Influence Of Servant Leadership, Organizational Safety Culture And Work Environment On Organizational Citizenship Behavior In Application Of Patient Safety With Affective Organizational Commitment

The success of the application of patient safety in hospitals, among others, is measured by how much the productivity of nurses in providing quality nursing care to patients and their families. Factors that influence patient safety: organization (safety culture), work environment, individual factors and citizenship behavior, work behavior, teamwork structure and (servant) leadership. In this regard, the purpose of this literature review study is to prove the influence of servant leadership, organizational safety culture and work environment on OCB in the application of patient safety with affective organizational commitment in hospital. This literature review is based on literature sources and related scientific research journals. The method used in this paper is to search from the EBSCO, ProQuest, and Google Scholar databases using keywords servant leadership, organizational safety culture, work environment, OCB, and patient safety. The study population was health workers in the hospital, which measures in the construction are 54 respondents, with a random sampling technique as the sample of the population. The data were analyzed using parametric and non-parametric statistics with SEM-PLS (Structural Equation Modeling-Partial Least Square). The research proves that: Servant leaders and organizational safety culture that is applied, as well as a supportive work environment, have a positive influence on OCB in the application of patient safety in hospitals. Furthermore, it is expected that nurse managers will be able to implement servant leadership and safety culture as well as adequate work environment support so that OCB in implementing patient safety can run optimally, this can be assessed based on patient safety incidents and service quality as hospital brand equity. Keywords​: Servant Leadership, Organizational Safety Culture, Work Environment, Affective Organizational Commitment, Organizational Citizenship Behavior, and Patient Safety Copyright © 2021 IAIC All rights reserved.


Title
Findings and Outcomes The influence of servant leadership, organizational commitment and job satisfaction on organizational citizenship behavior.
Servant leadership, organizational commitment and job satisfaction have a positive effect on organizational citizenship behavior. The variable that has the most dominant influence is servant leadership (2) .
The influence of servant leadership and empowerment on organizational citizenship behavior.
Servant leadership and empowerment simultaneously have a positive effect on organizational citizenship behavior. Servant leadership has a partially positive effect on organizational citizenship behavior. Empowerment has a partially positive effect on organizational citizenship behavior (3) .
Servant leadership: "the role of nurse managers in optimizing staff work ethics". Servant leadership applied by nurse managers is positively related to work ethic (4) .
Analysis of the patient safety culture in Awal Bros Batam Hospital, the Year 2016.
The status of patient safety culture at the Awal Bros Batam hospital in 2016 shows in the medium category, the average perception of patient safety culture is positive 70.82%. The greatest strength of patient safety culture is organizational learning and continuous improvement, feedback, and open communication about patient safety. While weaknesses are mainly in staffing, non-punishment responses to mistakes, handover, and transitions must be corrected immediately (5) . Analysis of factors related to the application of the Surgical Safety Checklist (SSC) in the operating room of Batam City hospital.
Obtained the implementation of SSC Batam city nurses are still not good, but there is a significant relationship between knowledge and training in the application of SSC according to the expected goals evident from the results of statistical tests showing the relationship of knowledge, training with the application of SSC (p-value 0.002) (6) .

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■ 142 5. The influence of organizational safety culture on affective organizational commitment in the hospital? 6. The influence of work environment on affective organizational commitment in the hospital?

Literature review 2.1. Servant Leadership
Servant leadership or leadership that serves is a concept of leadership that starts from a sincere feeling that arises from the heart to serve, putting the needs of followers as priorities, getting things done with others, and helping others in achieving common goals. This leadership concept was first introduced in 1970 by a Vice President of the American Telephone and Telegraph Company (AT&T) named Robert K. Greenleaf in his book The Servant as Leader [3]. According to Spears, Servant Leadership is a leader who prioritizes service, starting with the natural feeling of someone who wants to serve and to put service first. Furthermore, consciously, this choice brings aspirations and encouragement in leading others (7). Servant Leadership is a management style in terms of leading and serving in harmony, and there is interaction with the environment. A servant leader is someone who has a strong desire to serve and lead, most importantly can combine the two as a matter of positive reinforcement for each other [4].
According to Vondey, Servant Leadership is a leader who is very concerned about the growth and dynamics of the lives of followers, himself, and his community, so he prioritizes the achievement of personal ambitions and personal preferences (9) [5]. According to Poli, Servant Leadership is a process of reciprocal relations between leaders and those led in which in the process the leader initially appears as a part of serving the needs of those who lead which ultimately causes him to be recognized and accepted as a leader. Servant Leadership is a leader who prioritizes the needs of others, aspirations, and interests of others for themselves. A servant leader commits to serve others (10) [6].
Characteristic of servant leadership by Spears (7) as below: 1) Listening. Servant leadership listens attentively to others, identifies and helps clarify the desires of the group, as well as listening to their inner voice. 2) Empathy. Servant leadership tries to understand co-workers and be able to empathize with others. 3) Healing. Servant leadership can create emotional healing and self-relationships, or relationships with others, where relationships are a force for transformation and integration. 4) Awareness. Servant leadership has the awareness to understand issues involving ethics, power, and values. See situations and positions that are balanced and more integrated. 5) Persuasion. Servant leadership tries to convince others rather than force compliance. This most distinguishes between traditional authoritarian leadership styles and servant leadership. 6) Conceptualization. Servant leadership can see the problems from the perspective of conceptual means to think long term or visionary on a broader basis. 7) Foresight. Servant leadership is observant or thorough in understanding past lessons, current realities, and possible consequences of decisions for the future. 8) Stewardship emphasizes openness and persuasion to build the trust of others. 9) Commitment to the growth of people. Servant leadership has the characteristics to be responsible for doing business in improving the professional growth of employees and the organization they lead. 10) Building community. Servant leadership identifies ways to build community.
The dimension of servant leadership by Barbuto & Wheeler (11): 1) Altruistic calling, it means a strong desire to make positive changes in the lives of others and put the interests of others above their interests and will work hard to meet the needs of their subordinates. 2) Emotional healing, which is the commitment of a leader to improve and restore the enthusiasm of his employees. 3) Wisdom, the leader who is easy to understand the situation and the impact of the situation. 4) Persuasive mapping, that is, to what extent the leader has the skills to map the problem and conceptualize the highest likelihood that will occur and persuade someone to do something when articulating the opportunity. 5) Organizational stewardship, namely the extent to which the leader prepares the organization to make a positive contribution to the environment. 6) Humility, the humility of the leader.

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■ 143 7) Vision, which is the extent to which leaders seek the commitment of all members of the organization to a shared vision by inviting members to determine the future direction of the company. 8) Service, the extent to which service is seen as the core of leadership, and the leader shows his service behavior to subordinates.

Organizational Safety Culture
According to Pronovost, patient safety culture is a characteristic of a proactive patient safety culture, including a commitment from leaders to discuss and learn from mistakes, encourage and practice teamwork, create an incident reporting system (Unexpected Events, Nearly Injured Events, Non-Injury Events, and the potential for injury, Sentinel) and provide an appreciation for the staff who carry out patient safety programs well [8]. A positive patient safety culture will increase productivity. Whereas negative safety culture includes different career levels between medical staff and other staff, tenuous work team relationships, and unwillingness to admit mistakes. A negative safety culture will damage the effectiveness of a team and affect good organizational design (14) [9].
Measurement of patient safety culture can be done based on the underlying dimensions or based on the level of maturity of the organization in implementing patient safety culture. Some organizations develop measurement standards with each of their instruments including AHRQ, Stanford, and MaPSaF (Manchester Patient Safety Assessment Framework) [10]. But so far the AHRQ questionnaire HSOPSC (Hospital Survey Of Patient Safety Culture) is the most recommended for measuring patient safety culture because it has guaranteed its validity and reliability internationally (15) [11].

Organizational Citizenship Behavior (OCB)
Organizational Citizenship Behavior (OCB) is an attitude or work behavior carried out by employees outside their duties. This behavior is usually carried out if the employee has completed the task properly. Not only that, but OCB also reflects that employees feel concerned about other employees and the company, in this context OCB greatly affects the company [12]. Because after all employees who have OCB will tend to make a good contribution to the company so that it can indirectly help the company in carrying out its operations process and achieve the goals set. OCB dimensions are altruism, courtesy, sportsmanship, civic virtue, conscientiousness [13].

Work Environment
The work environment is everything that is around the worker and that can affect him in carrying out the tasks that are carried out or the responsibility. To increase its productivity, the work environment greatly influences performance because a good work environment will create ease of carrying out tasks [14]. This work environment itself consists of a physical work environment (lighting, air circulation, noise, color, air humidity, facilities) and non-physical (harmonious relationships, opportunities for advancement, and safety at work) attached to employees so that they cannot be separated from employee performance development efforts [15].

Patient Safety
Patient safety implemented in a hospital is a system where the hospital makes patient care safer which includes risk assessment, identification, and management of matters related to patient risk, reporting, and analysis of incidents, the ability to learn from incidents and their follow-up and the implementation of solutions to minimize the risk and prevent injuries caused by mistakes caused by carrying out an action or not taking the action that should be taken [16]. Based on Raleigh, patient safety programs (patient safety) focus on efforts to reduce the number of patient safety incidents that can be prevented. Patient safety incidents are any unintentional events and conditions that cause or have the potential to cause an injury that can be prevented in patients, consisting of Unexpected Events, Nearly Injured Events, Non-Injury Events, and the potential for injury Affective Organizational Commitment [17].  Figure 2) that Competence-Based Human Resource Management-CBHRM is one of the strategies to ensure the proper development of human resources and is often seen as a core component of all aspects of realizing organizational goals. CBHRM has been part of human resource management since 1990. Thus, an effective human resource management strategy must be introduced, reviewed, and evaluated regularly to ensure the quality of human resources as part of an organization [18].

Research Method
This literature review is based on literature sources and related scientific research journals. The method used in this paper is to search the internet from EBSCO, ProQuest and Google Scholar databases using keywords are servant leadership, organizational safety culture, work environment, organizational citizenship behavior, affective organizational commitment, and patient safety [19].

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■ 145 In this study, the researcher used data respondents, such as gender, age, and length of work of the respondents to provide information about the characteristics of the respondents. The questionnaire distributed as many as 54. The discussion in this chapter is the result of field studies to get answers to the questionnaire that measures the five main variables in this study, namely Servant Leadership, organizational safety culture, work environment, organizational citizenship behavior, and affective organizational commitment [20]. Data analysis uses parametric and non-parametric statistics using SEM-PLS (Structural Equation Modeling-Partial Least Square) regarding research variables, instrument testing, normality testing, hypothesis testing, and discussion of the results of hypothesis testing and Path Analysis [21]. This study uses path analysis to examine patterns of relationships that reveal the effect of a variable or set of variables on other variables, both directly and indirectly. The calculation of the path coefficient in this study was assisted by Smart PLS Version 3.0. To determine if the direct and indirect effects between variables, it can be seen from the calculation of the path coefficient, while to determine significance. The study population was health workers in the hospital. The sample is determined by the number of sample members (sample size) of 54 people by proportional random sampling technique [22].

Table 2. Research and Theoretical Issues
Based on internal consistency analysis data in the Table [3] above, the results show that the variables X1, X2, X3, and Y have composite reliability >0.600 except X4, so the questions developed on the 5 variables are reliable meaning cross-item questions developed on the questionnaire of the variables has the same consistency [23].

Convergent Validity
Convergent validity is used to see the extent to which a measurement is positively correlated with alternative measurements of the same construct. To see an indicator of a constructed variable is valid or not, it is seen from the outer loading value. If the outer loading value is greater than (0.4) then an indicator is valid (26) [24] .

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■ 146 Table 4. Convergent Validity Based on the above Table [4], it can be seen that the outer loading value for variables X1, X2, X3, X4, Y where the value of the items in the 5 variables tested is greater than 0.4, then all items developed for all variables are declared valid, meaning that the measurement is positively correlated with alternative measurements of the same construct thus the indicators of all construct variables are valid [25].

Discriminant Validity
Discriminant validity aims to assess an indicator of a constructed variable is valid or not, namely by looking at the Hetero-trait Mono-trait Ratio of Correlation (HTMT) <0.90, then the variable has a good discriminant validity (valid) (26) [26]. Based on the (Table 5) above, the correlation results obtained variables X1 with X2, X3, X4, Y and X2 with X3, X4, Y and then X3 with X4, Y, and X4 with Y have a correlation value <0.900, thus the value the correlation of all variables is declared valid. Analysis of structural models or (inner models) aims to test the research hypothesis. The part that needs to be analyzed in the structural model is the coefficient of determination (R Square) by testing the hypothesis. Collinearity testing is to prove the correlation between latent or construct variables is strong or not. If there is a strong correlation it means that the model contains problems if viewed from a methodological point of view, because it has an impact on the estimation of statistical significance. This problem is called the collinearity. The value used to analyze it is by looking at the value of the Variance Inflation Factor (VIF). If the VIF value is greater than 5.00 then it means there is a collinearity problem, and in contrast, there is no collinearity problem if the VIF value <5.00. Table 6. Collinearity From the above data, it can be described as follows: The VIF value for the correlation of X1 with Y, X2 with Y, X3 with Y, X4 with Y is <5.00 (there is no collinearity problem). Therefore, from the data above and the development of structural models in this case there is no problem. In this test there are two stages, namely testing the direct influence hypothesis and testing the indirect effect hypothesis. The coefficients of the hypothesis testing path are in the figure below: Test the significance of the structural coefficient of the path model (Structural Model Path Coefficient). This test is to determine the path coefficient of the structural model, the aim is to test the significance of all relationships or hypothesis testing. As (Figure 4) based on findings from sources that Servant Leadership is an important point in running a hospital organization, in this case, the application of Organizational Safety Culture (OSC), so this encourages organizational members to show Organizational Citizenship Behavior (OCB) behavior, which is also supported with the established Work Environment. And then furthermore Patient Safety will be realized through Affective Organizational Commitment in a health organization (hospital). Direct influence hypothesis testing aims to prove the hypotheses of the influence of a variable on other variables directly (without intermediaries). If the value of the path coefficient is positive indicates that an increase in the value of a variable is followed by an increase in the value of another variable. If the value of the path coefficient is negative indicates that an increase in a variable is followed by a decrease in the value of other variables. If the probability value (P-Value) <Alpha (0.05) then H0 is rejected (the effect of a variable with other variables is significant). If the value of probability (P-Value) >Alpha (0.05) then H0 is accepted (the effect of a variable with other variables is not significant). Table 7. Hypothesis of Direct Effect 1. The direct effect of variable X1 on variable X4 has a path coefficient of 0.512 (positive), an increase in the value of variable X1 will be followed by an increase in variable X4. The effect of the variable X1 on X4 has a P-Values value of 0.611>0.05, so it can be stated that the influence between X1 on X4 is not significant. 2. The direct effect of variable X1 on variable Y has a path coefficient of 0.663 (positive), an increase in the value of variable X1 will be followed by an increase in variable Y. The effect of variable X1 on Y has a P-Values value of 0.510>0.05, so it can be stated that the influence between X1 on Y is not significant. 3. The direct effect of variable X2 on variable X4 has a path coefficient of 0.109 (positive), an increase in the value of variable X2 will be followed by an increase in variable X4. The effect of variable X2 on X4 has a P-Values value of 0.914>0.05, so it can be stated that the influence between X2 on X4 is not significant. 4. The direct effect of variable X2 on variable Y has a path coefficient of 0.473 (positive), an increase in the value of variable X2 will be followed by an increase in variable Y. The influence of variable X2 to Y has a P-Values value of 0.636>0.05, so it can be stated that the influence between X2 on Y is not significant. 5. The direct effect of variable X3 on variable X4 has a path coefficient of 2.466 (positive), an increase in the value of variable X3 will be followed by an increase in variable X4. The effect of variable X3 on X4 has a P-Values value of 0.017<0.05, so it can be stated that the influence between X3 on X4 is significant. 6. The direct effect of variable X3 on variable Y has a path coefficient of 0.138 (positive), an increase in the value of variable X3 will be followed by an increase in variable Y. The effect of variable X3 on Y has a P-Values value of 0.011<0.05, so it can be stated that the influence between X3 on Y is significant. 7. The direct effect of variable X4 on variable Y has a path coefficient of 2.509 (positive), an increase in the value of variable X4 will be followed by an increase in variable Y. The effect of variable X4 on Y has a P-Values value of 0.015<0.05, so it can be stated that the influence between X4 on Y is significant.

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ISSN: 2528-2417 ■ 149 Testing the hypothesis of indirect effects aims to prove the hypotheses of the influence of a variable on other variables indirectly (through intermediaries). If the value of the indirect effect coefficient>direct effect coefficient, then the intervening variable is mediating the relationship between one variable with another variable. Conversely, if the value of the indirect effect coefficient<coefficient of direct effect, then the intervening variable does not mediate the relationship between one variable with another variable. The coefficient of determination (R Square) aims to evaluate the accuracy of the predictions of a variable. In other words, to evaluate how the variation of the value of the dependent variable is influenced by the variation of the value of the independent variable in a path model. Table 9. Coefficient of Determination Based on the table above, as shown in Table 7, it can be seen that squared multiple correlations of affective organizational commitment 0.586. It means that the influence of servant leadership, organizational safety culture, and work environment as indicators on affective organizational commitment are 58.6% quietly high if compared with the other variables are 41.4% apart from this research variable. Meanwhile, that squared multiple correlations of Organizational Citizenship Behavior 0.668. It means that the influence of servant leadership, organizational safety culture, and work environment as indicators on Organizational Citizenship Behavior are 66.8% quietly high if compared with the other variables are 33.2% apart from this research variable.

Conclusion
The hospital as one of the health service institutions that conduct individual health services is complete through inpatient, outpatient, and emergency services. To win the competition and the service continues, it is necessary to strive continuously to improve the quality of health services in the hospital. Patient safety has become a global issue in the quality of health services organized by hospitals. Servant Leadership becomes an important point in running an organization in the health sector, in this case, the hospital. The further implementation of Servant Leadership will encourage Organizational Safety Culture (OSC) by health and non-health workers to provide plenary services. This will also encourage health and non-health workers in hospitals to show Organizational Citizenship Behavior (OCB) behavior, in line with the organization's organizational commitment. The existence of an established Work Environment is also an important factor in its implementation, and in the end, Patient Safety will be realized through Affective Organizational Commitment in hospital a health organization.