadership style that is

focused on creating positive relationships is

associated with higher patient satisfaction, and

reducing patient mortality, medication errors, use of

controls and hospital-acquired infections.

Several factors that can affect one's leadership

style include many aspects, such as psychological,

sociological, cultural, political, historical,

geographical, technical, and economic aspects.

Based these factors it is very possible if the

leadership style in one country will also be different

from other countries, such as in two different

countries: leaders from different regions will also

give a difference in the leadership style. This

becomes a characteristic that grows and develops

closely related to a person's background and how the

values are instilled when he grows and grows older,

until finally becoming a leader (Laurent and

Djastuti, 2013).

Studies of the leadership style and its influence

on the work results or performance of its members

have been widely carried out. Tewal's research

found that there was a positive and significant

influence between organizational culture, leadership,

and motivation on nurse performance.

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Simultaneously that organizational culture,

leadership, and motivation significantly influence

nurse performance (Tewal, Mandey and Rattu,

2017). The difference with others, this research is

only focuses on leadership style.

Haan in his research found that there was a

relationship between leadership style (authoritarian,

democratic, participatory, liberal) and the work

motivation of nurses (de Haan, P.L.M., BitjuniH.J.

Kundre, 2019). The difference with this study is that

the dependent variable Haan examines nurses' work

motivation while this study examines the

performance variables of nurses implementing

inpatient rooms. Moura in his research found that

nursing leadership has a positive and significant

impact on job satisfaction (Moura et al., 2017). The

difference with this research is that the dependent

variable Moura examines nurse job satisfaction.

Duwayri explained that to achieve the highest level

of staff satisfaction nurse managers need to use

several leadership styles, which are relational

focused on transformational and transactional styles

(Duwayri, 2019). Research conducted by Artiningsih

found that the leadership style and motivation of the

head of the room had no significant effect on nurse

performance while discipline had a significant and

dominant effect on nurse performance (Artianingsih,

2016). Suratno's research found that leadership

strategies are very important to enhance the role of

nurses where leaders can form an effective work

environment for nurses and improve the quality of

service to patients. Health institutions must create a

healthy work environment that benefits nurses and

patients, monitors well-being and promotes healthy

behaviors to nurses (Suratno, Ariyanti and Kadar,

2018).

Goh's research found that nurse leaders in this

study tended to rate themselves higher than others.

The results imply the need to include self-awareness

elements in nursing leadership development

programs (Goh, Ang and Della, 2018). The

difference with this research is that the independent

variable besides Goh leadership style also examines

the organizational commitment variable. Overall

research focusing on leadership style and quality of

nurse performance (based on several previous

studies, these two factors are the most dominant in

improving the quality of service in a hospital) which

is still rarely done before.

2 METHODOLOGY

The study was conducted in the inpatient room at

Royal Prima Hospital Medan in August-December

2019. The hospital has implemented a modern

service system in the form of an integrated

computerized information system. The population

was 319 nurses implementing inpatient wards with a

sample of 76 respondents by random sampling

technique. Data collection was done by distributing

questionnaires containing 8 items each statement

about the leadership style of doctors (democratic,

participatory, authoritarian, and Laissez-faire) with

alternative answers Yes given a score of 3,

Sometimes given a score of 2, Not given a score of 1

and 20 statement items about the performance of the

implementing nurse with alternative answers Yes

given a score of 3, Rarely given a score of 2, Not

given a score of 1.

Validity and reliability tests were carried out on

30 nurses implementing at the same hospital as the

study location. The validity test results obtained

Rcount coefficient values in the range 0.393-0.749>

Rtable = 0.361, it was assumed that the data was

normally distributed. The reliability test results

obtained Cronbach's Alpha count values in the range

0.834-0.892> 0.7; assumed a reliable questionnaire.

Questionnaires were distributed in the second and

third week of December.

Data processing through the Editing stage: to

check the suitability of the data with expectations

and check the completeness and uniformity of the

data. Coding: to simplify the analysis and also to

speed up data entry. Processing: done after all

variables are coded. Data that has been given a code

is then entered first in the master table. Cleaning:

this process aims to ensure that the data that has

been entered is really clean from errors. Data were

bivariately analyzed using the chi square statistical

test and multivariate with multiple logistic

regression tests. The research process scheme is

given as in Figure1.

Doctor’s Leadership Style and Nurse Performance in Inpatient Room

223

Figure 1. Scheme of Leadership Style and Nurse

Performance Research

3 RESULTS AND DISCUSSION

Analysis of the research questionnaire based on

dummy categories (2 groups) with a mean or

average = 1.50; where all the variables above the

average are democratic (1.62); participatory (1.67);

authoritarian (1.55); free of action (1.54) and nurse

performance (1.57). The results of the measurement

of the research variable from the questionnaire as in

Figure 1 and Table 1. Figure 1 indicate the form and

data distribution value of each evaluated variables.

The measured data distribution for independent and

dependent variables can be seen in Figure 2.

Figure 2, D is Democratic, P is Participatory, A is

Authoritarian, F is Laissez-faire / Free action, and N is

Nurse Performance.

Based on the assessment of the implementing

nurses, there are still doctors who do not apply a

democratic leadership style (38.2%). This is evident

from the answers of implementing nurses that some

doctors in determining action plans to patients do

not always ask for ideas from implementing nurses

and do not respect the nature of implementing nurses

in carrying out health service tasks.

Figure 1: The measured data from questionnaire of 76

respondents.

The results of multiple logistic regression tests

on the doctor's democratic leadership style obtained

value of the regression coefficient = 1.714; p =

0.008 with the value Exp (B) = 5.553. This means

that the respondents considered that the democratic

leadership style applied by doctors was good, had a

5.553 times greater chance of carrying out tasks with

good categories compared to respondents who rated

the leadership style as not good.

A study conducted by Tewal found that there

was a significant positive effect between

organizational culture, leadership, and motivation on

nurse performance. Simultaneously that

organizational culture, leadership, and motivation

significantly influence nurse performance (Tewal,

Mandey and Rattu, 2017).

Human resource management in a hospital

requires the right leadership style so that it can form

a synergy between superiors and subordinates (in

this study between doctors and implementing

nurses). With the application of appropriate

leadership styles, it is expected that a harmonious

communication relationship between doctors and

nurses implementing in improving the performance

of health services to patients will be better.

Doctors who apply the majority participatory

style tend to carry out tasks in either category and

not vice versa. Chi square statistical test results

obtained p value (0.001) < (0.05) means that there

is a relationship between the participative leadership

style of the doctor and the task of the implementing

nurse.

The results of multiple logistic regression tests

on the physician participatory leadership style

obtained the value of the regression coefficient =

1.804; p = 0.008 with the value Exp (B) = 6.073.

100

150

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This means that respondents who rated the

participatory leadership style that doctors applied

were good, 6.073 times more likely to carry out

tasks in a good category compared to respondents

who rated the participative leadership style that

doctors applied was not good.

Nurses who state that doctors apply the majority

authoritarian style carry out tasks in either category

and those who declare doctors do not apply the

majority authoritarian style carry out tasks in the less

good category. Chi square statistical test results

obtained p value (0.002) < (0.05) means that there

is a relationship between the authoritarian leadership

style of the doctor and the performance of the

implementing nurse.

The results of multiple logistic regression tests

on the doctor's authoritarian leadership style

obtained the value of the regression coefficient =

1.937; p = 0.004 with the value of Exp (B) = 6.936

This means that respondents who rated the

authoritarian leadership style applied by doctors

were good, had a 6.936 times greater chance of

carrying out tasks in a good category compared to

respondents who assessed the authoritarian

leadership style applied by doctors was not good.

Nurses who state that doctors apply the laissez-

faire, the majority carry out tasks by category and

who state the doctor does not apply the freestyle act,

the majority carry out tasks with unfavorable

categories. Chi square statistical test results obtained

the value of p (0,000) < (0.05) means there is a

relationship between the free leadership style of

doctors' actions with the performance of the

implementing nurses.

The results of the multiple logistic regression test

on the doctor's free leadership style obtained a

regression coefficient of 1.804; p = 0.008 with the

value of Exp (B) = 6.073. This means that

respondents who judge doctors to adopt a free

leadership style of action as well, have a 6.073 times

greater chance of carrying out tasks in a good

category compared to respondents who judge the

leadership-free style of action that doctors apply is

not good.

From the results of the multivariate test in Table

2 it can be concluded that the leadership style of

Authoritarian is the dominant variable influencing

the performance of nurses implementing inpatient

rooms. This is evidenced from the coefficient value

of the Laissez-faire leadership style (1.804) higher

than the democratic leadership style (1.714), from

the participative leadership style (1.350) More

clearly as in Tables 2 and 3.

Table 1: Chi square test results (Bivariate Analysis).

Leadership

Nurse Performance

value

Good

Not Good

n % n %

Democratic

Applied 35 74,5 12 25,5 0,000

Not 8 27,6 21 72,4

Participatory

Applied 36 70,6 15 29,5 0,001

Not 7 28,0 18 72,0

Authoritarian

Applied 31 73,8 11 26,2 0,002

Not 12 35,3 22 64,7

Laissez-faire

Applied 32 78,0 9 22,0 0,001

Not 11 31,4 24 68,6

Table 2: Results of multiple logistic regression tests

(Multivariate Analysis).

Variables B Wald

Sig.

Exp

(B)

Democratic 1,714 7,024 1 0,008 5,553

Laissez-faire

1,804 6,988

0,008 6,073

Participatory

1,350 4,290

0,038 3,857

Authoritarian

1,937 8,401

0,004 6,936

Constant -3,196

17,205

0,000 0,041

In Trisnantoro's research, it is explained the

influence of various models or styles of doctor

leadership on the performance of implementing

nurses. Hospital core business is clinical services.

Patients and their families come to the hospital to get

clinical services from the health workers who work

in it. Health workers who work in hospitals consist

of various professions and each profession has a

diverse hierarchy of competencies. The large

number of variations is a barrier for the

implementation of services oriented to patient safety

and satisfaction, if there is no leadership that unites

the vision of service from these various professions.

For this reason, leadership is needed to build a spirit

of togetherness through shared vision and shared

values in the service mechanism in hospitals

(Trisnantoro et al., 2011). Much researched

assumptions indicate that greater physician

involvement in governance and management roles

Doctor’s Leadership Style and Nurse Performance in Inpatient Room

225

will have broader benefits for the efficiency and

effectiveness of health care organizations.

The results showed that there was an influence of

the doctor's democratic leadership style on the

performance of nurses implementing inpatients. The

statement of implementing nurses in general is that

doctors adopt a democratic leadership style (61.8%).

This is evident from the statement of implementing

nurses, among others, that doctors value the ability

of each implementing nurse in providing health

services; the doctor gives an explanation of the

implementation of nursing actions to the

implementing nurse openly; if there is a planning of

a new method for administering an action, the doctor

provides the widest possible information; and

doctors help implementing nurses in solving

problems related to the implementation of health

services.

Based on the results of multiple logistic

regression tests, the value of p 0.008 <0.05 means

that there is an influence of the democratic

leadership style of the doctor on the performance of

the executing nurse. In other words the more

democratic leadership styles are applied by doctors,

the task of implementing nurses also increases. But

there are still nurse nurses with poor performance,

this can be caused by a less supportive work

environment such as conditions when the patient is

busy, the nurse's workload is high, and the number

of nurses is still less compared to the number of

patients who must be served.

The results showed that there was an influence of

the physician participatory leadership style on the

performance of nurses implementing inpatient

rooms. This is based on the statement of the

implementing nurse who in general doctors apply a

participative leadership style (67.1%). This is

evident from the statement of the implementing

nurse which among others is that if there is a

planning of a new method in the delivery of health

services or actions, the doctor proposes to the

implementing nurse; the doctor gives direction to the

implementation of the duties of the implementing

nurse clearly; doctors appreciate the ability of

implementing nurses in carrying out health service

tasks; and doctors consider the results of the analysis

of the problem of implementing nurses related to

problems in the implementation of health services.

Based on the results of multiple logistic

regression tests, the value of p 0.008 <0.05 means

that there is an influence of the participative

leadership style of the doctor on the task of the

nurses implementing the inpatient room. In other

words the more applied the participatory leadership

style by doctors, the task of implementing nurses

also increased. But there are still nurses with poorly

performing tasks, this can be caused by a less

supportive work environment such as conditions

when the patient is crowded, the workload of nurses

is high, and the number of nurse nurses is still

insufficient compared to the number of patients who

must be served.

Based on the assessment of the executive nurse

that there were doctors who did not apply the

participative leadership style (32.9%) it was proven

that the nurse's response was that in determining the

action plan to the patient, the doctor did not always

ask for advice from the implementing nurse and

likewise in determining the purpose of the action on

the patient, the doctor makes his own decision

before proposing to the implementing nurse.

The results showed that there was an influence of

the doctor's authoritarian leadership style on the

performance of nurses implementing inpatients. The

statement of the implementing nurse generally states

that the doctor applies an authoritarian leadership

style (71.7%). This is evident from the statement of

implementing nurses, among others, that doctors

provide information only limited to the importance

of the task to the implementing nurse; the doctor

uses full authority in assigning duties to the

implementing nurse; and doctors crack down on

implementing nurses who violate the provisions of

the actions they provide. Based on the results of

multiple logistic regression tests the p value of 0.038

<0.05 means that there is an influence of the

authoritarian leadership style of the doctor on the

task of the implementing nurse in the inpatient room.

In other words the more authoritarian leadership

styles applied by doctors, the task of implementing

nurses also increases.

Ilyas states that theoretically there are three

groups of variables that affect performance, one of

which is an organizational variable with subvariable

leadership (Ilyas, 2016). In this case, what is meant

is the leadership of the doctor as the decision maker

as well as the person in charge of health measures

given to patients who in practice collaborate with

nurses. The American Medical Association

interprets collaboration between doctors and nurses,

the process by which doctors and nurses plan and

practice together as colleagues, working

interdependently within the boundaries of their

practice by sharing values and mutual recognition

and respect for everyone who contributes to caring

for individuals. , family and community (Rahaminta

and Sulisno, 2012).

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The results showed that there was an influence of

the doctor's Laissez-faire leadership style on the

performance of nurses implementing inpatients. This

is based on the statement of the implementing nurse

that in general doctors do not adopt a leadership

style that is free of action (53.9%). Evidenced by the

statement of the executing nurse, the majority said

no to the statement that in determining the action

plan to the patient, the doctor handed over to the

implementing nurse; doctors control the

implementation of actions to patients by nurses at a

minimum; and doctors rarely coordinate

implementing nurses in carrying out their duties.

Based on the results of multiple logistic regression

tests, the value of p 0.004 <0.05 means that there is

an influence of the Laissez-faire leadership style on

the performance of implementing nurses. In other

words the more authoritarian leadership styles

applied by doctors, it tends to affect the task of

implementing nurses. Based on the results of the

multiple logistic regression tests the four democratic

leadership style variables have an exponent value of

5.553; participatory leadership style has a coefficient

value of 3.857; authoritarian leadership style has a

coefficient value of 6.936; and the Laissez-faire

leadership style has a coefficient value of 6.073.

Of the four independent variable exponent

values, it is seen that the authoritarian variable has a

higher value, in other words the Laissez-faire

variable is the most dominant influencing the

performance of the implementing nurse.This

because doctors generally serve many patients so

that. So there is a tendency for doctors not to

coordinate or in other words tend to give freedom to

other implementing nurses to take actions and

decisions individually related to the provision of

health services in the inpatient room.

Management of human resources in a hospital

requires the right leadership style so that it can form

a synergy between superiors and subordinates in this

study are doctors and nurses implementing. With the

application of the right leadership style, it is

expected that there is a harmonious communication

relationship between doctors and nurses

implementing in improving the performance of

nursing care services to patients.

Some of the results of previous studies that are in

line with this study are Moura who found that

nursing leadership has a positive and significant

impact on job satisfaction (Moura et al., 2017).

Artiningsih's research found that the leadership style

of the head of the room was influential but not

significant to the performance of nurses in Brigjend

H. Hasan Basry Kandangan Hospital (Artianingsih,

2016). Research Naseem et al. find the

transformational style of the leader to achieve a

statistically optimal nurse presentation statistically

significant effect on the level of job satisfaction of

nurses (Naseem et al., 2018).

Sfantou et al.'s study found that leadership style

plays an integral role in increasing quality measures

in health care and nursing (Sfantou et al., 2017). Al-

Yami's research found a significant relationship

between nurses' organizational commitment in

relation to transformational leaders, showing staff

becoming more committed to the hospital when a

manager displays transformational leadership

characteristics (Al-Yami, Galdas and Watson, 2018).

Research by Fatimah et al. Found that there was a

significant leadership effect on nurse job satisfaction

(Fatimah, Wahyuni and Widjasena, 2016). The

results of the study are contrary to the results of this

study, namely Ibrahim et al. Which found that no

statistically significant relationship was found

between leadership style and nurse performance

(Ibrahim, Sanaa Abd El-Azim., El Sayed, Rasha

Ibrahim., Attala, Magdy Mamdouh & Elmezin,

2016).

The provision of nursing services is a complex

activity and involves various individuals. In order to

achieve the nursing goals, activities required to

apply leadership skills. Therefore, leadership arises

as a synergistic result of various skills ranging from

administrative (planning, organizing, controlling,

controlling), technical skills (management,

marketing, and procedural technical), and

interpersonal skills (Subanegara, 2005).

4 CONCLUSIONS

Modeling results show that the regression coefficient

value (r = 1.714: p = 0.008); participatory (r = 1.804:

p = 0.008); authoritative (r = 1.350: p = 0.038); and

laissez-faire (r = 1.937: p = 0.004) on performance.

The conclusion of this study is that the doctor's

leadership style has a significant effect on the nurse's

performance and the laissez-faire style is the

dominant factor. Doctors should avoid applying the

Laissez-faire leadership style because this variable

has the most dominant influence on the nurse's

performance. Implementing nurses should strive to

improve the duties of nursing care as best as

possible.

Doctor’s Leadership Style and Nurse Performance in Inpatient Room

227

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