Analysis retention of nursing staff during the covid-19 pandemic at the Dumai City Hospital in 2022

Background: The incidence of nursing staff turnover during the Covid-19 pandemic was the highest among all staff with work agreements at the Dumai City Hospital. With the reduced number of nursing staff, the hospital is at risk of experiencing disruptions in the availability of human resources. Purpose: Exploring information about nursing retention in Dumai city Hospital Method: This research was a phenomenological qualitative research conducted from March to April 2022, with a sample of 13 people. They were recruited using purposive sampling technique, and data were collected through in-depth interviews, observations, FGD and document searches. Data were analyzed using the colaizzi methode which consist of nine stages. Results: It was found that staffing by the head of the room for nursing staff during the afternoon shift and night shift still needs to be improved, the orientation of new nursing staff is experiencing rapid progress with the publication of orientation guidebooks and orientation report cards, preceptorship and mentoring have taken place naturally and needs to be improved by making guidelines and SOP, nurse career paths are still focused on PK 1 nurse assessment, nursing staff rotation is carried out based on urgent needs and conditions. Conclusion: The nursing staff retention program at the Dumai City Hospital, namely staffing, the orientation of nursing staff, preceptorship and mentoring, and career development of nursing staff still needs to be improved and developed from aspects of planning, organizing, implementing, monitoring


INTRODUCTION
The Coronavirus disease 2019 (Covid-19) pandemic has placed a heavy burden on the healthcare system, particularly on nurses who are faced with the greatest challenges regarding the unprecedented outbreak of coronavirus worldwide (1).A shortage of nurses is a global concern with a major impact on healthcare systems around the world (2)(3)(4).The impact of the Covid-19 pandemic on health resources and the management that organizes these resources is related to the urgency of the Covid-19 case incident that hit Indonesia.Based on the report on the analysis of Indonesia's Covid-19 data from the Covid-19 Handling Task Force issued on January 3, 2022, it is known that Indonesia has 2.97% of deaths (22,734 people) which is higher than the world's 2.17%. .The data that attracts attention is that there is a tendency to increase national cases, namely 7.3% compared to data 1 week before the report was published (5) the highest percentage of recovered cases for covid-19.
Riau Province is the province with the highest percentage o recovered cases of covid-19, namely 93.16% with a mortality rate of 4.48%.A total of 51.05% of Covid-19 cases in Riau province came from residents who live in Pekanbaru City with 12,897 cases, followed by Dumai City with 2,136 cases.Meanwhile the highest cumulative of Covid-19 cases is also led by Pekanbaru City, which was 1343.63 cases by 100.000 population.In Riau province, Pekanbaru city is the district city with the highest cumulative incidence rate, followed by Dumai City with 707.12 cases per 100,000 population.Likewise, the highest death rate due to Covid-19 in Riau province is in Pekanbaru City with 31.57cases per 100,000 population.The highest death rate due to Covid-19 in the second rank in Riau province is Dumai City, which is 12.91 cases per 100,000 population.So that Dumai City is the second highest city after Pekanbaru City with the highest number of deaths and the highest cumulative incidence rate in Riau province (5).
Dumai City Hospital is a type B hospital and as a referral hospital for the surrounding area, it is necessary to prepare various resources, especially human resources for health workers.In connection with the readiness of the Dumai City Hospital to provide quality services during the Covid-19 pandemic, Dumai City Hospital.It is known that when the researchers paid attention to the human resource data of the Dumai City Hospital, it was found that during the Covid-19 pandemic the human resources with the highest turnover were from nursing staff with the status of workers with contractual agreements, namely 44.68% in 2020 and 33.33% in 2015.2021 compared to the number of workers with contract agreements at the Dumai City Hospital.Overall, there were 38 people (12, 67%) of nursing staff who turned over during the Covid-19 pandemic base on the Profile of the Dumai City Hospital in 2021.
Hospital management support embodied in nursing staff retention programs can reduce nursing staff turnover.This is in line with previous research which concluded that the nursing staff retention program as an effort from the Head of Nursing needs to be supported by hospital management so that nursing staff retention is carried out.optimal because the two most important dimensions are: significant in the nurse retention program, namely support from hospital management and staffing functions (6).
The high turnover rate of nurses during the COVID-19 pandemic in 2020 is of particular concern to the Dumai City Hospital because it will affect the quality o service to patients.This study aims to analyze the retention of nursing staff during the COVID-19 pandemic.

METODE
This research was qualitative based on interpretive phenomenological approach.The research location at the Dumai City Hospital and was carried out in March and April 2022.The informants in this study were 13 people.With details, the main informants are 6 people, namely nursing staff who turn over during the Covid-19 pandemic.Supporting informants are 6 people consisting of 5 nursing HR (Human Resources) managers and 1 nursing committee chairman and 1 key informant.namely the Head of Nursing.This research was approved by ethics of KEPK Stikes Hang Tuah Pekanbaru with the number : 133/KEPK/STIKes-HTP/III/2022.Before asking participants consent, the researcher first explained the purpose of the study after obtaining written consent.
The data were obtained through indepth interviews, FGD, observation and document tracing methods.
In-depth interviews were carried out with the main informants, namely nursing staff who had turned over, and supporting informants, namely the head of the nursing committee, key informants.The FGD was conducted by the researcher to the supporting informants, namely the nursing manager of the Dumai City Hospital, namely the head of the ethics and quality of nursing section, and the staff.The observation method was carried out by researchers to observe various activities of the nursing staff retention program that took place in the Nursing Sector as well as those carried out in the inpatient room at the Dumai City Hospital.The document search method was carried out by researchers to obtain program documents such as decrees, guidelines, guidelines and SOP related to the nursing staff retention program at the Dumai City Hospital.Data analysis was carried out manually using the colaizzi approach, namely listening to participants verbal descriprion, reading verbatim transcripts, group significant statements into themes, and writing down descriptions and interpretations experienced b participant regarding phenomena.

Staffing
The appointment of nursing staff in the position of head of the room and head of the team is carried out by issuing a decree by the leadership once a year.Discussions about who will serve in the position of room head and team leader are discussed internally in the Nursing Division except this year, which is 2022, the discussion is held in an open meeting at the Hospital management meeting."…the decree is once a year.So if in general it is discussed in the 10th or 11th month… But yesterday it was discussed at the management level and an open meeting was held…" (Results FGD informan 7,8,9,10,and 11).
For staffing at the team leader level in the nursing room, the proposed name of the candidate is obtained from the head of the room."…we got suggestions from the head of the room and the head of the installation who the name would be proposed to be the head of the team because it was the head of the room and the head of the team who knew who was actively engaged, who could nurture his friends" (Informant 13) The researcher found that staffing at the head of the room, namely in the nursing room with a high Bed Occupation Rate (BOR), namely IRNA A Women (95.36%) and IRNA A Men (BOR 121.49% to regulate the number of nursing staff on duty still need to pay attention to the distribution of the number of nursing staff on shifts).afternoon and night shifts.
This is because there are more workers on duty in the morning service than those who work on the afternoon shift and night shift.So it is felt by implementing nurses / associates (PA) who work in the afternoon and evening shifts that they are overwhelmed to provide services if the number of patients is full.As a result they feel that they are understaffed."…lack of manpower" (Informant 3).
Then the researchers paid attention to the results of the document search, namely the official schedule in the two rooms, namely IRNA A Women and IRNA A Men.It is known from the two service schedules that in IRNA A Women's Room and in IRNA A Men's there are 5 workers who continuously work on the morning shift because of their position which causes them to be on the morning shift every day.The five personnel are the head of the nursing installation, 1 person, the head of the room 1 person and the team leader as many as 3 people.So that every day besides the 5 people there are nursing staff in the morningafternoon -night shift work pattern who get the morning shift on that day.This causes a buildup of nursing staff on the morning shift, while the number of staff working in the afternoon and evening tends to be less.

New nursing staff orientation
It is known from nursing staff informants who have stopped working that the orientation of nursing staff is an activity that is useful for adapting and as an opportunity to know more about the Dumai City Hospital environment.Things learned during orientation include hospital plans, nursing processes, documentation of nursing care, hours of work and hospital accreditation.

"About…the floor plan, the location at the Dumai City Hospital…they were given a common perception with the management about the nursing process, regarding documentation, then…the admission hours such as how many shifts then related to the Dumai City Hospital, the accreditation, what rooms are there" (Informant 4)
Orientation of nursing staff is a program that is still under development in the Nursing Quality Ethics Section in the Nursing Sector.At the beginning of 2022, the nursing staff orientation program made significant progress with the issuance of the Orientation Book and Orientation Report Book for new nursing staff at the Dumai City Hospital.The orientation book is given with the intention that the book functions as a pocket book.In addition to the orientation book, new nursing staff will be given an orientation report card.After 1 year of nursing staff on duty at the Dumai City Hospital, the orientation report card was replaced with a nursing report card book."Nursing is compiling an Orientation Book… the output of the Nursing Sector this year… Brothers and sisters are provided with one.In addition to being provided with an orientation book, he was also provided with an orientation report card...In this hospital there are 2 report cards.Reports for nursing staff and report cards for orientation.As soon as he entered he was provided with an orientation report card.So the nursing staff was given an orientation book so that they could have one perception and let it become their pocket book.Then he was given another orientation report card after a year was replaced with a report card for nursing staff" ((Results FGD informan 7,8,9,10,and 11)) "…the Nursing Sector program, report cards for nursing staff" (Informant 13).
The researcher found that the orientation of nursing staff was still a retention program that experienced rapid progress in early 2022 with the creation of an orientation book and a new nursing orientation report card.However, even so, this orientation program does not yet have an activity guideline and does not yet have an SOP so that it becomes the next agenda according to the findings of the researchers during the observation of the internal Sector meeting.

Preceptorship and Mentoring
All informants from nursing staff who had stopped stated that preceptorship and mentoring activities were activities that helped to adapt to new tasks as nursing staff and these activities were felt to be enjoyable because they were well received."You could say observing first.Follow the preceptor brother first.At that time, I joined the team leader, well accompanied by the chairman first to take action" (Informant 4) "I used to be warmly welcomed there…" (Informant 5) Preceptorship and mentoring are activities that are not yet in the form of a program in a structured form.Do not have SK or guidelines.Preceptorship and mentoring activities in the Nursing Room take place informally and naturally."…the preceptorship and mentorship program was for the orientation staff… We haven't done it in outline with the decree, right.But the process is already running in the room… her new orientation sister will stick to PJ in the room.Controlled with the book earlier, the orientation report card… There is a preceptorship process there" ((Results FGD informan 7,8,9,10,and 11)) The role as a precept and mentor in the nursing room is carried out by the team leader and by the shift person in charge.However, there are times when a Head of Room can act as a mentor and precept for new nursing staff."We hope that in the future whoever is appointed to be the Head of the Room and Head of the Team that we have, it is obligatory to be a precept for new siblings.At least the team leader becomes a preceptor"(Informant 13).

Nursing career path
The researchers found that most of the nursing staff informants had participated in an assessment for Clinical Nurse 1 (CN1) nursing staff except for 1 informant, namely informant 4 from IRNA A Male who entered in October 2019 who stopped working in September 2020.He had never been assessed because in At that time the assessment activity was postponed due to the Covid-19 pandemic."... have you ever had the assessment, bro, did you have that assessment once" (Informant 3) "CN is still CN 1 for all of us" Informant 5 " "Well, it's not time yet, sis.Because right after entering, the assessment was postponed due to the pandemic" (Informant 4) The nursing staff credentialing activity, namely assessment, is an element that is assessed in hospital accreditation so that its implementation has been started since 2015 at the Dumai City Hospital.This activity is a collaboration between the Nursing Committee and the Nursing Sector."From 2015 along with the hospital accreditation process, it has been running.…that's just for the implementation of the credential at the beginning… One time…With the Nursing Committee…sit together to set regulations and SOPs and flow…that is the process of credentialing nursing staff.There's already a fee.Every year it has been proposed by the Nursing Sector" ((Results FGD informan 7,8,9,10,and 11)) "We are still working on the CN 1 location.The real reason is…the instrument set for assessing those who want to go to CN 2… the equipment is not ready.Then we bring in speakers from outside for career paths...we have another meeting with the Division…we decided to follow the directions…so we use the bestari partner system and we will arrange later how the guidelines or guidelines for Clinical Nurse 2 (CN2) will be…we just have to wait for the mapping…from the Nursing Sector"(Informant 12) "From the Nursing Committee … have attended training on this credential and have received a bright spot for the implementation of the CN 2 credential… this year we are trying to get the CN 1 and 2 credentials around June July, hopefully it will be completed.It is hoped that CN 2 will have the instrument completed before implementation so that there will be an increase in CN -CN…" (Informant 13).
The results of the study show that the career path of nursing staff as a virginity retention program is undergoing development in 2022 with the efforts of the Nursing Committee together with the Nursing Sector to find solutions to problems with the CN 2 instrument which has long been a hindrance to CN 2 assessment activities.It can also be seen from the planning and preparation of assessment activities by the Committee for Nursing and Nursing for nursing staff who will advance to CN 2 in June or July.

Nursing staff rotation
The researcher found that some of the nursing staff who had turn over had positive experiences with the rotation of nursing staff while others responded negatively to these activities by quitting their jobs from the Dumai City Hospital."It is also a challenge because we have a lot of knowledge there.Gaining new knowledge" (Informant 1) Some of the nursing staff informants who had turn over said that they felt dissatisfied with the nursing staff rotation program they experienced so that it became one of the causes that gave rise to the desire to seek opportunities to work at private hospitals in Dumai City apart from the perceived unsatisfactory salary and compensation.At the time this research was conducted, namely data collection through interviews, the two informants had worked in 2 different private hospitals "…there have been people in the room who haven't moved for a long time…a lot of people in that room are old…" (Informant 5) "This seems like why I keep going, huh." (Informants 6) "The rotation is not done regularly at this hospital.The was carried out based on the provisions and needs….Some of the rotations stopped immediately…Because according to him it was not a refresher but a burden" ((Results FGD informan 7,8,9,10,and

11)) "We really don't have this… we don't have a special program on how to rotate…" (Informant 13)
It was found that the rotation of nursing staff was carried out according to the needs at the time so that some of the rotated nursing staff felt that they were being rotated continuously but those who had been rotated for longer were not rotated to another room.They feel they are not treated the same as other nursing staff.

Staffing
Staffing is interpreted as an organizational effort to make appointments regarding certain tasks carried out by certain people so that work can be carried out properly.In this context, efforts have been made at the Dumai City Hospital regarding the appointment of the head of the room and team leader in the nursing room so that they can carry out their duties as leaders according to their main duties and functions in each nursing room.The expectation from the appointment of the head of the room and the head of the team in the nursing room is that the head of the room and the team leader can organize existing resources in the form of nursing staff in the form of implementing nurses/associate nurses (PA) so that nursing services can be carried out as much as possible.
However, it turns out that in several nursing rooms that have high Bed Occupation Rate (BOR), namely IRNA A Women and IRNA A, they are overwhelmed to provide services on the afternoon shift and morning shift due to a buildup of nursing staff due to the presence of 5 people who work continuously in the morning apart from those who have their shifts.morning shift pattern in the morningafternoonevening while the number of nursing staff in the afternoon and evening shifts tends to be less.
This gives rise to the perception that their workload is high due to the hassle of serving patients from the point of view of the implementing nurse/associate (PA) even though the source of the problem is the staffing of the head of the room which must be further increased when the patient is full.So that there is an even distribution of nursing staff to prevent implementing nurses/associates (PA) from feeling overwhelmed and feeling the workload becomes heavy when in fact the workload is sufficient.This is in line with research conducted by Sultana in 2012 that proper staffing does have a positive effect on the realization of organizational goals (7).
The researcher recommends this strategy based on a research journal written by Iveta Ozolina (2014) which studied recommendations that could be implemented by the HR Department of a company.According to this research journal, one of the employee retention efforts of a company can be carried out by providing equal opportunities) for all its employees (8).In addition, this program is an embodiment of efforts to create fair competition so that it is useful as an employee retention program (9).
The criteria that can be taken into consideration in the selection program can involve various competencies for a leader in the nursing room based on the Nursing Management book 4th Edition written by Nursalam (2014) namely that a nursing leader should have the ability in terms of leadership which involves, among others, staffing and mentoring (10).Staffing of nursing staff in the room he leads includes staff arrangements to deal with the workload in the nursing room.Meanwhile, effective mentoring along with staffing abilities is the ability of the many abilities of a nursing leader that are in line with activities that are already running at the Dumai City Hospital but have not functioned as a good retention program.By getting bright seeds from a candidate for the head of the room and a candidate for the team leader, especially from the 2 dimensions of leadership, it is hoped that it can be a retention program to reduce the incidence of nursing staff turnover, especially from the Implementing Nurse / Associate (PA).

New nursing staff orientation
The Nursing Sector has made efforts to increase the orientation of nursing personnel as a nursing staff retention program with a coordination plan between the Nursing Division and the Personnel Sub-Section in the agenda for making guidelines and SOPs for the orientation of new nursing personnel at the Dumai City Hospital.It is hoped that this document will improve the planning function of nursing staff orientation activities as a program that can reduce the desire for turnover of new nursing staff.This is in line with the results of research by Choon Hee and friends in Malaysia in 2014 that the orientation of new nursing personnel carried out with a specific purpose has an impact on increasing the commitment of nursing staff to the organization (11).
So that the orientation of the new nursing staff can be improved, the researchers note that it is better to be in line with the orientation of the nursing staff there is a performance appraisal program for new nursing staff after the orientation period is complete.The performance appraisal program for new nursing staff after the orientation period is carried out with the aim of knowing the results of the evaluation of the abilities of nursing staff so as to facilitate HR management to direct them to their careers in the future.For example, the results of performance evaluations can be used as a basis for placing nursing staff, for example whether they are suitable to be placed in the medical-surgical nursing room or in the critical nursing room.
In addition, performance appraisal can also motivate nursing staff to keep trying to work with optimal work performance.This is in line with research conducted by Iqbal and friends in 2013 in Pakistan (12)

Preceptorship and mentoring
Opportunities for prestorship and mentoring activities as an effort made by Nursing HR management to increase nursing staff retention are actually very strategic because these activities already exist and are already running in the field.It just needs to get more attention and become an official program by the Nursing Sector in order to increase the commitment of nursing staff to Dumai City Hospital.
This expectation is in line with the results of research conducted by Szamalsagi in 2018 which stated that the mentoring program was effective for the adaptation process of new nurses in their activities in the world of work (13).In addition, it is also in accordance with the results of research conducted by Rodessa and friends in 2020 that the presence of preceptorship to new nursing staff helps them to adjust and can discourage their intention to stop working as nurses (14).
Recommendations for the Dumai City Hospital related to preceptorship and mentoring are that the Dumai City Hospital can integrate preceptorship that already exists naturally in the nursing room as a retention effort by standardizing it into programs in the Nursing Sector by establishing guidelines, guidelines, technical guidelines and SOPs for preceptorship.and mentoring.It is hoped that in this way preceptorship and mentoring activities can be planned, monitored and evaluated in a more organized manner so as to facilitate the transition of new nursing personnel to the world of work, namely minimizing the gap between the world of education and the world of work (15,16).So in general, effective preceptorship and mentoring can create a conducive work environment (17).

Nursing career path
The career path of nursing staff to become a nursing staff retention program needs to be improved so that it is more well organized because previously the Dumai City Hospital still focused on CN 1 nurse assessments and for several years still struggled with designing instruments for CN 2 assessments.even faster so that the career path of nursing staff can be used as a program that has an effect on the retention of nursing staff at the Dumai City Hospital.This is in line with research conducted by Pertiwi and RR Tutik in 2019 which examined the effect of nurse career paths on job satisfaction.The results of the study show that the nurse career path program can increase the job satisfaction of nursing staff which in turn can reduce their desire to stop working (6)

Rotation
Dhanraj and Parumasur (2014) conducted a study of employees regarding the effects of job rotation on employee productivity.The results show that job rotation has a positive impact on employee productivity in an organization (18).
However, what was found in this study was that there were nursing staff who actually wanted to stop working after being rotated for reasons of dissatisfaction with the rotation decision imposed on them because of the assumption that the rotation of nursing staff assigned to them was too frequent and unfair.In line with this, Khan et al.'s research concluded that rotation has an impact in the form of fatigue on employees which in turn has the effect of decreasing their commitment to organization (9).Therefore, to rotate employees, hospitals should have careful preparation and planning so that the rotation of nursing staff program has positive impact on the organization.

CONCLUSION
The nursing staff retention program at the Dumai City Hospital, namely the staffing section, orientation of nursing staff, training and mentoring of preceptorship, career development of nursing staff and rotation of nursing staff still needs to be improved and developed from aspects of planning, organizing, implementing, monitoring and evaluating which aims to increase knowledge or understanding of nursing staff and discipline them and increase morale and motivation.So that the activities that have taken place can be even more useful in an effort to prevent or reduce the turnover of nursing staff at the Dumai City Hospital.
It is recommended for hospitals to carry out the following programs to increase the retention of nursing staff, namely the performance appraisal program for nursing staff who have completed the orientation period as consideration for determining their placement and planning their future careers, preseptoship programs and adequate mentoring.So that with the preceptorship and mentoring program so that they are competent and do not refuse if they have to be rotated to another nursing room, the Fit and Proper Test program for prospective holders of room heads and team leaders in the Nursing Room, especially on staffing and mentoring abilities whose participants are open to civil servants