Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11779 The development of transformational leadership model based on caring as an effort to increase nursing performance Fitriyanti Patarrù,1 Sena Wahyu Purwanza2 1Bachelor of Nursing, Sekolah Tinggi Ilmu Kesehatan Stella Maris, Makassar; 2Bachelor of Nursing Science, Sekolah Tinggi Ilmu Kesehatan Maharani Malang, Malang, Indonesia Abstract Leadership plays a crucial role in formulating strategies to achieve an organization’s mission, vision, and goals. It occupies a significant position in broader initiatives aimed at enhancing nurse performance. Implementing an unsuitable leadership style, as dic- tated by leaders to their employees, can adversely affect employee motivation, performance, and job satisfaction. The study aimed to develop a transformational leadership model based on the princi- ple of caring to improve nurse performance. This study employed an explanatory design and involved 115 respondents selected through cluster sampling techniques. Data were collected using questionnaires that had undergone both validity and reliability testing. The study examined variables such as personal factors, organizational factors, staff factors, work factors, transformational and caring leadership, and nurse performance. For data analysis, partial least squares were utilized with a significance threshold set at t>1.96. The research findings indicate that personal factors exert a positive influence on both transformational leadership and caring (t=5.677). Organizational factors also positively impact transformational leadership and caring (t=4.474), and staff factors exhibit a positive influence on these leadership styles as well (t=4.157). However, work factors do not directly impact transfor- mational leadership and caring (t=0.554). Notably, both transfor- mational and caring leadership styles positively affect nurse per- formance (t=7.755). The development of a transformational lead- ership model based on caring is influenced by multiple factors, including personal, organizational, and staff factors. Implementing this leadership model can significantly improve nurses’ performance, thereby leading to enhancements in the qual- ity of health services provided in hospitals. Introduction Employee performance in an organization is closely tied to the expectations and demands placed on them to fulfill their responsi- bilities and achieve the organization’s goals.1,2 The issue of nurs- ing performance is influenced by various factors, including lead- ership.3 Leadership is one of the important factors that play a key role in determining strategies to achieve an organization’s mis- sion, vision, and objectives.4,5 Nursing services are an integral component of health service performance. Nurses, as service providers, are at the forefront and play a pivotal role in shaping a hospital’s reputation. The image of a healthcare facility is often evaluated by patients based on their perception of the quality of nursing health services they receive during their hospital stay.6–8 The ideal performance standard value that hospitals should achieve is typically set at 70-80%. However, many hospitals still struggle to meet this percentage of performance standards.9 Data from the World Health Organization (WHO) for Southeast Asia indicates that approximately 35% of healthcare service users express satisfaction with the services provided, while about 55% express dissatisfaction.10 The research obtained the results of the performance of nurses in Sudan Hospital is 32%.11 Research at South Africa’s Hospital Emergency Department in Gaeteng Province found that nurse performance was 68.3%.12 In East Java province, the performance percentage is 52%, while the perfor- mance percentage data for Lavalette Hospital ranges from 55% to 67%. These figures indicate that nurse performance in the region is still categorized as poor, which poses a problem in providing health services to patients, including in Indonesia. Transformational leaders should have the ability to inspire and Correspondence: Fitriyanti Patarru', Bachelor of Nursing, Sekolah Tinggi Ilmu Kesehatan Stella Maris, Makassar, Indonesia. E-mail: patarrufitriyanti@yahoo.com Key words: caring, performance, transformational leadership. Contributions: FP, conceptualization, data curation, formal analysis, methodology, validation, visualization, resources, investigation, writing – original draft, review and editing; SWP, conceptualization, investiga- tion, methodology, formal analysis, validation, visualization, writing – original draft, review and editing Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the ethical feasibility test for this research was carried out by the ethics committee of the Faculty of Nursing, Universitas Airlangga, Surabaya, with proof of certificate num- ber 1916- KEPK dated 14 February 2020. The research ethics include the principle of beneficence and nonmaleficence, respect for human dignity, and the principle of respecting for justice. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research did not receive external funding. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 12 September 2023. Accepted: 13 October 2023. Early access: 6 November 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11779 doi:10.4081/hls.2023.11779 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:11779] [page 11] Non -co mmerc ial us e o nly motivate their subordinates to embrace change, especially when the change impacts employee performance or the employees them- selves. This is crucial in ensuring that the organization’s goals and objectives are effectively implemented.13 Leadership style positive- ly and significantly affects nurse performance.14,15 A leader should also possess a genuine concern for their employees. Caring behav- ior places significant emphasis on empathy, respect, and considera- tion for others. The leader’s demonstration of caring behavior towards their executives or staff is referred to as caring leadership. This process can significantly influence the group’s dynamics and their collective efforts in achieving common goals through the implementation of caring behavior.16–18 Therefore, the organization needs reformist leaders and care that can be the driving motor of transformation to create good cooperation between leaders and sub- ordinates that can improve the performance and quality of health services by implementing transformational leadership models. The four elements of the Transformational Leadership Style are inter- connected with each other. They include setting an example for those around them (Idealized Influence), increasing employee moti- vation through inspirational motivation, encouraging employees to solve problems in innovative ways (Intellectual stimulation), and providing necessary physical facilities and infrastructure to support employee work.14,19 These four elements must be possessed and effectively realized by a hospital leader. On the other hand, Swanson’s caring behavior consists of five aspects: knowing, being with, doing for, enabling, and maintaining belief.20 The choice of an appropriate leadership style can lead to the attainment of both indi- vidual and organizational goals. Conversely, an inappropriate lead- ership style may result in the abandonment of organizational goals, causing employees to feel upset, agitated, disaffected, and dissatis- fied. This study aimed to develop a leadership model, specifically focusing on the elements of the transformational leadership style, while also incorporating the element of caring. Materials and Methods The study utilized an explanatory design and targeted a popu- lation of 221 nurses working across various units, including inpa- tient, intensive care, and outpatient departments. A sample of 115 nurses was selected using cluster sampling, a form of probability sampling. The inclusion criteria for nurse participants in this study were employment at PT. Nusantara Sebelas Medika Lavalette Hospital, willingness to participate as a respondent in the study, minimum educational qualification of an associate’s degree in nursing, minimum work experience of three years. These criteria were applied to identify suitable participants for the research. Variable factors that influence leadership are personal factors, organizational factors, staff factors, work factors, caring-based transformational leadership, namely idealized influence, inspira- tional motivation, intellectual stimulation, individualized consider- ation and caring dimensions maintaining belief, knowing, being with, doing for, enabling and independent variables were observed simultaneously with nurse performance variables. Data were col- lected using questionnaires from each sub-variable. The indepen- dent variable instrument is for personal factors. It consists of 3 sub- variables, namely personality, experience and expectations,2 Organizational characteristics consist of development and training sub-variables as well as organizational structure using a question- naire from WorldatWork which was adopted from research.21 The leadership behavior questionnaire (LTQ/Leadership Trait Questionnaire) is a measure that can be used to assess the charac- teristics of superior behavior,22 Subordinate behavior question- naires and expectations questionnaire,2 The job characteristics instrument in this research is based on the theory of Hackman and Oldham (1980) in research,23 The measuring tool used for transfor- mational leadership is a modification of the Multifactor Leadership Questionnaire (MLQ) by Bass and Avolio in research.24 Meanwhile, the independent variable instrument is The instrument regarding nurse performance standards.2 Data analysis included both descriptive and inferential meth- ods. Descriptive analysis involved calculating measures like fre- quency, mean, median, and mode for data on a nominal or ordinal scale. Inferential analysis utilized a variance-based Structural Equation Modeling (SEM) known as Partial Least Square (PLS). The research was conducted following ethical principles and rig- orous testing. Focus Group Discussions (FGDs) were carried out to identify solutions to strategic problems. These discussions were conducted in two sessions: the first included 13 implement- ing nurses, and the second involved the Head of Nursing Committee and 13 heads of rooms. The insights and findings from the Focus Group Discussions were used to develop plans for enhancing the transformational leadership model based on caring within the hospital and for improving the standard of nurse care. To address the issues identified during the FGDs, further consultations with experts were conducted to create a develop- ment module that included content about the significant factors in enhancing transformational leadership based on caring to improve nurse performance. Results Based on Table 1, it can be found that of the 115 respondents, the majority of respondents are female 75.7%, aged 21 - 40 years 69.6%, the last person in Nursing D3 69.6%, staffing status as a permanent employee 80.0 %, and have been working for 1-5 years 60.9%. Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Distribution of respondent characteristics. Characteristics of respondents n % Gender Male 28 24.3 Women 87 75.7 Age <21 years old 0 0 21-40 years old 80 69.6 41-60 years old 35 30.4 Education Nursing diploma 80 69.6 Bachelor degree 35 30.4 Master degree 0 0 Staffing status Permanent employees 92 80.0 Honorary employees 23 20.0 Contract employees 0 0 Long working time <1 year 0 0 1-5 years old 70 60.9 >5 years old 45 39.1 Total 115 100 [page 12] [Healthcare in Low-resource Settings 2024;12:11779] Non -co mmerc ial us e o nly Personal factor variables consist of personality, experience, and expectations. Organizational factor variables consist of devel- opment and training as well as organizational structure, staff factor variables consist of staff expectations, boss behavior, and subordi- nate behavior and work factor variables consist of objective perfor- mance, feedback, correction, job design and job schedule. Transformational and caring leadership variables consist of ideal- ized influence, individualized consideration, inspirational motiva- tion, and intellectual stimulation, and nurse performance variables consist of caring, collaboration, empathy, response speed, decency, and honesty (Table 2). The results of the study that there is a significant influence of personal factors (personality, experience, and expectations) on transformational leadership and caring (ideal influence, motiva- tional inspiration, intellectual stimulation, intellectual considera- tion) (t = 5,677>1.96). There is an influence of organizational fac- tors (development and training and organizational structure) on Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Transformational leadership based on caring Ideal influence Good 33 28.7 Enough 51 44.3 Less 31 27.0 Motivational inspiration Good 33 28.7 Enough 25 21.7 Less 57 49.6 Intellectual stimulation Good 40 34.8 Enough 26 22.6 Less 49 42.6 Individual configuration Good 36 31.3 Enough 27 23.5 Less 52 45.2 Performance Caring Good 27 23.5 Enough 30 26.1 Less 58 50.4 Collaboration Good 55 47.8 Enough 40 34.8 Less 20 17.4 Empathy Good 35 30.4 Enough 40 34.8 Less 40 34.8 Response speed Good 54 47.0 Enough 38 33.0 Less 23 20.0 Courtesy Good 49 42.6 Enough 32 27.8 Less 34 29.6 Honesty Good 69 60.0 Enough 34 29.6 Less 12 10.4 Total 115 100 Table 2. Variable distribution. Variables n % Personal factors Personality Good 46 40.0 Enough 42 36.5 Less 27 23.5 Experience Good 63 54.8 Enough 37 32.2 Less 15 13.0 Hope High 79 68.7 Are 36 31.3 Low 0 0 Organizational factors Development and training Good 23 20.0 Enough 49 42.6 Less 43 37.4 Organizational structure Good 62 53.9 Enough 41 35.7 Less 12 10.4 Staff factor Staff expectations High 26 22.6 Are 64 55.7 Low 25 21.7 Leader behavior Good 59 51.3 Enough 31 27.0 Less 25 21.7 Subordinate behavior Good 57 49.6 Enough 45 39.1 Less 13 11.3 Occupation factor Objective performance Good 92 80.0 Enough 23 20.0 Less 0 0 Feedback Good 66 57.4 Enough 24 20.9 Less 25 21.7 Correction Good 70 60.9 Enough 45 39.1 Less 0 0 Design jobs Good 35 30.4 Enough 65 56.5 Less 15 13.0 Work schedule Good 39 33.9 Enough 53 46.1 Less 23 20.0 [Healthcare in Low-resource Settings 2024;12:11779] [page 13] Non -co mmerc ial us e o nly transformational leadership and caring (ideal influence, motiva- tional inspiration, intellectual stimulation, intellectual considera- tion) (t = 4,474 > 1.96). There is a significant influence of staff fac- tors (expectations, the behavior of subordinates, and superiors’ behavior) on transformational and caring leadership (ideal influ- ence, motivational inspiration, intellectual stimulation, intellectual consideration) (t = 4,157 > 1.96). There is no influence of work factors (objective performance, feedback, correction, job dimen- sions, work schedule) on transformational leadership and caring (ideal influence, inspirational motivation, intellectual stimulation, intellectual consideration. (t = 0,554> 1.96), transformational lead- ership and caring (ideal influence, inspirational motivation, intel- lectual stimulation, intellectual consideration) to nurses’ perfor- mance (caring, collaboration, empathy, speed of response, polite- ness, honesty) (t = 7,755 > 1.96) (Table 3). Focus Group Discussion (FGD) results show that it is neces- sary to improve the implementation of transformational leadership models based on caring headroom by hospitals by Making hospital policies regarding the application of a caring-based transforma- tional leadership model based on personal factors, organizational factors, staff factors to improve nurse performance, conduct out- reach to nurses, increase knowledge of the head of the room, train the application of caring-based transformational leadership, Increase the responsibility and commitment of the headspace, improve nurse performance by applying caring-based transforma- tional leadership. Discussion The variables of personality, experience, and expectations have been validated and considered effective in measuring personal fac- tors. They play a dominant role and are categorized as good indi- cators. The statistical tests demonstrate that personal factors signif- icantly affect transformational leadership and caring. Personality traits are evaluated based on several factors: the leader’s adaptabil- ity, creativity, decision-making ability, cooperation skills, emotion- al control, and self-confidence. Experience is measured through the duration of work, the extent of knowledge, proficiency in skills, adherence to procedures, and a sense of responsibility in ful- filling duties. Expectations are determined by the nurses’ aspira- tions for career advancement, recognition, and improved perfor- mance. Most nurses at Lavalette Hospital Malang exhibit good rat- ings for personality, experience, and expectations. The application of leadership type depends heavily on personality characteristics owned by a leader, personality is a certain characteristic or charac- ter that becomes unique to each individual. The research findings indicate a positive and significant correlation between personality and transformational leadership.25 Organizational factor variables have sub-variables namely development and training and organizational structure. In the sub- variables the organizational structure belongs to the category both but on the development and training category is sufficient. Based on statistical test results, the two sub-variables are valid for mea- suring organizational factor variables. Statistical test results show that organizing factors positively affect transformational leader- ship and caring. Human Resources Development is an activity that must be carried out by an organization to improve employees’ knowledge, ability, and skills to comply with their work demands.21 While the organizational structure is the unity of the organizational framework set out for the managerial process, the system is the pattern of behavior that arises and occurs in organiz- ing the organization and management. The results of this study are in line with research which states that the cultural factors of the organization have a significant effect on leadership.26 Organization is one of the factors that affects an individual’s performance, because the organization is a system of roles, activity flows and processes of work relationship patterns and involves several peo- ple as executors of tasks designed to achieve common goals. The staff factor has sub variables namely staff expectations, boss behavior, subordinate behavior. Sub-variabrel expectations of staff fall into the category of having moderate expectations and for sub variables of superior behavior and subordinate behavior fall into the category of good. Based on statistical test results, the 3 sub-variables are valid for measuring staff factor variables. In sta- tistical test results, there was a significant influence of staff factors on transformational leadership and caring. Thus, it can be inter- preted that the better the staff factor, the better it tends to improve transformational leadership and caring. The expectations of the staff in this study are to discuss the level of satisfaction felt by nurses during their work, namely the satisfaction of service wages, facilities and infrastructure and relationships between leaders. As for the behavior of the boss, the assessment of the nature and behavior of the boss such as being able to communicate well to subordinates, creative, insightful and able to motivate. For subor- dinate behavior, discuss feelings in carrying out the basic duties and functions of nurses that are their responsibility. The work factor variable has sub-variables, objective perfor- mance, feedback, correction, job design, and job schedule. Sub variable objective performance, feedback, and corrections fall into both categories, while the design of the work and the work sched- ule is sufficient. Based on statistical test results it can be known that 5 sub-variables are valid to measure staff factor variables In the results of statistical tests obtained results that there is no signif- icant influence of work factors on transformational leadership and caring. The work factor in this study discusses the ability to work based on the SOP that has been made by the hospital, evaluating the performance that has been done. The head of the room also gives corrections and directs its subordinates if it is not proper in carrying out its performance. The head of the room can set the shift schedule clearly. The study previous states that by modifying or changing the characteristics of the work, it should be more consid- Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 3. Hypothesis test. Influence Original Sample (O) T Statistics (O/STDEV) p Personal factors (X1) -> Transformational Leadership and Caring (X5) 0.332 5.677 0.000 Organizational factors (X2) -> Transformational leadership and Caring (X5) 0.328 4.474 0.000 Staff factor (X3) -> Transformational leadership and Caring (X5) 0.305 4.157 0.000 Job factor (X4) -> Transformational leadership and Caring (X5) 0.034 0.554 0.580 Transformational leadership and caring (X5) -> Nurse performance 0.515 7.755 0.000 [page 14] [Healthcare in Low-resource Settings 2024;12:11779] Non -co mmerc ial us e o nly ering the individual aspects.27 The individual aspect in question is that a leader must have a desire to present himself or herself to be able to do the job. Transformational leadership and caring are not directly affected by the employment factor. The employee’s work factor is basically individual because basically, each person’s work ability has a different character. Transformational leadership based on caring variables has sub- variables of idealistic influences, motivational inspiration, intellec- tual stimulation, and individual contingency. Sub variables of transformational leadership and caring for motivational inspira- tion, intellectual stimulation, and individual consideration fall into fewer categories whereas the dimensions of idealistic influence in the category are sufficient. Based on statistical test results, it can be known that 4 sub-variables are valid for measuring leadership and caring variables. Statistical test results show that there is a sig- nificant influence of transformational and caring leadership on the performance standards of professional nurses. Thus, it can be inter- preted that implementing transformational leadership and caring tends to improve the performance standards of professional nurses. This research is in line with research that transformational leader- ship style has a positive and significant effect on nurse perfor- mance.28 According to Bass, 1997 the transformational leadership model is a leadership style that can excite and motivate subordi- nates in order to develop and achieve higher performance, past pre- viously thought. Transformational leadership based on caring is a model of leadership style that transforms or transforms something into another different form. A transformational leader must be able to optimally transform the organization’s resources in order to achieve meaningful goals in accordance with the target stipulated. Transformational leadership is outlined in four main characteris- tics, namely: the idealization of influence, inspirational motiva- tion, individuality, and intellectual stimulation and developed by incorporating the caring element, namely maintaining belief, knowing, doing for, being with, and enabling because the key to improving the quality of nursing services is to emphasize caring behavior. Therefore, it takes a leader who applies caring attitude in leading his subordinates. Performance is a pattern of actions performed to achieve goals measured based on comparisons with various standards.29 Performance is the achievement of the objective of a particular activity or activity to achieve the company’s goals as measured by a standard. The results of the previous study showed that there is a significant influence of transformational leadership on perfor- mance.30 This shows that the greater the influence of transforma- tional leadership, the better the performance of nurses. The appli- cation of transformational and caring leadership models by the head of the room or manager can have a good impact on the per- formance of nurses. Applying the dimensions of transformational leadership including ideal influence/charisma, motivation inspira- tion, individual consideration, and intellectual stimulation integrat- ed with caring dimensions, namely maintaining belief, knowing, doing for, being with, and enabling, can have a positive influence on the performance of nurses in hospitals. The influence of trans- formational leadership makes employees more loyal to their work. Research limitations during data collection are as follows: It is necessary to take a personal approach to the implementing nurse when filling out the questionnaire so that it takes quite a long time and the researcher adjusts the official holiday schedule with the nurse and Focus Group Discussion (FGD) with the executive nurse, head of room and representatives of hospital management with limited time because it was carried out online and the limited time each nurse concerned had considering the responsibility in providing nursing care. Conclusions The transformational leadership model based on caring is influenced by various factors, including personal factors, organiza- tional factors, and staff factors. The development of this model has the potential to impact nurses’ performance positively and can be adopted by hospitals, particularly for ward managers or heads of departments, to enhance the quality of healthcare services. The findings from this research offer valuable insights and understand- ing for leaders and heads of departments in implementing a caring- based transformational leadership model, contributing to the development of nursing science as evidence-based practice. References 1. Sukoco BM, Adna BE, Musthofa Z, et al. Middle Managers’ Cognitive Styles, Capacity for Change, and Organizational Performance. 2022; Available from: https://scholar. unair.ac. id/en/publications/middle-managers-cognitive-styles-capaci- ty-for-change-and-organiza 2. Nursalam. Manajemen Keperawatan: Aplikasi dalam Praktik Keperawatan Professional. Edisi 5. Jakarta: Salemba Medika. 2018. 3. Efendi F. Transforming nurses from frontline to front leaders: lesson learned from the pandemic. J Ners 2022;17:1. 4. Yudaningsih Y. Pengaruh Pelatihan Kepemimpinan Spiritual Terhadap Peningkatan Kinerja Ketua Tim Keperawatan Rumah Sakit Umum Daerah Kota Semarang pelayanan Rumah Sakit Umum Daerah Kota. J Manaj Kesehat Indones 2016;4:242-9. 5. Almutairi RL, Aditya RS, Kodriyah L, et al. Analysis of orga- nizational culture factors that influence the performance of health care professionals: A literature review. J Public Health Africa 2022;13:2415. 6. Rohita T, Nursalam N, Hadi M, et al. Relationship quality of nursing work life and burnout among nurses: A systematic review. Gac Med Caracas 2022;130:S1205-S1214. 7. Yani RWE, Khoiri A, Bramantoro T. Patient’s Satisfaction in Utilizing Public Health Center Services During The COVID- 19 Pandemic Based on Gender, Age, Education Level, and Occupation. Asia Pacific J Heal Manag 2022;17:1797. 8. Utomo MT, Sampurna MTA, Melisa M, et al. Nurse workload, missed nursing care, and the contributing factors in the Neonatal Intensive Care Unit in a limited resource setting: A case from Indonesia. F1000Research 2022;11. 9. Kemenkes RI. Laporan Kinerja Ditjen Kesehatan Masyarakat Tahun 2016. 2017. 10. Fitri IL. Pengaruh Implementasi Six Sigma dan Total Quality Management terhadap Kepuasan dan Kinerja Keuangan pada Rumah Sakit Surabaya. 11. Mukhtar HF, Ibrahim M, Ahmed O. Effect of Proposed Program of Patient Safety on N urse’s Performance and Quality of Care at Kosti and Rabak Teaching Hospitals-Sudan. Int J Res -GRANTHAALAYAH 2019;4:1-6. 12. Goldstein LN, Bch MB, Sa F, et al. The accuracy of nurse per- formance of the triage process in a tertiary hospital emergency department in Gauteng Province, South Africa. South African Med J 2017;107:243-247. 13. Fatima SN. Pengaruh Kepemimpinan Transformasional dan Disiplin Kerja terhadap Kinerja Pegawai RSU Aliyah Kendari. Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2024;12:11779] [page 15] Non -co mmerc ial us e o nly J Manaj dan Kewirausahaan 2020;12:43-56. 14. Gani AA. Pengaruh Gaya Kepemimpinan Transformasional Dan Kepuasan Kerja Terhadap Kinerja Pegawai. Celeb Equilibrum J 2020;1:12-22. 15. Muenjohn N, Ishikawa J, Muenjohn P, et al. The effect of inno- vation and leadership on performance in China and Vietnam. Asia Pacific Bus Rev 2021;27:101-10. 16. Meo MY. Hubungan Caring Leadership Kepala Ruang dengan Kinerja Perawat dalam Melaksanakan Asuhan Keperawatan. 17. Bakar A, Qomariah SN, Iswati I. Effect of caring behaviour approach to improve nurses’ caring character in medical-surgi- cal wards. J Ners 2022;17:110-4. 18. Lukmanulhakim L, Afriyani A, Haryani A. Caring Efficacy and Nurse Caring Behavior in Taking Care of Critical Patients. J Ners 2019;13:55-61. 19. Aziz A, Padil M, Mujtahid M, et al. Transformational leader- ship style in rural schools during pandemic: A case study in Indonesian non-WEIRD community. Int J Eval Res Educ 2022;11:947-53. 20. Alligood M. Nursing theory & their work (8th ed). The CV Mosby Company St. Louis. Toronto. Missouri: Mosby Elsevier. Inc. 2014. 21. Rachmatika SM. (2015) ‘Pengaruh Evaluasi Pelatihan dan Pengembangan Karir Terhadap Kinerja Pegawai Negeri Sipil Kota Yogyakarta’’, Universitas Negeri Yogyakarta, pp. 1-27. 22. Northouse PG. Leadership: Theory and Practice, 6th edition. California: Sage Publications, Inc. 2012. 23. Megawati S. Pengaruh Job Characteristics Terhadap Motivasi Karyawan Divisi Operasi pada PT Pembangkitan Jwa-Bali (PJB) Unit Pembangkitan (UP) Muara Tawar. Universitas Indonesia. 2012. 24. Soegiarto M. Pengaruh Kepemimpinan Transformasional Terhadap Kinerja Karyawan Pada CV. Norton Surabaya. Jurnal Riset Bisnis dan Investasi 2016;2:143. 25. Permatasari PAB. Pengaruh Kepribadian Terhadap Gaya Kepemimpinan Transformasional Di Pt. Istana Mobil Roda Mas (Honda Istana Jember). J Chem Information Modeling 2014;53:1689-99. 26. Mufidah SZ. Hubungan gaya kepemimpinan dengan budaya organisasi di rumah sakit islam sultan agung Semarang rela- tionship between leadership style with organizational culture in hospital Sultan Agung Islamic Semarang. Unissula Nursing Conference Call for Paper & National Conference 2018;1:83- 89. 27. Thomas A, Buboltz WC, Winkelspecht CS. Job characteristics and personality as predictors of job satisfaction. Organ An 2004;12:205-19 28. Muttaqin LZ. Pengaruh Kepeimpinan Transformasional dan Pengembangan SDM Terhadap Kinerja Perawat RSJ Grhasia Yogyakarta, Universitas Negeri Yogyakarta. 29. Dessler G. Human Resources Management. 14th Edition. USA: Pearson. 2016. 30. Murtiningsih. Pengaruh Gaya Kepemimpinan Transformasional Pada Kinerja Perawat Rumah Sakit Islam Siti Aisyah Madiun. Jurnal Ekonomi Manajemen Sumber Daya 2015;17:54-66. Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [page 16] [Healthcare in Low-resource Settings 2024;12:11779] Non -co mmerc ial us e o nly