The Relationship Between Workload with Work Stress on Nurses in Intensive Installation of Bangil General Hospital Pasuruan District

Work stress due to excessive demands on the workplace is a problem of human resource management in the hospital. The high workload is one of the factors that cause work stress for nurses. The purpose of this study was to determine the relationship between workload and work stress on nurses in the Intensive Care Unit at Bangil Hospital. The design of this study was an analytic survey using cross-sectional study. The population of all nurses working in the Intensive Care Installation with a sample of 40 respondents and using purposive sampling technique. Workload instruments use work sampling observation sheets, while work stress instruments use questionnaires based on Sulsky and Smith's theory of Jusnimar, (2012) modified. The results of the study using Spearman rho showed a relationship between workload and work stress on nurses with p-value = 0.000 (<0.05) and an r-value of 0.551. The level of dependency of the client and the amount of labor that is not appropriate is a factor of high workload so that nurses experience work stress. There needs to be an evaluation of the number of nurse needs or the provision of rewards and stress management training for nurses to adapt and control work stress.


INTRODUCTION
Work stress is a problem that we often hear and is a complaint from some people in the last period; almost all professions have different sources of stressor depending on the type of work and personal of each person. The nurse profession is also a source of its stressors. Nurses working in critical care areas have a higher level of stressors because the clients in the area are very complex, nurses must be skilled, and they are also required for continuous observation (Hussein, Aniza, & Ahmad Taufik, 2012). The use of sophisticated and ethical technology in managing client problems also contributes to sources of stress (Manisha & Pawar, 2014).
Many factors influence the complexity of clients in critical care areas, including clients being treated by more than one doctor, multiple diagnoses, almost all treatments are total care, not directly attended by families and critical conditions of clients who can die at any time which can be stressors for nurses. Mealer, Shelton, Berg, Rothbaum, & Moss, (2007), ICU nurses are susceptible to experiencing Post Traumatic Stress Disorder (PTSD) compared to nurses in other units. Based on the research, it was found that out of 230 ICU nurses there were 54 respondents who experienced PTSD (24%), while of 121 respondents from general nurses there were 17 respondents who experienced PTSD (14%). Whereas in Thailand there are around 4.4% of nurses who want to leave the nursing profession and are expected to increase to more than 15% by 2020. Even in previous studies found around 30% of hospital nurses in Thailand intend to leave the profession because of work stress caused by nonconducive work conditions such as a heavy workload and low social support in the workplace (Kaewboonchoo, Yingyuad, Rawiworrakul, & Jinayon, 2014). The results of the study describe the work stress of nurses from (Kurniasih, 2014) in the ICU room of Dr. Sardjito Yogyakarta found that 83% experienced moderate work stress, as many as 12.3% experienced high work stress and as much as 4.2% experienced low job stress.
The results of the preliminary study found that there were two nurses of the HCU Teratai on February 10, 2018, saying that they often felt shortness of breath and the throat felt dry during work. Other information obtained from the head of the nursing section in Bangil Hospital, there were four nurses from the HCU Teratai room who wanted to move to another treatment room in the hospital because they felt the workload was different from the previous room. This means that there are 44.4% of HCU Teratai nurses who want to move because the total number of HCU Teratai nurses is nine people.
Whereas in the HCU Melati room data obtained in 2017 there were 1023 clients with an average BOR of 68.1%. Based on the calculation of power according to the Ministry of Health 2005, the number of workers needed is 19 people. Currently, there are 15 nurses in HCU Melati room including 15 heads of rooms. The difference in demand for energy causes the workload of HCU Melati nurses to be higher, and that can lead to work stress. Also, there are also other complaints felt by nurses in the HCU Melati room, which is irritability, often misunderstanding at work, often experiencing indigestion (diarrhea) and feeling tired and difficult to take a holiday when they are sick, especially during the afternoon and night.
The workload is defined as the amount of work a person must complete in the period that has been given, and excessive workload or overload is a source of stressors (Radzali, Ahmad, & Omar, 2013). The number of energy needs that are less can cause workload to increase. Increased workload can cause work stress which is characterized by rapid breathing, digestive tract disorders, unmotivated, often misunderstood and low work performance (Wahyudi, 2017).
If the work stress on the nurse is not managed, then it will ultimately affect the care of the client, employee welfare and organizational performance. This is very important especially for new nurses who are just entering the profession in the healthcare industry. Managing this stressor can avoid high rates of nurse turnover at work (Sang Long, Owee Kowang, Ai Ping, & Muthuveloo, 2014). Another impact of work stress that is not overcome in individuals is the caring behavior of nurses to clients is not good (Desima, 2013), decrease in nurse commitment and performance (Ekienabor, 2016)and also have an impact on work performance (Wahyudi, 2017). Whereas according to (Eggert, 2000) work stress on nurses can affect the quality of service to clients and ultimately nurse goal satisfaction is also not achieved.
There are two comprehensive approaches that can be done to overcome work stress, namely stress management training (which focuses on increasing one's ability to handle stress) and the intervention of workplace organizations (Chandola, 2010). The form of response from the workplace organization that can be done is the addition of some nurses by the needs and giving rewards to the best nurses every month. A comprehensive approach that includes stress management training and organizational intervention tends to produce positive results for individuals and organizations. The purpose of this study was to determine the relationship between workload and work stress on nurses at the Intensive Nursing Installation in Bangil Hospital, Pasuruan Regency.

METHOD
The research method used in this research is analytic survey research using a cross-sectional design. The population of this study was nurses who worked in the Intensive Nursing Installation totaling 40 nurses. Workload measurement utilizing the work sampling observation sheet instrument. Work sampling on nurses who are observations is activities or nursing care activities carried out by nurses in carrying out their daily tasks in the room. This work sampling method can observe things specific to work such as a) what activities are being carried out personally during working hours; b) whether the personal activities are related to their functions and duties during working hours; c) proportion of work time used for productive or unproductive activities; d) personnel workload patterns are associated with the time and schedule of work hours (Ilyas, 2004in Juliani, 2009). The work sampling method will get the right information from some personnel examined about the activity and the number of observations of activities from starting to come home.
Bivariate analysis to determine the relationship between the characteristics of respondents with work stress using the Chi-Square test and Spearman Rho. While to find out the relationship between workload and work stress nurses use the Spearman Rho test. To find out the relationship between the two variables whether or not significance with the significance of 0.05 where if p <0.05 then H1 is accepted which means that there is a relationship between the workload of the nurse and the work stress of the nurse, while p> 0.05 then H1 is rejected which means that there is no the relationship between nurses' workload and the work stress of nurses. While the value of r is the correlation coefficient. The value of r ranges from -1.0 to +1.0. If the value of r = 0 means there is no correlation between the independent and dependent variables. The amount of r = -1 illustrates that there is a negative relationship between the independent and dependent variables. In other words, the "+" and "-" signs indicate the direction of the relationship between the variables being operationalized.

RESULT
The results of research carried out in June-July 2018 obtained general data including gender, age, education, work experience, and intensive care training.  Table 2 shows that the majority of nurse respondents who were respondents in this study were female, as many as 28 people (70%). Viewed from the age of the implementing nurse, most of them were 21-30 years old, namely 23 people (57.5%). Most of the nurses who work in the Intensive Nursing Installation at Bangil Hospital are D3 of nursing education, namely 33 people (82.5%). Whereas based on the background of working experience in intensive areas, the majority of them have worked for 1-3 years as many as 20 people (50%) and most of them have never attended intensive care training as many as 29 people (72.5%). Based on table 3 shows that the activities carried out by the implementing nurses in the Intensive Care Installation at Bangil Hospital were mostly doing direct care as many as 23,585 minutes (393.1 hours). Whereas the average time needed to take care treatments is 589.6 minutes (9.8 hours).  Table 4 shows that the most productive activities occurred in the morning shift as much as 351.5 minutes (83.7%). While the most non-productive activities occur in the night shift, which is 156.6 minutes (23.7%). Based on Table 4 shows that the majority of nurses in Intensive Care Hospital Bangil have high workloads, namely 24 people (60%) and most of them also experience moderate work stress as many as 29 people (72.5%). * refers to p <0,05 Table 5 shows that there is no significant relationship between gender and work stress of nurses because of the value of p = 0.704 (p> 0.05). Respondents of female sex experienced more moderate stress, namely 52.5% (21 nurses). While from the age factor of respondents with work stress there is a significant relationship with p = 0.011 (p <0.05). Nurses with ages between 21-30 years are more often experiencing moderate stress, namely 20 nurses (50%). The level of education of respondents with work stress did not have a significant relationship p = 0.55 (p> 0.05). Nurses with a D3 education level of nursing often experience work stress that is 65% (26 nurses).
Work experience in intensive space with the occurrence of work stress turns out to have a significant relationship; it can be seen with a value of p = 0.022 (p <0.05). Nurses with 1-3 years of work experience have the highest frequency of experiencing stress as many as 37.5% (15 nurses).
Intensive care training has a significant role in determining the level of stress experienced by nurses; it can be seen from the value of p = 0.004 (p <0.05) which means there is a significant relationship between intensive care training with moderate stress on nurses. Nurses who experienced the most moderate stress were 62.5% (25 nurses) who had never attended intensive care training. Table 6 Analysis of the relationship between workload and the work stress of nurses at the Intensive Nursing Installation at Bangil Hospital in July 2018 (n = 40) Table 6 shows the results of the bivariate correlation statistical test using the Spearman correlation test showing that the p-value is 0,000 (p <0.05), indicating that there is a correlation between workload and the work stress of nurses at the Intensive Nursing Installation in Bangil Hospital Pasuruan Regency with r-value of 0.551 meaning that it has a moderate level of correlation.

DISCUSSION Workload
The results showed that of the three types of actions observed; it was evident that the direct kind of care was the most performed action by nurses in the Intensive Care Installation at Bangil Hospital compared to indirect and non-nursing / nonproductive treatments. Most of the respondents also have a high workload. Nurse workload is influenced by several factors including, the number of clients who are treated conditions or the level of dependence of clients, the average day of care of each client, direct and indirect nursing actions and the frequency of nursing actions (Kurniadi, 2013). The standard workload according to Gilies (1994) in Juliani (2009) is 420 minutes (7 hours) for the morning shift, 660 minutes for the afternoon shift and the night shift is 660 minutes (10 hours). The optimum productive time for nurse work is 80%. Therefore, Juliani (2009) concluded that the nurse's productive time is called a workload. In the morning shift the fertile time is 336 minutes (5.6 hours), while for the afternoon shift is 288 minutes (4.8 hours) and for the night shift is 528 minutes (8.8 hours). If the nurse has worked above 80% of her productive time (excellent productive standard), then it can be said that the nurse's workload is inappropriate or high and if the nurse works below 80% productive time, then it is said the nurse's workload is mild.
The high nurse workload at the Intensive Care Installation at Bangil Hospital is because almost all of the clients who are treated require semi-total care up to total care so that the time needed for direct care activities is more than secondary care. The observation results of the overall work sampling of the three shifts of nursing staff at the Intensive Nursing Installation in Bangil Hospital, on average, the implementing nurses had a high workload. The highest workload is located in the morning shift and afternoon shift, decreasing in the night shift. The workload of each change shows differences.
The frequency of nursing productive activities in the morning shift is more than the afternoon and evening shifts. While the highest non-productive activities are on the night shift, and directly decrease in the afternoon and morning shifts. It happens because the activities in the morning are quite a lot. Routine activities carried out to begin to meet the client's basic needs, provide therapy, documentation, to support examinations where the nurse must deliver and pick up the client, accompany the visite doctor and others.

Work stress
Nurses who work at the Intensive Nursing Installation at Bangil Hospital mostly experience moderate stress levels with dominant behaviors perceived based on questionnaires, they try to provide services to clients kindly, even though they feel tired at that time.
Job stress is defined as an adaptive response (adjustment response) mediated by individual differences and psychological processes, as a result of environmental actions, situations or events that cause excessive physical and mental demands on someone (Ivancevich and Matteson inLuthans, 2012). Whereas Beehr and Newman are inside Luthans (2012) interpret job stress as a condition that occurs as a result of interaction between employees and their work and characterized or characterized by human changes that force them to deviate from their normal functions.
One of the causes of work stress experienced by nurses in the Intensive Care Unit at Bangil Hospital is a high workload. By research from Aini & Purwaningsih, (2013) in the Semarang Hospital emergency room which provided data that out of 29 respondents, it turned out that there were 27 respondents (93.1%) who had a high workload. Of the 27 respondents who experienced moderate stress as much as 82.8%.
Critical and unstable client conditions can also be a stressor factor for respondents. The ability and knowledge of respondents in caring for vital and unstable clients can determine the level of stress experienced by respondents. The age of young nurses can describe a small work experience. A little work experience indicates that the nurse is not yet faced with difficult conditions that are required to make a decision immediately. So that if there is a difficult problem, nurses tend to panic, causing work stress. Therefore the results of the analysis indicate a relationship between age and the incidence of work stress.

The relationship between the characteristics of respondents with work stress of nurses in the Intensive Care Installation at Bangil Hospital, Pasuruan Regency
This study shows that the characteristics of age, work experience and having attended intensive care training have a relationship with the occurrence of work stress on nurses. While the gender characteristics and education level of respondents have no contact with the presence of work stress on nurses. Research conducted by Jusnimar, (2012) in the ICU room the Dharmais Cancer Hospital showed that more young nurses experienced work stress than older nurses. It is due to the more former age group being able to carry out tasks and adapt to the environment more easily.
Research conducted by Martina, (2012) in the inpatient room of the Lung Hospital Dr. Moehammad Goenawan Partowidigdo Cisarua Bogor shows that nurses who experience the most work stress are nurses with a work period of 6 months to 3 years. This is because a longer work experience will improve one's skills at work, the easier it is to adjust the work so that it can face pressure at work.
This study shows that nurses who have never attended intensive care training are more at risk of experiencing work stress than nurses who have attended training. The