Comparative Study of The Effect of Training on Nurses Performance Re- lated To The Safety Targets of Fall Risk Patients at General Hospital Indonesian Christian University Jakarta

Patient’s Safety is part a service system in a hospital to give comfort and protection, so the patient feel more secured. Fall patient’s accident is mostly reported happen to adult patient when they were having a care unit. Patien’s safety training is purposed to add nurses performance motivation to prevent fall patient. This research is meant to see whether there is a connection between the workshop, attitude, motivetion of nurses performance and the patient safety from fall accident in General Hospital Indonesian Christian University, Jakarta. This research used quantitative method combine with comparative study design. This comperative study is conducted by comparing the nurses performance toward patient safety of fall accedent between those who had the trainng workshop and those who dont have the training workshop. The ammount of the sample to this research is 94 respondents, which is divided into two groups. 56 respondents who had the workshop training and 38 respondents who did not have workshop training. Then two these two groups are conducted an osbervation and being compared. The technique of sample taking is using total sampling technique. The result of this research showed that there is an influence of training (p=0,000) motivation (p = 0,010), to patient safety of fall accident prevention OR (Odd Ratio) valvue is 8,603 times higher than to thoses who did not have the patient safety training workshop. This research recommends the necessary to conduct a workshop training to develop attitude, motivation and standarized nurse performance to prevent patient fall accident risk. Keyword : Atitude; Motivation, Patient safety, Performance Nurses; Training Introduction Patient safety in a hospital is a service system in a hospital that provides protection for patients to be safe. Hospitals are required to apply patient safety standards. This includes measuring and identifying risks to patients, reporting and analyzing incidents, the ability to learn and follow up on incidents and implement solutions to prevent, reduce and minimize risks. The incidence of injuries from falls in hospital is often reported to adult patients while undergoing hospitalization. Treatment of patients hospitalized requires specific treatment, in connection with various conditions and various cases of disease. Each patient is a unique person with various disorders and uniqueness. In this case, there are various kinds of diseases with various patient conditions that will affect the way nursing services are provided. Service provision is of course adjusted to the patient's condition which is full of risks. There are many risks that may occur and one of them is Falling Patients. Dwi Rohyani, et al | Comparative Study of The Effect of Training on Nurses Performance.... Journal Educational of Nursing (JEN) Vol. 3 No. 2 (2020) 54 To prevent and anticipate falling patients with or without injury, it is necessary to carry out an assessment since the patient first entered the treatment room. Not only that, periodic or periodic reviews of the patient's risk of falling are also important. This fall risk assessment can be carried out since the patient starts registering or registering, namely by using a drop scale. This needs to be done through socialization orientation and training to nurses. The General Hospital of the Christian University of Indonesia has carried out 16 accreditation standards for 2011 and has completely passed the 2012 KARS version accreditation in 2015 and 2018 SNARS 1 accreditation passed PARIPURNA various things are done to implement patient safety goals. One of the indicators of the quality of the Indonesian Christian University Hospital is the safety target for falling patients. There are 148 nurses at Indonesian Christian University Hospital, 16 midwives, 30 nonmedical staff (TNMR), staff. In 2017, the number of employees who have attended the patien safety training is 148 people. Meanwhile, in 2018 there were 104 people. Based on the data obtained, in the implementation of the patient safety program at the General Hospital of the Christian University of Indonesia, there were patient safety incidents from 2015 to November 2016 in all service units. Patient Safety Incidents Fall 2014 to November 2016 The number of incidents included in the KPRS team at General Hospital of Indonesian Christian University Jakarta in January December 2015 recorded 20 incidents as follows KTD (unexpected events) 11 incidents (55%), KNC (near injury incidents) 7 incidents (35%), KTC (Non-Injury Incidents) 2 incidents (10%), while in January November 2016 there were 3 incidents as follows KTD (unexpected incidents) 19 incidents (48.17%), KNC (near injury incidents ) 10 incidents (25.64%), KTC (NonInjury Incidents) 10 incidents (25.64%) the data were patient safety incidents in the first, second, third, fourth and fifth targets. Meanwhile, KTD data on the risk of falling in hospitalization in 2017 amounted to 4 incidents, in 2015 KTD were 3 incidents and in 2018 KTD were 2 incidents with age categories ≥ 1 year, 15-30 years, 30-65 years, ≥ 65 years, which should be this should not happen (SPM 2008). The impact of all the above incidents if not resolved immediately is that the same incident will repeat itself, prolong treatment, injury, disability and death arise. Based on the description above, it can be understood that there is still a gap between the performance of the nurses at the Indonesian Christian University Hospital and the patient safety incident at the risk of falling in hospitalization. Supposedly, after training patien safety, there is an increase in knowledge, attitude and motivation so that the performance of nurses in implementing patient safety at risk of falling goes well. This means, no fall patient safety incidents occur. However, data at Indonesian Christian University Hospital still shows patient safety incidents at risk of falling. The impact of this is that patient care days increase. The purpose of this study was to determine the effect of patient safety training and confounding variables (characteristics, attitudes and motivation of nurses) on the performance of nurses implementing the patient's risk of falling safety targets. Methods This research is a quantitative study with a cross-sectional comparative study design, by comparing the performance of nurses on patient safety, the risk of falling between nurses who have received training and those who have not received training at Indonesian Christian University Hospital in April May 2019. The population of this study is a nurse who works at the Indonesian Christian University Hospital in the inpatient unit as many as 94 nurses. From the existing sample, 56 nurses have received training and 38 nurses have not received training. Results and Discussion Dwi Rohyani, et al | Comparative Study of The Effect of Training on Nurses Performance.... Journal Educational of Nursing (JEN) Vol. 3 No. 2 (2020) 55 Nurse Characteristics Table 1Frequency Distribution of Nurse Characteristics at General Hospital of Indonesian Christian University from April to May 2019 Nurse Characteristics Training Not Training Yet Amou nt (%) Amount (%) Age 20-40 year 44 78,57 30 78,94 41-60 year 12 21,43 8 21,06 Gender Man 3 5,36 4 10,53 Woman 53 94,64 34 89,47 Education 3-Year Diploma 34 60,71 30 78,94 Nursing Midwifery 22 39,29 8 21,06 Length of Working < 4 year 28 50,0 19 50,0 > 4 year 28 50,0 19 50,0


Introduction
Patient safety in a hospital is a service system in a hospital that provides protection for patients to be safe. Hospitals are required to apply patient safety standards. This includes measuring and identifying risks to patients, reporting and analyzing incidents, the ability to learn and follow up on incidents and implement solutions to prevent, reduce and minimize risks.
The incidence of injuries from falls in hospital is often reported to adult patients while undergoing hospitalization. Treatment of patients hospitalized requires specific treatment, in connection with various conditions and various cases of disease. Each patient is a unique person with various disorders and uniqueness. In this case, there are various kinds of diseases with various patient conditions that will affect the way nursing services are provided. Service provision is of course adjusted to the patient's condition which is full of risks. There are many risks that may occur and one of them is Falling Patients.
To prevent and anticipate falling patients with or without injury, it is necessary to carry out an assessment since the patient first entered the treatment room. Not only that, periodic or periodic reviews of the patient's risk of falling are also important. This fall risk assessment can be carried out since the patient starts registering or registering, namely by using a drop scale. This needs to be done through socialization orientation and training to nurses.
The General Hospital of the Christian University of Indonesia has carried out 16 accreditation standards for 2011 and has completely passed the 2012 KARS version accreditation in 2015 and 2018 SNARS 1 accreditation passed PARIPURNA various things are done to implement patient safety goals. One of the indicators of the quality of the Indonesian Christian University Hospital is the safety target for falling patients. There are 148 nurses at Indonesian Christian University Hospital, 16 midwives, 30 nonmedical staff (TNMR), staff. In 2017, the number of employees who have attended the patien safety training is 148 people. Meanwhile, in 2018 there were 104 people.
Based on the data obtained, in the implementation of the patient safety program at the General Hospital of the Christian University of Indonesia, there were patient safety incidents from 2015 to November 2016 in all service units. Patient Safety Incidents Fall 2014 to November 2016 The number of incidents included in the KPRS team at General Hospital of Indonesian Christian University Jakarta in January -December 2015 recorded 20 incidents as follows KTD (unexpected events) 11 incidents (55%), KNC (near injury incidents) 7 incidents (35%), KTC (Non-Injury Incidents) 2 incidents (10%), while in January -November 2016 there were 3 incidents as follows KTD (unexpected incidents) 19 incidents (48.17%), KNC (near injury incidents ) 10 incidents (25.64%), KTC (Non-Injury Incidents) 10 incidents (25.64%) the data were patient safety incidents in the first, second, third, fourth and fifth targets. Meanwhile, KTD data on the risk of falling in hospitalization in 2017 amounted to 4 incidents, in 2015 KTD were 3 incidents and in 2018 KTD were 2 incidents with age categories ≥ 1 year, 15-30 years, 30-65 years, ≥ 65 years, which should be this should not happen (SPM 2008). The impact of all the above incidents if not resolved immediately is that the same incident will repeat itself, prolong treatment, injury, disability and death arise.
Based on the description above, it can be understood that there is still a gap between the performance of the nurses at the Indonesian Christian University Hospital and the patient safety incident at the risk of falling in hospitalization. Supposedly, after training patien safety, there is an increase in knowledge, attitude and motivation so that the performance of nurses in implementing patient safety at risk of falling goes well. This means, no fall patient safety incidents occur. However, data at Indonesian Christian University Hospital still shows patient safety incidents at risk of falling. The impact of this is that patient care days increase.
The purpose of this study was to determine the effect of patient safety training and confounding variables (characteristics, attitudes and motivation of nurses) on the performance of nurses implementing the patient's risk of falling safety targets.

Methods
This research is a quantitative study with a cross-sectional comparative study design, by comparing the performance of nurses on patient safety, the risk of falling between nurses who have received training and those who have not received training at Indonesian Christian University Hospital in April -May 2019. The population of this study is a nurse who works at the Indonesian Christian University Hospital in the inpatient unit as many as 94 nurses. From the existing sample, 56 nurses have received training and 38 nurses have not received training.  Table 1 shows the results of the characteristics of the respondents with the largest percentage, namely those aged 20-40 years 78.57% who have been trained while 78.94% have not been trained. This is supported by the results of the study which states that there are significant differences between all age factors before learning or after receiving training for patien safety and environmental factors. As you get older the more you see experience, consideration, a strong work ethic and a commitment to quality. The period of productive age at work and the labor force is indicated by the period of young adults (20-40 years) and media adults (40-65 years). Table 1 shows the results of the characteristics of the respondents with the largest percentage of female gender at 94.64 for respondents who have been trained while those who have not been trained are 89.47. According to the research results, the majority of respondents were female (75.6%). Based on the analysis and observations of researchers, it can be seen that women have a higher level of adherence than men to the operational standards of patient risk fall.

Nurse Characteristics
Meanwhile, the majority of educational characteristics were 3-Year Diploma of Nursing education are 60,71% of respondents who had been trained while those who had not been trained were 78,94. Educational background will affect performance.
While the characteristics of the working period < 4 years and > 4 years are the same, about 50% of both respondents who are trained and those who have not been trained. Work experience is defined as an activity or process that a person has experienced when earning a living to make ends meet. The work period shows how long a person has worked at each job or position. Many studies have been on the relationship between employee seniority and productivity. Although a person's work performance can be traced from previous work performance, so far no conclusive conclusion can be drawn between these two variables. Period of work expressed as work experience. Based on attitude questionnaire, the respondent will fill in the questionnaire with an assessment using a Likert scale (1)(2)(3)(4). After that these results are processed using the middle value to be included in the good attitude category with a value of 45-80 and a lack of value with a value of 16-47. Table 5 shows the results of the attitudes of nurses with the largest percentage (60.71%) of good attitudes who participated in the training, while those of good attitudes who had not trained were (76.31%). This is supported by the results of research which states that there is an influence of knowledge which will have an influence on attitudes to support the application of a patient safety program, this is the same as the results of research which state that education or training can have an influence on the application of a patient safety program. Attitude factors influenced by the individual have an influence on the implementation of patient safety. Attitudes are evaluative statements, whether pleasant or unpleasant about a person's object or event. Generally, researchers have assumed that attitudes have three components, namely awareness, feelings and behavior.

Description of Nurse Attitudes and Motivations
Nurses need to have a caring attitude in implementing the risk of falling safety. Because caring orientation begins with a fundamental belief in humans and human capacities through events, transitions and how to deal with the future with meaning. Maintaining the trust of others is the basis of caring, from this attitude the nurse determines what is important and when a caring attitude is needed. In this case, the nurse needs to approach the client with a belief that the client is a significant person.
According to the analysis and observations of researchers, a good attitude greatly affects the performance of the application of patient safety, the risk of falling. This analysis is supported by the theory of performance, namely the factors that affect performance, one of which is a psychological factor, namely attitude.
Based on motivation questionnaire, the respondent will fill in the questionnaire with an assessment using a Likert scale (1)(2)(3)(4). After that the results are processed using the mean value to be included in the motivation category, both values 37-72 and less motivation values 12-36. Table 3 shows the results of the description of motivation for the majority of good motivations who have been trained as many as 50 respondents (89.28%) and 10 respondents (26.32) who have not trained good motivation.
In accordance with one research that says that there is a relationship between training, work motivation and employee performance. Therefore, the motivation of nurses also has an important role in implementing patient safety, the risk of falling, increasing nurse satisfaction, the risk of falling patient safety incidents does not occur so that the quality of nursing care services increases.
According to the researcher's analysis, good and strong motivation in implementing standard operating procedures for the risk of falling safety increases the performance of nurses. Because motivation is an interaction between expectations after deducting performance, with assessment contributions related to achievement minus results. Work motivation is a condition that influences a person to continue to improve, direct, and maintain their behavior that is related either directly or indirectly to their work environment. Respondents' performance was observed through the observation sheet on the implementation of patient safety at risk of falling, whether respondents had been trained or were not trained in patient safety. The assessment is carried out based on a nominal scale and a standard value based on hospital policy, it is said that the performance is good if the value is ≥ 76 and the performance is less if the value is ≤ 76. Table 3 shows the results of the description of the nurse's performance on the implementation of patient safety at risk of falling, the assessment of the nurse's performance was observed through observation sheets, interviews with patients and evaluated on the patient's medical record. The results of observations of the performance of nurses who have been trained and who have not been trained, found that the majority of trained nurses have better performance while those who have not been trained in patient safety have lower performance. The low presentation value for respondents who have been trained is at 53.57% (three), namely explaining the intent and purpose of placing stickers on the risk of falling by 53.57%, the statement of 5 (five) educating families and patients that the identity bracelet must always be worn until the patient is allowed to go home by 57.14%, statement 11 (eleven) monitors the effects of drugs by 21.42%, statement 12 (twelve) provides education to patients and families by 46.42%, statement 14 (fourteen) re-monitors the patient The risk of falling when there was a change in therapy was 17.85% and statements of 24 (twenty four) cutting the patient's identity bracelet into small pieces before being thrown into the trash was 48.21%.

Performance Description
According to the researcher's analysis, from the above results the nurse's performance that needs to be improved is the education of nurses to patients and their families, the consistent attitude of nurses in carrying out standard operational procedures on the implementation of patient safety at risk of falling. Training in the scope of quality and patient safety is one of the means to increase the need for new knowledge and to improve nurse performance. This is supported by the theory that the staff who receive training need to be given feedback or the results of the knowledge obtained from the training received so that staff can develop their performance better.
One of the standards of patient safety is the use of performance improvement methods for evaluating and improving patient safety programs, by conducting performance data through reporting incidents that occur in the hospital. Therefore, it is hoped that every incident that occurs can be handled properly. The handling referred to starting from the initial assessment stage and re-assessment is carried out recording and reporting, then analyzing the cause of the problem so that the hospital leadership submits it to the Hospital Patient Safety Committee (KKPRS) to analyze the root of the problem which is confidential. This is expected to improve the performance of nurses in the application of safety patien: the risk of falling.  Table 4 describes the results of the chisguare bivariate analysis that Age 20 -40 years of good performance is 52.7% higher than those aged 41 -60 years in 40% there is no significant relationship between Age and nurse performance (p ≥ 0.05). This means that there is no relationship between Age and the performance of nurses in the application of the patient safety risk of falling at the General Hospital of Indonesian Christian University.

Relationship among Characteristics, Attitudes, Motivation and Performance of Nurses
The results obtained in this study are in line with research which proves that there is no significant relationship between age and understanding of nurses in the experimental group with a p value of 0.460 and there is no significant relationship between age and understanding of nurses in the control group with p value of 0.373. Table 4 explains the results of the chisguare bivariate analysis that gender women perform well (50.6%) higher than male gender (48.9%) in good performance there is no significant relationship between gender and nurse performance (p ≥ 0, 05). This means that there is no relationship between gender and the performance of nurses in the application of fall risk safety patien at the General Hospital of Indonesian Christian University. Table 4 explains the results of the chisguare bivariate analysis that the 3-Year Di-ploma Nursing education has good performance (53.1%), which is higher than the S1 Ners education (43.3%) there is no significant relationship between education and nurse performance (p ≥ 0 , 05). This study was supported by the results of research which stated that the level of education was not related to the attitude and performance of the patient safety implementation program (p ≥ 0.05). The results of this study are inversely proportional to the results of the study which states that there is a significant relationship between the level of education and the compliance of nurses in implementing patient safety guidelines. A person's education level has an effect in responding to something that comes from outside. Highly educated people will be more rational and creative and open to accepting various reform efforts, they will also be more able to adapt to various changes. Education achieved by someone is expected to be a determinant factor of productivity, including knowledge, skills, abilities, attitude and behavior, which are sufficient in carrying out their work activities as well as implementing the patient's risk of falling patient safety targets.
However, this is not proven in this study. According to the researcher's analysis, this could be due to the fact that nurse education at the General Hospital of Indone-sian Christian University is almost uniform, namely 3-Year Diploma. However, in working, nurses must not only have formal education but must be equipped with a variety of training -training that supports jobs that are not obtained during education, including training in patient safety at risk of falling. So that in terms of differences in work experience education and training -the training obtained while in this hospital has been able to reduce a large difference between 3-Year Diploma graduates, work experience and training and finally there is an increase in the performance of nurses on patient safety targets at risk of falling. Table 4 explains the results of the chisquare bivariate analysis that length of working is less than four years of good performance (53.2%) higher than length of working more than four years (46.8%) in good performance there is no relationship significant between length of working and nurse performance (p ≥ 0.05). This means that there is no relationship between length of working and the performance of nurses in applying the patient safety risk of falling at the General Hospital of Indonesian Christian University.
According to the researcher's analysis, characteristics affect performance. This is supported by the theory of organizational performance which states that there are 3 factors that influence performance, namely individual factors, psychological factors and organizational factors. In this theory, it is said that individual variables which include abilities and skills, background (family, social level of experience), demographics (age, ethnicity, gender) affect performance. However, in this study the characteristics of respondents did not affect performance due to various factors that influenced performance need studying or research on this matter.  Table 5 explains the results of the chisquare bivariate analysis that good attitude is higher in good performance (50.8%) than less attitude in good performance (48.4%), there is no significant relationship between attitude and nurse performance ( p ≥ 0.05), then Ho is accepted. This means that there is no relationship between attitudes and performance of nurses in the application of the patient safety risk of falling at the General Hospital of Indonesian Christian University.

The Relationship between Attitudes and Performance of Nurses
According to the researcher's analysis, a good attitude will improve the performance of patient safety implementation at the risk of falling. Attitudes can also influence individuals to take certain actions. However, in this study attitude is not related to performance. This is because the results of this study indicate that there is no dominant attitude between good and less.  Table 6 explains the results of the chi-square bivariate analysis that good motivation is higher in good performance by (60%) than less motivation in good performance (34%) there is a significant relationship between motivation and nurse performance (p value 0.010), then Ho was rejected. This means that there is a relationship between motivation and the performance of nurses in the application of the patient safety risk of falling at the General Hospital of Indonesian Christian University.

The relationship between motivation and nurse performance
Motivated nurses work best when the workplace has the following characteristics: autonomy decisions, work climate, teamwork, learning opportunities, exploitation and combined with a positive support structure and positive working conditions.
In the performance theory, it is stated that individual motivation greatly affects a person's performance, therefore nurse motivation plays a very important role in implementing the safety patien culture of the risk of falling.
According to the researcher's analysis, nurse motivation has an important role in the implementation of patient safety at risk of falling. In this case, nurse satisfaction increases, patient satisfaction is good, patient safety incidents risk of falling does not occur and the quality of nursing care services in implementing patient safety increases. In carrying out performance on patient safety goals, the risk of falling, caring orientation is needed by nurses, starting from maintaining belief, Knowing, being with, doing for to enabling.  Table 7 explains the results of the chisguare bivariate analysis that participating in good performance training is higher (69.9%) than those who have not participated in the training (21.1%). There is a significant relationship between training and nurse performance (p value 0,000), so Ho is rejected. This means that there is a relationship between training and performance of nurses in the application of the patient safety risk of falling at the General Hospital of Indonesian Christian University.  According to the researcher's analysis, when nurses receive training, the nurse's understanding increases and performance will increase. This is because nurses get a strong understanding and can implement it in Nursing services. Staff who receive training need to be given feedback or the results of the knowledge obtained from the training received so that staff can develop their performance better. The facts show that the existence of training is seen positively by staff and the writing of the survey results shows that on average two-thirds of staff perceive that the training received by staff is useful and helps staff performance in carrying out their duties and obligations. It was also stated that training should be effective in accordance with the principles of learning that should be applied in a continuous training program. Attitudes and motivation of nurses in participating in patient safety training need to be started by knowing (Knowing), togetherness (being with) then doing what is received during the training and then facilitating patients to avoid falling injuries. Swanson's theory is useful in providing guidance on how to develop useful and effective strategies. The patient's decision on Nursing services on the risk of falling safety targets is one indicator of the quality of Nursing services.

Effect of training on nurse performance
This means that the research results obtained should be accompanied by repetition of the training program in the form of continuous training. In the context of the results of this study, continuous training is important to print an adequate pattern in the memory of nurses regarding the application of patient safety in Nursing services, material that provides specifics is increasingly being developed so that it has relevance to the duties and responsibilities of nurses in providing safe care, and transfer of knowledge. can support nurses to learn quickly about the implementation of patient safety at risk of falling in the Nursing service. In addition, it is necessary to develop and socialize and manage nurse performance standards for performing the expected performance in the application of patient safety and managed through advanced training programs that are in line with the KKPRS program.

Conclusion
The characteristics of the nurses in this study indicate that the characteristics of the respondents with the largest presentation are gender woman, Age 20-40 years, 3-YEAR DIPLOMA Nursing education and length of working less than four years.
Description The attitude of the biggest presentation nurses is being good who participate in training (60.71%) and have not been trained (76.31%). The description of the majority of motivation good motivation that has been trained (89.28%) and motivation good that has not been trained (26.32%).
The description of the performance of nurses on the implementation of patient safety, the risk of falling is 53.57%, educating families and patients that identity bracelets must always be worn until the patient is allowed to go home by 57.14%, monitoring the effects of drugs by 21.42%, providing education to patients and family by 46.42%, re-monitoring the patient's risk of falling when there was a change in therapy by 17.85% and cutting the patient's identity bracelet into small pieces before throwing it into the trash by 48.21%.
There is a significant relationship between training and nurse performance in the application of patient safety with the risk of falling with a value of p = 0.000. However, in the LR Backward method, it can be seen that the influence of motivation on performance is not significant (p = 0.656). This can be caused by increased motivation that can occur simultaneously with training. While the OR (Odd Ratio) value is 8.603, which means that training has an opportunity to increase performance by 8.603 times compared to what is not done by training.