A Nurse’s Performance, Personality, and Situation Awareness in Fall Risk Prevention

One indicator of a nurse’s performance evaluation regarding implementing patient safety programs in hospitals is the risk of a patient falling. An audit of fall risk prevention at Siloam Hospitals in Surabaya was used to evaluate nurses’ performance in preventing patient falls. The impact of personality and situation awareness characteristics on the nurse’s output performance in preventing fall risk was examined. A cross-sectional research design was used in the observational analytic research method. Forty-five nurses made up the total sample. The EPPS and SEAFAP questionnaire were the instruments used in the data analysis, which applied the linear regression test. The following personal characteristics have a p-value of 0.05 or less: Order (p-value 0.016), Autonomy (p-value 0.019), Affiliate (p-value 0.012), Succorance (p-value 0.012), and Nurturance (p-value 0.009). With a p-value of 0.040, situation awareness impacts output performance. Both overall personality and situation awareness have a p-value of 0.006 and influence output performance, respectively. Situation awareness and personality-based needs have an impact on output performance. To provide specific solutions to improve the probability of patients falling, the recommendations for enhancing the fall risk prevention programs can be carried out through discussion and interviews.


Introduction
Patient safety is the guiding principle of medical services worldwide.Developing nations like Indonesia also implement it to ensure high service standards (Sukesih & Faridah, 2020).Efforts to prevent the risk of falling are part of patient safety goals that must be implemented in hospitals.Healthcare facilities must establish a strategy to lower the risk of patients being injured as a result of falls following Regulation Number 11 of 2017 concerning Patient Safety issued by the Minister of Health of the Republic of Indonesia.The hospital establishes a program to reduce fall risk based on appropriate policies and procedures.Implementing fall risk prevention in hospitals is based on extrinsic factors, namely by fulfilling safe facilities and infrastructure for patients, fall risk prevention systems, and professionals who provide care to patients (Chu, 2017).One of the extrinsic factors for falls is the hospital setting impairment, psychological trauma, loss of independence, and even death.This results from intricate interactions between internal and external elements rather than just one factor (Kim et al., 2015).Healthcare workers are the most significant number of human resources that make prolonged and intensive contact with patients, and this task can pose a risk that threatens work safety (Nurmalia et al., 2022).The nurse must evaluate the risk factors and implement preventive measures based on the circumstances of the patient's fall caused by various reasons.Nurses who care for patients also manage patient safety in hospitals; as a result, nurses are in a prime position to use active preventative strategies to reduce the risk of patient falls.Nurses must evaluate each patient's unique needs and fall risk before developing a plan of care to reduce the patient's risk of falling while in the hospital.This will help prevent patients from falling in the hospital (Kim et al., 2015).
Professional nurses have a fall risk assessment to complete, plan and carry out preventive measures, and evaluate the process (Luzia et al., 2018).According to M. Kinoshita (2019), the lack of explanation to patients and failure in teamwork as well as the lack of discipline of nurses to fill out a fall risk assessment on the grounds of busy work caused the incidence of patients falling (Kinoshita et al., 2019).Awareness is knowing what one feels inside and using it to guide decisionmaking, having realistic benchmarks of one's abilities, and having strong self-confidence.Emotional intelligence includes self-awareness, a useful talent in all facets of personal, social, and professional life (Mansouri & Tajrobehkar, 2015).As a result, those with high emotional intelligence can better manage their emotions by keeping a positive outlook, leading to higher work performance (Krishnan et al., 2018).People with high levels of self-awareness can accurately measure their moods and feelings and understand how those feelings affect others.They are also receptive to criticism from others on continually improving themselves and can make the right choices under pressure and in the face of uncertainty (Okpara & Edwin, 2015).Nurses have roles and responsibilities for patients, families, and companions to be involved in fall risk prevention activities, from implementing fall risk identification to intervention (Luzia et al., 2018).
The roles and responsibilities of nurses in implementing patient fall risk prevention are not all fulfilled because each nurse has different abilities and behaviors to carry out responsibilities in carrying out patient fall risk prevention.Distinctive traits in behavior refer to Personality, a characteristic of a person that can be identified according to his pattern, behavior, cognition, and emotion.Individual Personality has an important role in performance.Personality also determines an individual's motivation and attitude toward work and how the individual wants to develop in his career (Ahanchian et al., 2015).Each nurse has 15 needs; the difference is the degree of each need and the constellation of each of these needs.One of the personality developments proposed by Allen L. Edward states that Achievement, Order, Affiliation, Deferences, Exhibition, Autonomy, Succorance, Intraception, Dominance, Abasement, Nurturance, Change, Endurance, Heterosexuality, and Aggressive influence Personality.Psychological factors in the Personality of nurses greatly affect their performance of nurses (Shafii et al., 2018).Similar to individual characteristics, knowledge, and nursing performance are significantly correlated.This study examined the relationship between Personality and nurses' capability to prevent patient falls in the inpatient wards of Siloam Hospitals Surabaya, and the relationship between situation awareness and nurses' ability to prevent patient falls.

Method
This study used descriptive analytics with a cross-sectional approach from January to June 2020.This study's population was nurses who received general orientation and training in preventing patient fall risk at inpatient Siloam Hospitals Surabaya, East Java, Indonesia.The inclusion criteria were active nurses at inpatient wards, internal medicine, surgery, ICU, and pediatric wards, as they have the highest incidence of falls.The sample was determined using stratified random sampling, and 45 nurses were chosen.Independent variables were Personality and situational awareness.
The instrument for personality measurement was an EPPS (Edward Personal Preference Schedule) psychological test questionnaire consisting of 15 parameters and considering the opinions by choosing very high, high, low, or very low for each Personality.SEAFAP (Self-Evaluation of Awareness for Falling Accident Prevention) questionnaire was used to measure situation awareness by considering opinions that are not very well understood, not understood, understood, and very well understood.The dependent variable was output performance measured using medical records in terms of completeness and accuracy of nurse documentation for the patient's fall risk prevention.
The data collection used was a questionnaire tested for validity and reliability.A descriptive analysis was conducted to describe the results of the research variables, namely the respondent's characteristics, Personality, and situational awareness.Analysis of the influence of independent and dependent variables using linear regression statistical tests.This research has been approved by the Ethical Committee of Nursing Faculty Universitas Airlangga concerning the protection of Human Rights and welfare in health research Number 22034-KEPK.

Result and Discussion
The characteristic of respondents in this study is shown in Table 1, with most of the respondents being female (97.8%), between 25 -50 years old (75.5%), and having >4 years length of working (53.3%).The distribution of work units was 29 in inpatient wards (64.4%), 9 in ICU (20.0%), and 7 in pediatric (15.6%).Based on Table 1, Personality based on order, autonomy, affiliation, succorance, and Nurturance impact nurses' output performance with p-value <0.05, respectively, 0.016, 0.019, 0.012, 0.012, and 0.009.A multicollinearity test was done to obtain the relationship between Personality as the independent variable and Output Performance as the dependent variable, and the following results were significant with p-value= 0.037.Source: Primary Data Personality is an individual characteristic based on the needs of Achievement, Order, Autonomy, Change, Endurance, Deference, Affiliation, Intraception, Succorance, Dominance, Abasement, Nurturance, Heterosexuality, Exhibition, and Aggression.This test is categorized into an inventory test which contains 225 pairs of statements where each individual taking this test will be asked to choose the statement that best describes themselves.The results of this test will obtain a profile of the needs of each individual which is felt to be more important, which will motivate the emergence of certain behaviors to achieve these needs (Table 2).As shown in Table 2, most personalities are dominated by the 'High' category: achievement, order, autonomy, change, endurance, deference, affiliation, intraception, succorance, dominance, abasement, and exhibition.While the 'Low' category dominates Nurturance, aggression, and heterosexuality.Based on Table 3, the highest score for the 'Very understood' category was 'Situation assessment and actions for prevention' (73.3%), while the lowest score was 'Environmental improvement for prevention' (42.2%).
The eight assessment indicators on output performance obtained the highest score in the ' Appropriate' category: ' Carry out and documenting reassessments in the patient's medical record' (95.6%).The lowest score was 'Documenting the results of patients falling scores when patient transfers and discharges on the form according to its use in the medical record' (37.8%) (Table 4).Most nurse respondents have a 'low performance' (75.6%) on fall risk prevention based on the completeness and accuracy of medical records (Table 5).
Nurses' situation awareness is based on six patient fall risk prevention indicators impacting their output performance with p-value= 0.040.It can be concluded that the nurse performs better when the situation awareness score is higher.Personality is an individual characteristic that is based on needs.Stable degree of characteristics and tendencies, which makes a person different from others in psychological behavior.Individual Personality has an important role in performance.Personality also determines an individual's motivation and attitude toward work and the desire to develop in his career (Ahanchian et al., 2015).People with healthy personalities have a high correlation between their self-awareness and self-awareness to behave well (Allport, 1983).This means that a person's achievement primarily in the field of work is influenced by his Personality and self-awareness, which cannot be separated because they are interrelated and related to shape their daily behavior.Personality based on the theory of needs is a need that will underlie how a person views things, thinks, and behaves, which will then distinguish one individual from another because not everyone has needs on the same level.The theoretical basis of EPPS is the theory of needs (needs) proposed by Henry A. Murray.Edwards then selected the 15 needs proposed by Murray and developed appropriate statements to describe those needs.Measurements were made based on 15 needs, namely Achievement, Order, Autonomy, Change, Endurance, Deference, Affiliation, Intraception, Succorance, Dominance, Abasement, Nurturance, Exhibition, Heterosexual, and Aggression (Murray, 1953).All the needs described by Murray exist in every nurse, but what distinguishes one nurse from another and becomes a certain characteristic of him is related to the strength or weakness of the need in the person concerned.The stronger this need dominates him, the higher the score or value depicted on his EPPS profile, and vice versa.
The need of high-order are needs that have sufficient opportunities to be realized in behavior as they tend to have high orderliness and are organized and neat, including in planning and activities.The need's order influences the nurse's output performance with a p-value <0.05, which is 0.016.A work plan created when the patient arrives has set out the nurses' roles and responsibilities for nursing care to reduce the risk of patients falling.Nurses with high-order need personalities will use nursing care to carry out their planning tasks when caring for patients, which, if done, will affect the nurse's performance to be high.The impact of regularity and accuracy in the implementation of nursing care to prevent the risk of falling patients, the incidence of falling patients will be able to prevent, will also be made by these nurses.A low affiliation need is a need that has sufficient opportunities to be realized in behavior as the need to get closer and cooperate with others.Affiliation must influence the nurse's output performance with a p-value <0.05, which is 0.012.Nurses with low affiliation needs cannot work in teams, so the performance of nurses in carrying out and recording monitoring evaluations of the implementation of the nursing care plan to prevent the risk of patients falling is very low, 64.4%.The Personality of nurses who tend to prefer to work alone have difficulty when they have to carry out work that is integrated with other professions or departments.Low Nurturance Needs needs that have little chance of being manifested in behavior as the need to provide support and assistance to others.Nurturance needs to influence the nurse's output performance with a p-value <0.05, which is 0.009.
Nurses must respect and assist colleagues.Failure to do so can reduce trust and support from coworkers or patients.Low succorance needs have little chance of being manifested in behavior to be supported and helped by others.
The need for succorance influences the nurse's output performance with a p-value < 0.05, which is 0.012; nurses with low succorance needs must be balanced with responsibility because they will depend on their work to other nurses, so it becomes a problem in the future.Nurses required assistance and support from patients or coworkers on information relevant to patients at risk of falling.The nurse work team has to be informed about patients' risk of falling so that the observation and preventive strategy may be successfully implemented (Kinoshita et al., 2019).The high need for autonomy has quite a chance to be manifested in behavior firmly adhering to principles, independence, and not being easily influenced to act freely and independently.The need for autonomy influences the nurse's output performance with a p-value < 0.05, which is 0.019; each nurse has their roles and responsibilities in carrying out their duties.According to the Indonesian Ministry of Health ( 2018), nurses have the authority to carry out their role in providing patient care, including assessment, determination of nursing diagnoses, implementation of interventions, and evaluations.Based on the findings of the evaluations, nurses implement fall risk prevention activities.Nurses are the clinical authority who must implement these interventions (Kemenkes RI, 2018).
To reduce the risk of patients falling, nurses involve patients and families in the care process while providing nursing care for patients for 24 hours.The importance of teamwork and trust from the patient results in the continuity of the nurse's performance that remains consistent and fosters a sense of security for the patient.The position of nurses with working hours of 8 to 10 or even 12 hours allows them to have a lot of time to establish good relations and know the uniqueness of patients as holistic human beings, thus placing nurses as patient advocates.The work of nurses cannot be carried out individually; teamwork is needed to communicate every fall risk prevention activity that is carried out every shift and must be conveyed to the next nurse on duty so that nursing care for patients continues.The nurse's Personality, manifested in behavior that provides low support and assistance, tends to ignore how to meet limitations that can prevent the patient's or team's negligence in dealing with the risk of falling.One of the causes of patients falling is that nurses do not carry out.Nurses show caring in nursing as a relationship between nurses and those characterized by their attitudes, concerns, experiences, and experiences.In this relationship's sensitivity, communication occurs with elements of active listening and expressions of understanding and empathy (Nur Aini, 2018).
Six components comprise SEAFAP situation awareness: situation assessment and action for prevention; recognition needs for teamwork; recognition needs for decision-making; communication needs for fall prevention; environmental improvement for prevention; and communication for fall prevention.Situation awareness in assessing the situation and actions to prevent the risk of falling has become part of nursing care that must be implemented.A fall risk assessment needs to be carried out and monitored closely to prevent incidents of patient falls; the risk of falls can be identified and prevented (Kinoshita et al., 2019).All nurses employed at Siloam Hospitals Surabaya in the inpatient facilities have completed education and training through general orientation programs and specialized orientations, such as prevention of the risk of patients falling.To lower the incidence of a patient's risk of falling, nurses can analyze the situation of reducing a patient's risk of falling as part of their job (Kinoshita et al., 2019).The implementation of the initial evaluation of the patient's risk of falling and the determination of the interventions completed on each new patient who will be treated at Siloam Hospitals Surabaya are examples of how it is done in this situation.Situation awareness needs recognition for teamwork, a high category; individual goals, expectations, experiences, and prejudices about the situation influence comprehension or understanding.So, it can be concluded individual experiences around the individual more influence comprehension or understanding.
The nurse's responsibilities can be grouped into independent and interdependent.Independent means that nurses' duties can be carried out on their initiative, for example, caring for and motivating patients.Interdependence means that the nurse's duties cannot be carried out without a doctor's order, for example, writing patient prescriptions (Dal Molin et al., 2018).Nurses' situational awareness of the need for fall prevention, environmental improvement for prevention, and communication for fall prevention.Nurses carrying out communication needs to be related to falling risk prevention with other professions are often hampered due to the assumption that this is not an important job for them (Kinoshita et al., 2019).In improving the environment to prevent patient falls, the nurse's job is only to report if facilities are not functioning, and there is no action to evaluate whether the repairs have been done.Nurses are more likely to focus on caring for patients related to their clinical authority.For fall prevention communication, communication regarding the condition of patients at risk of falling each shift is often ignored due to busy activities and interruptions in every activity from doctors so that nurses prioritize instructions given by doctors to carry out rather than communicating about this matter to the next shift or work team.In communication for the prevention of fall risk, it is only used if there is an incident of a patient falling by making an incident report.Communication regarding the risk of falling patients is rare and not fully recorded in the patient's medical record.At SA Level 3 for the category of communication needs components for fall prevention, 44.4% of the results were very understanding, communication for understanding and patient needs on fall prevention who understood very well was only 33.3% so the impact on nursing care would not be achieved.Cooperation with other medical teams in handling and assisting dangerous situations in patients (28.9%) has an impact on patients falling during patient activities with other medical teams, nurses work individually and carry out routine activities related to doctor's instructions to meet risk-related needs patient falls are not performed.Asking for help from other medical staff when leaving the patient (24.4%) resulted in the patient being left alone and falling.The nurse supervised the condition of the floor, obstacles, and falling objects (33.33%).Patients who exhibit predictable risk behavior should always be seen by medical professionals (24.4%).The limitations of nurses, if they replace nurses who will leave patients and the work system in nursing, is to apply a modified nursing care model between the team and the primary due to the insufficient number of nursing professionals.The findings of this study support Widura Imam Mustopo's (2017) research which claims that SA level 3 is the ability to project forward actions to be taken based on environmental elements.This level is achieved through knowledge of the status and dynamics of the elements as well as a comprehensive understanding of the situation (SA level 1 and level 2) which demonstrates the importance of knowledge and time to decide on the appropriate course of action according to the objectives.The low Situation Awareness of nurses is due to the absence of responsibility and the addition of regular knowledge related to preventing the risk of patients falling more on situation assessment and actions nurses' prevention.
According to the study's findings, individual personal characteristics and situational awareness impacted how well individuals performed in reducing their risk of falling.Three factors-individual factors, psychological factors, and organizational aspects-affect a person's performance (Gibson, 2012).Another study stated gender was found to have a significant correlation with occupational accidents (Nurmalia et al., 2022).Situational awareness and personal characteristics are connected and cannot be separated.There is a correlation between the independent variables of personality characteristics and situation awareness, as shown by the results of the multicollinearity test.These results also align with Allport's (1983) theory which emphasizes that success in work shows personality development based on self-awareness to change into a better individual (Allport, 1983).The study was only conducted in one hospital; other hospital nurse's employees may have different outcomes.

Conclusion
The findings of the research conducted for this study indicate that context awareness and Personality both affect output performance.A nurse's capacity to prevent patient falls in the inpatient wards at Siloam Hospitals Surabaya is influenced by their Personality and their requirements for Order, Autonomy, Affiliation, Succorance, and Nurturance.Situation awareness affects the output of nurses in terms of patient fall preventive action in the inpatient wards at Siloam Hospitals Surabaya.Situation awareness of the output performance in patient fall risk prevention focuses more on the situation's assessment and the nurses' preventative actions.At the Inpatient Installation of Siloam Hospitals in Surabaya, recommendations for raising the risk of patients falling to nurses are carried out through talks and interviews to offer workable solutions for enhancing the risk of patients falling.Personality tests can be developed to assess the efficiency of healthcare institutions' input, process, and output.According to Abraham and Nair (2015) 4-level approach, additional research can further determine the impact of context awareness.

Table 3 .
Nurse's Situation Awareness on Fall Risk Prevention

Table 4 .
Output Performance Assessment Based on Completeness and Accuracy Medical Record in Fall Risk Prevention

Table 5 .
Personality and Situation Awareness Impact on Output Performance