Can Nurse Performances Achieved?

Empowerment of Nurses and Work

Environment through Work Attitude

I Made Adi Wahyu Udaksana1, I Wayan Gede Supartha2, I Made Artha Wibawa3, Ida Bagus Ketut

Surya4
1
Candidate of Doctoral Program, Faculty of Economics and Business, Udayana University,
Denpasar, Bali, Indonesia; Email: adiudaksa@gmail.com
2
Professor and Lecturer at Department of Management, Faculty of Economics and Business,
Udayana University, Denpasar, Bali, Indonesia
3
Lecturer at Department of Management, Faculty of Economics and Business, Udayana
University, Denpasar, Bali, Indonesia
4
Lecturer at Department of Management, Faculty of Economics and Business, Udayana
University, Denpasar, Bali, Indonesia

Abstract: The purpose of this study was to examine the mediating role of work
attitudes on the effect of nurse empowerment and work environment on the performance
of emergency room nurses in hospitals in Bali. Is the attitude of workers able to mediate
in improving the performance of nurses? The method of determining the sample using a
saturated sample with a sample of 221 nurses. Data analysis was carried out using the
SEM-PLS method. The results showed that nurse empowerment had a positive and
significant effect on nurse performance, work attitude had a positive and significant
effect on nurse performance, work environment had a negative and insignificant effect
on nurse performance, and nurse empowerment had a positive and significant effect.

Keywords: Empowerment, Work Environment, Work Attitude, Performance

1. Introduction

Human resources are the core and driving force of all activities in every company,
because without humans an activity is impossible to run (Carnevale & Hatak, 2020).
Every hospital expects workers/nurses who have expertise, skills and are balanced in
work efficiency and effectiveness. The increase in the performance of the nurses is not
only beneficial for the company, but also for the nurses themselves. One of the
organizations that can be researched is the hospital's Emergency Department. The
emergency department is a service unit that must prioritize saving lives and preventing
disability where patients who enter the emergency department of the hospital need fast
and appropriate help (Chiew et al., 2019). Regarding the performance of emergency
room nurses at district hospitals in Bali, data on patient mortality in the emergency
room for less than 24 hours reached 5 per 1000 patients from the target of less than 2
per 1000 patients (Fusi-Schmidhauser et al., 2020). Interviews and brief observations
were conducted by the head of the emergency room at the Government Hospital in Bali,
the performance of nurses in the emergency room was influenced by the conditions of
the work environment and the empowerment of nurses. The working environment in
question is that nurses who work in the emergency room have a high number of
working hours and are arranged in tight work shifts; workers who have worked for a
long time have not received the appropriate award and are still employed in the
emergency room. Empowerment of workers in the nursing environment is a strategy in
shaping the attitude of a nurse (Udod et al., 2020); (Usman et al., 2021). Empowerment
as a strategy to improve job satisfaction and performance has received much attention in
general management research and in nursing management in particular (Maan et al.,
2020); (Jabbar et al., 2020). Having a comfortable work environment will form its own
empathy for the attitude of the nurses (Ghaedi et al., 2020); (Leon et al., 2020).
Competitive advantage and efforts to maintain competition are important for an
organization to focus on nurses' work attitudes and nurse performance. Work attitude is
a driving factor for improving performance. Attitudes towards work and organizational
commitment have a positive and significant effect on nurse job satisfaction. There is a
positive relationship between job satisfaction, work attitude, and job equity with the
performance of nurses in an organization Inuwa et al. (2017). Hettiararchchi &
Jayarathna (2014), found that work attitudes are influenced by job satisfaction,
organizational commitment, and organizational involvement where work attitudes have
a significant impact on nurse performance. The results of other studies show that there
is a significant effect of work attitudes on nurse performance; it means that positive
work attitudes held by nurses will be able to improve nurse performance (Shahab,
2014).
Chin (2012) found a positive correlation between work values and work attitudes
(including work involvement and organizational commitment). The mediating effect is
shown in work attitudes and work involvement on work values and performance job.
Schat & Frone (2011) says that psychological pressure at work can reduce task
performance and contextual performance, where work attitude is a partial mediation
between workplace psychological pressure and nurse performance. Psychological stress
threatens a number of valuable resources derived from an individual's work, including
co-worker relationships. The results of previous studies were not significant between
work attitudes and nurse performance. Susanty et al. (2013) found that attitudes towards
work were not significant on job satisfaction and nurse performance. Ahmad et al.
(2010) found an insignificant impact of organizational commitment on job satisfaction
and work attitudes on job performance. A good servant requires a perfect mix of
intellectual, behavioral, and spiritual intelligence. These three things are internal to us to
build a person who is intelligent, polite, and authoritative, so as to be able to provide
careful and accurate service as well as fun. The principles of attitude in local wisdom
that are universal in various fields of life are called Catur Sewaka (Astin et al., 2017).
Work attitude based on the concept of local wisdom of Catur Sewaka (four ways to
serve). Hospital emergency room nurses must have a work attitude based on the concept
of Catur Sewaka. If the interaction is done well, it will be able to increase the closeness
between nurses and patients which in turn improves the performance of hospital
emergency room nurses. This will make the patient as the main customer feel satisfied
with the emergency room service.
Improved nurse performance requires nurse empowerment and a good work
environment. Researchers have done a lot of research on nurse empowerment. This
research aims to determine the effect of implementing empowerment by considering
three factors including delegation, management involvement, encouragement and giving
gifts and determining priority classifications that can support performance (Meyerson,
2012). Hanaysha (2016) obtained research results showing that nurse empowerment
(training) has a significant positive effect on organizational commitment in improving
performance. Nurse empowerment has a direct effect on improving performance
(Fernandez, 2013). Several previous studies have examined the relationship between
nurse empowerment and performance. Liao (2016) who conducted research in nursing
schools found that psychological and structural empowerment could increase the
competence of nurses in improving performance. Empowerment of nurses is very
important for staff to do what needs to be done for patients in a timely manner while
still paying attention to the main interests of patients so that performance increases
(Pradhan, et al. 2014). Psychological empowerment has a significant individual
influence on job satisfaction which will improve the performance of Al-Ababneh
(2017).
Research that examines the effect of the work environment on performance was
obtained by several researchers. A good work environment will increase job satisfaction
which will have an effect on increasing work motivation in achieving organizational
goals and objectives (Raziq, 2015). A conducive physical workplace environment
predicts nurse engagement, especially when environment affects cognitive well-being,
emotional, and physical well-being which will lead to the success of an organization
(Kataria et al., 2012). (Almeida et al., 2019) get the results that the work environment
can improve the performance of nurses. A work environment with a workload greatly
affects the performance of nurses, which will have an impact on individuals (Asamani et
al., 2015). A good work environment will improve the health of nurses which will
improve the performance of the nurses themselves towards their organization (Hafee et
al., 2019). A well-designed and comfortable work environment will affect the
involvement of nurses in work so as to improve service quality (Madu, 2017). The work
environment affects the satisfaction of bank employees in Gana which will be able to
increase the productivity and performance of nurses (Agbozo et al., 2017).
The results of previous studies were inconsistent about the effect of nurse empowerment
on nurse performance. Humborstad (2011) conducted a study of 290 participants who
found that the relationship between empowerment and efforts to improve the service
performance of Chinese nurses was not significant. Bose & Emirates (2018) conducted
a study of 80 nurses in the UAE, concluding that there was no significant relationship
between nurse empowerment and nurse performance. The dimensions of empowerment
(choice and meaning) have no effect on nurse performance (Durrah et al., 2014).
(Mustafa & Bon, 2012) said that nurse empowerment had no effect on nurse
performance.
The results of previous studies were inconsistent about the effect of the work
environment on the performance of nurses. Amoroso (2015) found that the work
environment had no effect on the performance of nurses. Aspects of the physical
environment have no significant effect on the performance of nurses (Samson et al.,
2015). Mæstad et al. (2010) stated that they did not find a relationship between the work
environment and the improvement of services to patients. This study concludes that
health workers are working too hard and increasing the number of jobs is unlikely to
improve the quality of health services. Training has a positive effect on service quality
but not by directly improving service quality. Various gaps between environmental
empowerment, work environment, work attitude, and nurse performance are described
as follows.
This study aims to determine the mediating role of work attitudes on the influence of
nurse empowerment and the work environment on the performance of nurses in the
emergency room at hospitals in Bali. Researchers consider that in improving
performance it is necessary to strengthen the internal aspects of individuals and external
causes that refer to the surrounding environment. Meanwhile, external causes that
influence behavior include social conditions and people's views. When the nurse's
personality is in line with their work, the satisfaction of the nurse will increase by itself.
A person will better understand the meaning of their work and get the opportunity to
develop their self in the world of work. Therefore, there needs to be a match between
individuals and the work or tasks they perform in the workplace.

2. Theory and Hypotheses

Attribution Theory
Attribution Theory was developed by (Heider, 1958) which argues that a person's
behavior is determined by a combination of internal forces, namely factors that come
from a person, and external forces, namely factors that come from outside of the person.
This theory explains the situation around which causes a person's behavior in social
perception called dispositional attributions and situational attributions (Weiner, 2010).
Dispositional attributions are internal causes that refer to aspects of individual behavior
that exist within a person, such as personality, self-perception, ability, and motivation.
Situational attributions are external causes that refer to the surrounding environment
that can influence behavior, for example social conditions, social values, and
community views. This study uses attribution theory to explain and predict the effect of
nurse empowerment, work attitude and work environment on the performance of
emergency room nurses.

Person-job fit theory

Person-job fit theory is based on the nurse's personality and work. When the nurse's
personality is in line with their work, the satisfaction of the nurse will increase by itself.
A person will better understand the meaning of their work and the opportunity to
develop their self in the world of work. Person-job fit is defined as the fit between
individuals and the jobs or tasks they perform in the workplace. This definition includes
capabilities based on the needs of nurses and equipment availability to meet these needs,
as well as job demands and the ability of nurses to meet these demands (Grobler, 2016).
Previous research stated that in the selection of nurses, organizations must find
applicants who have talents and abilities that match the given job (Sekiguchi, 2004).
Person-job fit is assessed by determining the required jobs according to job analysis that
has been determined by the competent authorities in the organization so that the talents,
knowledge and abilities of workers are in accordance to the demands of the job.
(Sulistiowati et al., 2018) explained that person-job fit is defined as the suitability
between individuals and the jobs or tasks performed at work. Suitability includes the
needs of nurses and equipment availability to meet these needs, as well as job demands
and the skills of nurses to meet these demands.

The influence of nurse empowerment on the performance of nurses in the ER at

Hospitals in Bali

The success of a company is largely determined by the workers on the front lines,
therefore it is important for a company to provide training and always improve the
competence of nurses so that quality services are provided to customers who can
increase patient satisfaction (Meyerson, 2012). The concept of nurse empowerment is
very important for staff to do what needs to be done for the patient at the right time
keeping the best interests of the patient (Pradhan et al., 2014). Empowerment has a
positive and multidimensional role in the functions and outcomes of an organization
(Mustafa & Bon 2012). Nurse empowerment is very influential on job satisfaction
which can improve nurse performance (Al-Ababneh, 2017). Nurse empowerment has a
positive effect on nurse productivity (Hanaysha, 2016). Structural empowerment and
psychological capital are significantly and positively correlated to student competence
(Liao, 2016). Nurse empowerment also has a direct impact on performance as an
influence on job satisfaction and innovation, the two main causes of the pathway by
which empowerment practices influence behavioral outcomes (Fernandez, 2013). The
role shown by the empowerment of nurses on performance, this study proposes the first
hypothesis as follows:

H1: Empowerment of nurses has a positive and significant effect on the performance of
nurses in the ER at Hospitals in Bali.

The effect of nurse empowerment on the work attitude of nurses in the ER at

Hospitals in Bali

Nurse empowerment has a direct influence on satisfaction and innovation, both of

which will affect a person's behavior (Fernandez, 2013). Empowerment of nurses has a
positive effect on organizational commitment; good teamwork on organizational
satisfaction will affect good attitudes on nurses (Hanaysha, 2016). Shahab (2014) states
that empowerment will affect the job satisfaction of nurses and will improve their
attitude towards their work. Psychological empowerment has a significant influence on
nurse job satisfaction to improve performance (Wang, 2012). Empowerment will have a
positive and significant effect on work attitudes (Sherafati & Mohammadi, 2014).
Empowerment plays an important role in shaping work attitudes related to work, job
satisfaction, and job involvement (Gazzoli, 2012). Significant differences in
empowerment and work attitudes are based on demographic factors such as gender, age,
marital status, educational qualifications, appointment, income and experience
(Surekha, 2016). The role shown by the empowerment of nurses on work attitudes, this
study proposes the second hypothesis as follows:

H2: Empowerment of nurses has a positive and significant effect on nurses' work
attitudes in the ER at Regency/Municipal Hospitals in Bali.

The influence of the work environment on the performance of nurses in the ER at

Hospitals in Bali.

This modern era causes an organization to face challenges because of a dynamic

environment. A good work environment will increase job satisfaction which will affect
the performance of nurses (Raziq, 2015). A conducive physical work environment
predicts nurse involvement because the environment will affect a person's cognitive,
emotional, and physical well-being (Kataria et al., 2012). (Almeida et al., 2019) get the
results that the work environment can improve the performance of nurses. A work
environment with a workload greatly affects the performance of nurses, which will have
an impact on individuals (Asamaniet al., 2015). A good work environment will improve
the health of nurses which will improve the performance of the nurses themselves
towards their organization (Hafee et al., 2019). A well-designed and comfortable work
environment will affect the involvement of nurses in work (Madu, 2017). The work
environment affects the satisfaction of bank employees in Gana which will be able to
improve the performance of nurses (Agbozo et al., 2017). The role shown by the work
environment on performance, this study proposes a third hypothesis as follows:

H3: the work environment has a positive and significant effect on the performance of
nurses in the ER at Regency/Municipal Hospitals in Bali.

The influence of the work environment on the work attitude of nurses in the ER at
Hospitals in Bali.

The work environment is one of the factors that cause satisfaction of someone’s job.
Nurses who are satisfied with their work tend to be more loyal and productive (Tio,
2014). The work environment can involve social relations in the workplace as well as
maintaining relationships between colleagues, supervisors and the organization. The
work environment is one of the most important factors that affect the level of
satisfaction & motivation of nurses (Raziq, 2015). The work environment has a positive
and significant relationship with respondents' attitudes towards work (Yusuf &
Metiboba, 2012). Westerman (2017) found that orientation and suitability of the work
environment are very important for younger generation workers on work attitudes
which are indicated by satisfaction and intention to keep working. A better work
environment will have an effect on improving work attitudes, higher job satisfaction,
and lower intentions to leave either directly or indirectly (Wu et al., 2019). The work
environment will also affect the work attitude of nurses in reporting events that occur
while in the hospital (Yoo, 2017). Work environment suitability and orientation have a
positive impact on nurses' work attitudes and increase nurse job satisfaction
(Westerman, 2017). The role shown by the work environment on attitudes, this study
proposes a fourth hypothesis as follows:

H4: The work environment has a positive and significant effect on the work attitude of
nurses in the ER at Hospitals in Bali.

The influence of work attitudes on the performance of nurses in the ER at

Hospitals in Bali.

A good work attitude will affect the performance of nurses, with a good work attitude,
nurses will have a good personality so that they are able to adapt to the work
environment and have good working relationships (Shahab, 2014). The nurse's
performance is influenced by work-related attitudes such as satisfaction, leadership,
work commitment and work involvement (Hettiararchchi & Jayarathna, 2014). A nurse
with a positive attitude to the jobs will be aware of the dynamics of the business and be
able to adapt to the organizational environment, leading to a holistic development in
performance and productivity of the entire organization. The right work attitude will be
able to improve the performance of nurses (Hettiararchchi & Jayarathna, 2014). Chin
(2012) found a positive relationship between work values and work attitudes (including
work involvement and organizational commitment) with job performance. Workers'
attitudes towards time have a positive and significant effect on perceptions of
performance in the private sector (Omolayo & Oluwafemi, 2012). Performance will be
more effective if a leader always provides work motivation on a regular basis and
creates a conducive work environment (Djibu, 2020). Inuwa et al. (2017) found that
work attitude is a driving factor for improving performance. Attitudes towards work and
organizational commitment have a positive and significant effect on nurse job
satisfaction there is a positive relationship between job satisfaction, work attitude, and
equity with the performance of nurses in an organization. Nurse performance is an
important dimension in terms of the health care sector, especially the role of doctors and
nurses is very important in dealing with patients. The nurse's performance is influenced
by work related work attitudes such as satisfaction, leadership, work commitment and
work involvement (Chiang & Hsieh, 2012). The role shown by work attitudes on
performance, this study proposes the fifth hypothesis as follows:

H5: Work attitudes have a positive and significant effect on the performance of nurses
in the ER at Hospitals in Bali.

The role of work attitude as a mediating variable for nurse empowerment on the
performance of nurses in the ER at Hospitals in Bali.

The role of work attitudes in mediating the effect of nurse empowerment in improving
performance in organizations has been widely studied by previous researchers.
Psychological empowerment and work attitudes positively affect job performance.
Work attitudes act as partial mediators between perceived organizational support and
performance, as well as between psychological empowerment and performance
(Humborstad, 2011). Work attitude has a direct mediating effect between nurse
empowerment and performance (Chiang & Hsieh, 2012).

The results of the study revealed that nurse empowerment and work-related attitudes
had a positive relationship with performance (Ibua, 2016). Worker attitude is a
mediating role between nurse empowerment and company performance. Empowerment
of nurses, especially training will improve the performance of nurses mediated by the
work attitude of nurses (Ginsburg et al., 2016). Fletcher (2018) found that employee
training and development will increase the desire to keep working in improving
performance through good work attitudes. Work attitudes fully mediate the relationship
between psychological empowerment and perceived nurse performance (Mirza, et al.,
2015). The role shown by work attitude as a mediating variable of nurse empowerment
on performance, this study proposes the sixth hypothesis as follows:

H6: Work attitude mediates nurse empowerment on nurse performance in the ER at

Hospitals in Bali.

The role of work attitude as a mediating variable of the work environment on the
performance of nurses in the ER Hospital in Bali.

The role of work attitudes in mediating the influence of the work environment in
improving performance in organizations has been widely studied by previous
researchers. A good work environment will improve performance through good work
attitudes (Berta et al., 2018). Physical work space and easy access to meeting places
lead to good work attitudes, higher perceived group cohesiveness and job satisfaction
which will increase performance (Lee, 2005). A good workplace will improve job
performance (task performance and contextual performance) which is mediated by work
attitudes (Schat & Frone, 2011). Work attitude is mediation between the work
environment and increasing work ability to improve performance (Schat & Frone,
2011). Factors of work attitude have a significant impact in improving performance
(Marie, 2015). Work attitude is one of the means to increase the influence of the work
environment on the performance of nurses. So, it is better to provide benefits to nurses,
and apply a standardized layout workspace (Gamal, 2018). The role shown by work
attitude as a mediating variable of the work environment on performance, this study
proposes a seventh hypothesis as follows:

H7: Work attitude mediates the work environment on the performance of nurses in the
ER at Hospitals in Bali.

Based on the theory and the study of the results of previous research, the research
conceptual framework as Figure 1.

Nurse
empowerment

Emergency
Work attitude Nurse
Performance

Work
environment
3. Method

Research design: This research is a quantitative research by examining the causal

relationship of exogenous and endogenous variables. The variables studied in this study
were four variables, namely nurse empowerment, work environment, work attitude, and
nurse performance. The indicator for measuring empowerment uses a questionnaire
developed from the research concept of Conger & Kanungo (1988). Measurement of the
work environment through a questionnaire developed from the results of Razik's
research (2015). Measurement of work attitudes through questionnaires Shahab (2014)
and Astina et al. (2017).

Participants: This research was conducted in all ER hospitals in Bali as many as nine
ER’s hospital. The method of determining the sample using a saturated sample. Based
on these criteria, 221 emergency room nurses became the research sample.

Data collection tools: The research instrument was collected using a questionnaire
distributed to the head of the room for variables of nurse empowerment, work
environment, work attitude, and performance of emergency room nurses.

Data analysis: The data analysis technique used SEM-PLS.

4. Results and Discussion

4.1 Result

Outer model assessment was conducted to determine the validity and reliability of the
indicators and latent variables of the study. Validity is calculated using the values of
convergent validity and discriminant validity. While the reliability is calculated using
the value of the indicator reliability and the value of internal consistency reliability. The
value of convergent validity is known from the value of the loading factor and
discriminant validity through the value of AVE (Average Variance Extracted). The
loading factor value of all measurement indicators is above 0.5 and the AVE value of all
variables is also above 0.5. This figure shows that all measurement indicators meet the
 conditions of convergent validity and each of these indicators is valid in measuring
research variables.

Reliability testing uses the value of composite reliability and Cronbach's alpha value,
where the value of all indicators is above 0,7, it means that all latent variables have
consistent and reliable results. Summary results of testing the validity and reliabilities as
in Table 1.

Table 1 Test validity and reliability

Variable/Indicat Outer Average Composite Cronbach”s Explanation
or Loading Variance Reliability Alpha
Extract
(AVE)
Nurse Empowerment (PK)
PK1 0,802
PK2 0,791
PK3 0,643
PK4 0,583 0,595 0,871 0,829 Valid
PK5 0,752 and
PK6 0,723 reliabl
PK7 0,598 e
Work
Environment
(LK)
LK 1 0,854
LK2 0,902 0,72 0,914 0,875 Valid
LK3 0,848 6 and
LK4 0,845 reliabl
e
Work Attitude
(SK)
HR HRK 0,854
K 1 0,864 0.77 0,945 0,927 Valid
HRK 0,892 5 and
2 0,898 reliabl
HRK 0,895 e
3
HRK
4
HRK
5
AD ADL 0,959
L 1 0,962 0,92 0,960 0,916 Valid
ADL 2 and
2 reliabl
 e
CS CS1 0,753
CS2 0,799 0,66 0,888 0,831 Valid
CS3 0,804 7 and
CS4 0,899 reliabl
e
Nurse Performance (KP)
KT KT1 0,92
KT2 1 0,820 0,948 0,926 Valid
KT3 0,92 and
KT4 4 reliabl
0,94 e
0
0,83
4
KA KA1 0,93 0,784 0,962 0,954 Valid
KA2 0 and
KA3 0,83 reliabl
KA4 3 e
KA5 0,90
KA6 4
KA7 0,86
3
0,87
6
0,82
5
0,91
2
KK KK1 0,84 0,747 0,970 0,966 Valid
KK2 5 and
KK3 0,89 reliabl
KK4 2 e
KK5 0,88
KK6 1
KK7 0,89
KK8 6
KK9 0,89
KK1 2
0 0,87
KK1 5
1 0,78
8
0,82
5
0,87
 6
0,88
0
0,86
2

This study examined the mediating role on the effect of empowering the working
attitude of nurses and working environment on the ER Nurse Performance of District
hospitals in Bali. The following is the value of each R-Square as shown in Table 2
below.

Table 2. Value Coefficients of R-square

Variable R-Square R-Square Adjusted
ER Nurse 0.806 0.800
Performance

Based on Table 2 above, the R-Square value for the ER nurse performance variable is
0.806, this means 80.6 percent variation from the ER nurse performance able to be
explained by the role of work attitude on the influence of nurse empowerment and the
work environment while 19.4 percent was explained by other variables outside the
research model.

Value of Q Square (Q2) Predictive relevance in a structural model is used to measure

how well the observed values generated by the model and also the parameter estimates
are the Q-Square value is calculated by the formula:
Q2= 1- (1 – R12) (1 – R22)
= 1-(1-0.586) (1-0.806)
= 1- (0.0805)
Q2= 0.9194

The value of Q2 has a range value of 0 < Q2 < 1, where the closer to 1 means the better
the model. The results of the calculation of the value obtained from Q 2 equal to 0.9194,
so it can be concluded that the model has predictive relevance. Thus, it can be explained
that the magnitude of the contribution of the nurse empowerment variable, work
environment, and overall work attitude to the ER nurse performance variable is 91.94
percent. While the remaining 8.06 percent is the contribution of other variables that are
not included in this model.

4.2 Discussion

Acceptance of the hypothesis can be calculated from the results of the path coefficient and

the significance of the model based on t-statistics and p-value. In the path coefficient, the
relationship between two variables can be categorized as significant if the t-statistic value is

greater than 1.96 and the p value is less than 0.05. The results of hypothesis testing are as

shown in Figure 2, Table 3 and Table 4 below. 

Figure 2. Measurement Model of PLS Results.

Source: author’s calculations
Table 3 Path Coefficients and Specific Indirect Effects

Between Path Coefficient t- p- Information

Variables Statistics Valu
e
Nurse 1,984 1,984 0,048 Positive and
empowerment -> significant
Nurse
performance
Nurse 0,472 4,459 0,000 Positive and
empowerment -> significant
Work attitude
Work environment 0,037 0,453 0,651 Positive and
-> Nurse not
performance significant
Work environment 0,354 4,175 0,000 Positive and
-> Work attitude significant
Work attitude -> 0,751 10,169 0,000 Positive and
 Nurse significant
performance

Table 4. Direct effect and indirect effect

Direct Indirec Total P- Informatio
effect t effect effect value n
s
PK -> 0,156
KP (1,984)
PK -> 0,472
SK (4,459)
PK -> 0,355 0,511 0,000 Partial
SK -> (3,915) (5,017 mediation
KP )
LK -> 0,037
KP (0,453)
LK -> 0,354
SK (4,175)
LK -> 0,266 0,302 0,000 Full
SK -> (4,080) (2,978 mediation
KP )
SK -> 0,751 0,000
KP (10,169
)

Based on the path coefficient in Table 3, the results of can be explained the hypothesis researches
follows. 
H1: The Effect of Nurse Empowerment on Nurse Performance

Based on the results of the analysis, the coefficient value of nurse empowerment on nurse

performance was 0.156 with a t-statistics value of 1.984 (t-statistics > 1.96) and a p-value of

0.048 (p-value <0.05). This shows that the first hypothesis is accepted, this means that nurse

empowerment has a positive and significant effect on nurse performance. These findings indicate

that the empowerment of nurses in the emergency department of hospitals in Bali is able to

encourage the performance of emergency room nurses. Empowerment of emergency room nurses

in hospitals in Bali is an important factor in improving nurse performance, this is in accordance to

research results (Meyerson, 2012); Pradhan et al., (2014); Mustafa and Bon (2012); Al-Ababneh
et al. (2017); Hanaysha (2016); Liao (2016); (Fernandez, 2013) who found empowerment had a

positive effect on performance.

H2: The Influence of Nurse Empowerment on Work Attitudes

Based on the results of the analysis, the coefficient of nurse empowerment on work attitudes was

0.472 with a t-statistics value of 4.459 (t-statistics> 1.96) and a p-value of 0.000 (p-value <0.05).

This shows that the second hypothesis is accepted, this means that nurse empowerment has a

positive and significant effect on nurses' work attitudes. The results of these findings indicate that

the empowerment of emergency room nurses in hospitals in Bali is an important factor in

improving work attitudes, this is in accordance to the results of research Shahab's (2014); Wang

(2012); Sherafati & Mohammadi (2014); Gazzoli (2012); (Fernandez, 2013); Hanaysha (2016)

who found empowerment had a positive effect on work attitudes.

H3: Effect of Work Environment on Nurse Performance

Based on the analysis, the coefficient of work environment on nurse performance was 0.037 with

t-statistics value of 0.453 (t<1.96) and p-value of 0.651 (p-value>0.05). This shows that the third

hypothesis is rejected, this means that the work environment has no significant effect on the

performance of the emergency room nurse. These findings indicate that the work environment is

not able to provide support for the improvement of services provided by emergency room nurses.

A good working environment in the emergency department of hospitals in Bali has not been able

to provide full support in improving the performance of emergency room nurses. These findings

(Raziq, 2015); (Kataria et al., 2012); Almeida et al. (2019); Asamani et al. (2015); (Hafeez et al.,

2019); (Madu, 2017); (Agbozo et al., 2017) who found that a good work environment will

increase employee satisfaction so that it will provide good performance.

H4: Effect of Work Environment on Work Attitudes

Based on the results of the analysis, the coefficient value of the work environment on attitudes
work of 0.354 with a t-statistics value of 4.175 (t> 1.96) and a p-value of 0.000 (p value 0.05).

This indicates that the fourth hypothesis is accepted. These findings indicate that a good work

environment in The ER of hospitals in Bali is able to improve the work attitude of nurses. The

results of this study support the opinion of Tio (2014); Raziq (2015); Yusuf (2012); Westerman

et al., (2008); Wu et al. (2019) (Yoo, 2017); (Westerman (2017) who found that the work

environment has a positive effect on work attitudes.

H5: The Effect of Work Attitudes on the Performance of Emergency Nurses

Based on the results of the analysis, the coefficient value of work attitudes on the performance of

emergency room nurses is 0, 751 with t-statistics of 10.169 (t-statistics> 1.96) and p-value of

0.000 (p-value <0.05). This shows that the fifth hypothesis is accepted, this means that work

attitudes have a positive and significant influence on the performance of emergency room nurses.

The results of these findings indicate that a good working attitude in the emergency room nurses

of hospitals in Bali is able to support the improvement of the performance of nurses who run the

hospital. The results of the study support the opinion (Shahab, 2014); (Schleicher et al., 2015);

(Hettiararchchi & Jayarathna, 2014); Chin (2012); (Omolayo & Oluwafemi, 2012); (Djibu, 2020);

(Chiang & Hsieh, 2012); Inuwa et al. (2017) who found that work attitude had affect positive on

performance. Based on the results of the path coefficient in Table 4, the results of can be

explained the hypothesis research as follows.

H6: Role of Mediation Work Attitude Variables Empowerment for Nurses on the

Performance of Nurses in the ER Hospital in Bali

Based on the analysis of the test results influence the empowerment of nurses to nurse

performance is known to have a significant positive correlation (t = 1.984, β = 0.156). Also

tested the effect of empowerment of nurses to work attitude mediating variables result is

empowering nurses significant positive effect on work attitude (t = 4.459, β = 0.472).

Assessment of the effect on the performance of nurses working attitude in mind that the work

attitude has a significant positive correlation to the performance of nurses (t = 10.169, β =

0.751). From the steps above, it is known that work attitude has a partial mediating effect in the

relationship between nurse empowerment and nurse performance. This shows that work

attitudes have a partial mediating effect in the relationship between nurse empowerment and

nurse performance. The sixth hypothesis in this study was accepted. Work attitudes in this

study are explained using three dimensions, namely relationships with colleagues, adaptation to

the environment, and Catur Sewaka (Four ways of service in local wisdom). The three

components of work attitude owned by the ER at hospitals in Bali are very good and this

encourages the strategies developed in an effort to improve the performance of ER nurses to

run according to plan. The existence of a sense of togetherness and mutual trust between

employees that lead to mutual cooperation for the progress of the hospital. The values of local

wisdom of Catur Sewaka, namely bhakti (working in freedom), jemet (diligent in work), tresna

(loving the job) and asih (care to the patients) have a positive impact on the performance of

emergency room nurses. The results of this study indicate that the work attitude that is applied

to the ER at hospitals in Bali is able to partially optimize the empowerment of nurses to

improve the performance of ER nurses.

H7: Role of Mediation Work Attitude for Work Environment Variables on the

Performance of Nurses in the ER Hospital in Bali

Based on the analysis of the test results influence the performance of the nurse's work

environment is known to have a relationship that was not significant (t = 0.453 β = 0.037).

Work environment also tested the influence of the mediating variables work attitude is the

result of work environment significant positive effect on work attitude (t = 4.175, β = 0.354).

Assessment of the effect on the performance of nurses working attitude in mind that the work
attitude has a significant positive correlation to the performance of nurses (t = 10.169, β =

0.751). From the steps above, it is known that work attitude has a full mediating effect in the

work environment relationship on nurse performance. This shows that work attitude has a full

mediating effect in the work environment relationship on nurse performance. The seventh

hypothesis in this study was accepted. Work attitude in this study is able to mediate in the

relationship between empowerment and the environment on performance. The existence of a

good attitude based on Sewaka chess (Four ways of devotion in local wisdom) and a sense of

togetherness make the work environment more positive.

Conclusions and Recommendations

Based on the results of the analysis and discussion, it can be concluded that the work attitude

variable plays a full role in mediating the full relationship between the work environment and

nurse performance. A good work environment will be able to improve work attitudes. The

work environment and work attitudes of ER nurses are increasing; there will be an increase in

the performance of ER nurses. Based on the results of the analysis and discussion, it can be

concluded that the work attitude variable plays a part in mediating the relationship between

nurse empowerment and nurse performance. This means that the empowerment of nurses will

be able to improve work attitudes. Empowerment of nurses and work attitudes are increasing,

there will be an increase in the performance of emergency room nurses. A good work attitude

in every nurse will give the spirit to work with others so as to create a sense of comfort, in the

end it will create a work environment that will encourage each nurse to be able to work

optimally in order to produce good performance in serving patients.

The results of the study proved that the emergency department of hospitals in Bali had a high

nurse work attitude, nurse empowerment, and work environment. Based on this, the hospital

management makes a program about empowering nurses that need to be improved, such as the
 abilities and skills of emergency room nurses so that they will convince emergency room

nurses to work optimally, give authority to emergency room staff in making decisions when

serving patients and always provide understanding, socialization, and information to nurses.

Emergency department so that they know the development of science and knowledge in the

field of emergency. In addition, the work attitude of nurses that must be continuously improved

is to always maintain good relations with co-workers, always adapt to the work environment

and apply the attitude of the local Balinese culture of Catur Sewaka: bhakti, jemet, tresna,

asih in providing services.

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