TRANSFORMING LEADERSHIP, EFFECTIVE COMMUNICATION, AND PATIENT SAFETY CULTURE: THE ROLE OF TRUST AMONG HOSPITAL X EAST JAKARTA NURSES

ABSTRACT


Introduction
A culture of patient safety is an effort to reduce unexpected injuries in healthcare to the lowest acceptable value.There are several factors, namely continuous improvement, prioritizing safety, non-punitive response to errors, reporting errors and incidents, evaluating incidents, studying and making changes that have an effect, open communication, personnel management, staff education and teamwork (Sariroh, 2023).Patient safety culture in organizations includes a culture of fairness, a reporting culture, a flexible culture, and a learning culture that interacts with each other in order to create an information culture (Hartanto & Warsito, 2017).Patient safety culture has directly visible indicators, including technology, training, procedures, and behavior, while those that do not appear to be a person (worker) are related to awareness, knowledge, motivation, etc. (Azizsyah, 2023).
Transformational leadership is the ability of leaders to change the work environment, work motivation, work habits and work values felt by subordinates to optimize their performance to achieve organizational goals (Anggraeni & Santosa, 2013).According to Abraham Maslow's theory, the leader's efforts transform followers from one low level of need to a higher level of need.The leader also transforms the expectations for followers' success and values and develops the organizational culture to achieve the goals the leader has set.Through transformational leadership, followers can achieve performance that exceeds what the leader has expected (performance beyond expectations) (Jufrizen, 2018).
Effective communication is the exchange of information, thoughts, and feelings, which causes changes in attitude so that a good relationship is established between the sender and recipient of the message (Harapan, Ahmad, & MM, 2022).Measurement of the effectiveness of the communication process can be seen from the achievement of the goals of the sender of the message.The message perceived by the receiver is the same as the intention and image of the sender.The background of the means of communication affects the delivery of messages (Putriana, 2022).
Trust is a person's willingness to be vulnerable to the actions of another party based on the expectation that the other party will perform specific actions that are important to the trustee, regardless of the ability to direct or control the other party.Vulnerability is the willingness to take risks.Faith reflects a person's wishes, assumptions or beliefs about the likelihood that his future actions will be beneficial, good or harmful to his interests.(Mayer et al., 1995).
Based on the results of a survey of patient safety culture in 2022 Hospital X in 2022 East Jakarta.Three indicators of health culture assessment are still low and need to be improved, namely reported events, hospital management support for patient safety and staffing at Hospital X.
Based on the patient satisfaction survey in 2022, it turns out that hospital X has not been reached in quarters I, II, and III.The target achievement is 92.46%.Meanwhile, the achievements were in the first quarter (89.49%), the second quarter (88.75%), the third quarter (88.85%), and the fourth quarter (99.43%).Meanwhile, the data on external complaints entered in 2022 at Hospital X amounted to 47 complaints.Of the 47 complaints, there were 6 complaints to nursing staff.
Based on the above background, the researcher is interested in researching "The Influence of Transformational Leadership and Effective Communication on Patient Safety Culture with Trust as Mediation in Nursing Personnel at X Hospital East Jakarta."

Research Methods
This study uses a cross-sectional quantitative research design using Structural Equation Modeling (SEM) with Smart Partial Least Square (PLS) software.(Hair Jr et al., 2021).Then, use a quantitative descriptive approach (Three Box Method).Data collection by distributing questionnaires.This research was conducted on June 20 -June 30, 2023, at X Hospital, East Jakarta.
The sampling technique in this study used stratified random sampling, where the sample taken was a nursing functional staff who provided services to patients at hospital X.The formula for calculating the number of samples in this study researchers used the Slovin formula (2005).Based on the calculation of population data using the Slovin formula with 5% precision and exclusion criteria, the number of samples in this study was 98 respondents.The constellations in this study are as follows:

Figure 1. Research constellations
The research hypothesis is formulated as follows: H1: There is a transformational leadership influence on patient safety culture.H2: There is an influence of transformational leadership on trust H3: There is an effective communication influence on patient safety culture.H4: There is an effect of effective communication on trust H5: There is a trust influence on patient safety culture.H6: There is a transformational leadership influence and communication of effectiveness in the face of patient safety culture with trust as mediation.

Results and Discussion
Based on the validity test results, it is known that the loading factor value in each question item of each research variable has a loading factor value of > 0.70, meaning that all question item indicators are valid indicators.Then stated for validity can also be assessed by Average Variance Extracted (AVE) where the AVE value of each construct > 0.50 (valid).Each indicator is also declared reliable by meeting Cronbach's alpha requirements of each variable > 0.70 and composite reliability of each > 0.70.A total index value of 98 with an interval value can be calculated at 73.5 and will result in a range of 24.5, which will be used as the basis for the interpretation of the following index values: Value Criterion 24,5-49 Low 49,1 -73,5 Keep 73,6 -98 Tall a. Transformational leadership analysis A transformational leadership indicator with a high average index of 76.03.This shows that transformational leadership plays a vital role in patient safety culture.This is to Bass's theory of transformational leadership, namely the ability of a leader to change the work environment, work motivation, work patterns, and work values prepared by subordinates so that they can achieve organizational goals where there are four dimensions and indicators (ideal influence, inspirational motivation, intellectual starts, individual considerations).(Benard M. Bass, 1985).

b. Effective communication analysis
An effective communication indicator with a high average index of 77.18.This shows that effective communication plays a vital role in safety culture.This is to Berlo's theory of effective communication, namely the exchange of information, ideas, and feelings that produce changes in attitude so that a good relationship is established between the messenger and the recipient of the message, where there are eight dimensions and indicators (direct, firm, friendly and friendly, clarity, accuracy, context, flow, culture).(Berlo, 1960).Effective communication is conveyed verbally or non-verbally, concretely and symbolically.When communicating, the individual expresses himself through words, movements, the intonation of voice, facial expressions and distance.This element works harmoniously to increase messages or conflicts to produce contradictions (Potter & Perry, 2010).c. Trust analysis A confidence indicator with a high average index of 75.88.These results suggest that trust in the scope of the sample is of high intensity and plays a role in the patient's long-lasting culture.This is consistent with Mayer et al.'s theory of trust, which is a person's willingness to be vulnerable to the actions of others based on the expectation that others will perform specific actions that are important to the trustor, regardless of the ability to monitor or control others, of which there are four dimensions and indicators (integrity, benevolence, competency, predictability).Mayer et al. (1995).Trust is a person's expectations, assumptions or beliefs about the possibility that his actions are helpful, beneficial, or at least not detrimental to the interests of others.Trust is a hospital's reliability, promise, and goodness that customers expect or feel.When trust is established, the commitment to the relationship between the hospital and the customer can be mutually beneficial.(According to Robinson, 1996) d.Analysis of patient safety culture The indicator of patient safety culture has a high average index of 76.95.These results show that the patient safety culture in the sample is high-intensity and plays a role in transformational leadership, effective communication and trust.This is to the Agency of Health Care Research and Quality's theory of patient safety culture, which is an effort to reduce the risk of unexpected injury in health care to the lowest acceptable value, where there are ten dimensions and indicators (Continuous improvement, giving priority to safety, nonpunitive response to errors, error and incident reporting, evaluating incidents, study and make effective changes, open communication, personnel management, staff education and teamwork).(AHRQ, 2014).Based on the results of the hypothesis test in Table 4 and Figure 2 above, the following conclusions can be given: 1.The results of testing the direct effect of transformational leadership on patient safety culture showed that the T value of 3.464 was more significant than 1.98 (t statistics count > t statistics table) and p-value of 0.001 (p-value < 0.05); there was a significant influence of transformational leadership variables (X1) on patient safety culture (Y). 2. The results of testing the direct effect of transformational leadership on trust showed that the value of T 4.586 was more significant than 1.98 (t statistics count > t statistics table) and p-value of 0.000 (p-value < 0.05), so there was a significant influence of the transformational leadership variable (X1) on trust (Z).3. The results of testing the direct effect of effective communication on patient safety culture showed that the value of T 3.573 was more significant than 1.98 (t statistics count > t statistics table) and p-value of 0.000 (p-value < 0.05), so there was a significant influence between the variables of effective communication (X2) on patient safety culture (Y). 4. The results of testing the direct effect of effective communication on trust show that the value of T 3.520 is more significant than 1.98 (t statistics count > t statistics table) and p-value of 0.000 (p-value < 0.05), so there is a significant influence of the influential communication variable (X2) on trust (Z). 5.The results of testing the direct effect of trust on patient safety culture showed that the T value of 5.145 was more significant than 1.98 (t statistics count > t statistics table) and p-value of 0.000 (p-value < 0.05), so there was a significant influence between the trust variable (Z) on patient safety culture (Y). 6.The results of testing the indirect influence of transformational leadership on patient survival culture with trust as mediation showed that the T value of 3.252 was more significant than 1.98 (t statistics count > t statistics table) and the p-value of 0.001 (p-value < 0.05) so that there was a significant influence between the transformational leadership variable (X1) on patient survival culture (Y) and trust as mediation (Z).Furthermore, the results of testing the indirect effect of effective communication on patient survival culture with trust as mediation showed that the T value of 2.937 was more significant than 1.98 (t statistics count > t statistics table) and p-value of 0.003 (p-value < 0.05) so that there was a significant influence between the influential communication variable (X2) on the patient's survival culture (Y) with trust as mediation (Z).From the results of Table 6, the SRMR value is 0.064.So, it can be concluded that the model shows a good fit.The goodness of Fit Index (GoF) is classified as small = 0.1, medium = 0.25 and large = 0.36.Table 4.16.above informs that the GOF value on the patient safety culture variable is 0.776.The test results showed that the GOF was more than 0.36.This means transformational leadership, effective communication, and trust have a profound influence on patient safety culture.In this study, transformational leadership (X1) had an effect on patient culture (Y), which had a path coefficient of 0.276, with a T-statistics value of 3.464 and a P-value of 0.001.Because the T-statistic value > T table (1.652) and P-value < 0.05, there was a positive and significant influence of 27.6% between transformational leadership variables (X1) on patient safety culture (Y).Thus, the research hypothesis that transformational leadership positively and significantly affects patient safety culture is "accepted."

Hypothesis test results with path test
From the results of this study, it was found that the dimension that most describes the transformational leadership variable is the inspirational motivation dimension of 89.9%, where efforts to achieve common goals involve teams and are supported by nurses.The highest indicator of the talent optimization dimension that describes transformational leadership is that the leader provides encouragement and advice that prioritizes patient safety at work by 94.6% and aims to motivate nurses so that patient safety is a top priority.Moreover, the % of intellectual stimulation 83% needs to be improved again, and leaders praise or appreciate nurses if they do an excellent job with patient safety procedures 84.7%.
From the results of this study, it was found that the most significant dimension describing the variable of patient safety culture was the dimension of non-punitive response to error for incidents of 79.6%, where nurses received a positive response when reporting patient safety incidents and would not receive punishment.The highest indicator of the talent optimization dimension that describes patient safety culture is training related to patient safety intensively and periodically, then learning from each other and sharing experiences about patient safety by 99.1%.Personnel management and cooperation between teams need to be improved again so that services and work are completed quickly by 65.3%.This is to Bass's theory of transformational leadership, namely the ability of a leader to change the work environment, work motivation, work patterns, and work values prepared by subordinates so that they can achieve organizational goals where there are four dimensions and indicators (ideal influence, inspirational motivation, intellectual starts, individual considerations).(Benard M. Bass, 1985).
The Agency of Health Care Research and Quality's theory of patient safety culture is an effort to reduce the risk of unexpected injury in health care to the lowest acceptable value, where there are ten dimensions and indicators (Continuous improvement, giving priority to safety, nonpunitive response to errors, reporting errors and incidents, evaluating incidents, studying and making changes that have an effect, open communication, personnel management, staff education, and teamwork).(AHRQ, 2014).A patient safety culture is the values shared among members of an organization about what is essential, their beliefs about how things operate within the organization, and the interaction of those values with work units and structural and organizational systems that produce norms of behavior within the organization that promote safety.The three main components of safety culture are learning culture, fair culture, and reporting culture.A culture of fairness is a culture of trust, in which what is acceptable and unacceptable is defined and fairness and accountability are essential components.A reporting culture encourages and facilitates the reporting of errors and safety issues and is committed to fixing what is broken.A learning culture learns from mistakes, near misses, and other identified safety issues.The three components are interrelated.Without a fair culture, your reporting is minimal, and without reporting, you do not have the opportunity to learn and grow.(Ulrich & Kear, 2014)

Influence transformational leadership on trust
In this study, transformational leadership influence (X1) on trust (Z) has a path coefficient of 0.531 with T-statistics of 4.586 and a P-value of 0.000.Because the Tstatistic value > T table (1.652) and P-value < 0.05, there was a positive and significant effect of 53.1% between the transformational leadership variable (X1) and trust (Z).Thus, the research hypothesis that transformational leadership positively and significantly affects trust is "accepted." From the results of this study, it was found that the dimension that most describes the transformational leadership variable is the inspirational motivation dimension of 89.9%, where efforts to achieve common goals involve teams and are supported by nurses.The highest indicator of the talent optimization dimension that describes transformational leadership is that the leader provides encouragement and advice that prioritizes patient safety at work by 94.6% and aims to motivate nurses so that patient safety is a top priority.Intellectual stimulation needs to be improved again, where the leader praises or appreciates the nurses if they do an excellent job in the Patient safety procedure by 84.7%.
From the results of this study, it was found that the dimension that most describes the variable of Trust is the integrity dimension of 85.5%, where efforts to perform services according to standards in carrying out patient safety practices and devote themselves to prioritizing patient safety in the hospital.The highest indicator of the talent optimization dimension that illustrates trust is having adequate experience handling patient safety at 97.3%.Moreover, the aspect that needs to be improved again is predicting the risks that occur in hospitals related to patient safety by 88.1%.This is to Bass's theory of transformational leadership, namely the ability of a leader to change the work environment, work motivation, work patterns, and work values prepared by subordinates so that they can achieve organizational goals where there are four dimensions and indicators (ideal influence, inspirational motivation, intellectual starts, individual considerations).(Benard M. Bass, 1985).
Mayer et al.'s theory of trust is the willingness of a person to be vulnerable to the actions of others based on the expectation that the other will perform specific actions that are important to the trustor, regardless of the ability to monitor or control others, of which there are four dimensions and indicators (integrity, benevolence, competency, predictability).(Mayer et al., 1995).Trust is a person's expectations, assumptions or beliefs about the possibility that his actions are helpful, beneficial, or at least not detrimental to the interests of others.Trust is a hospital's reliability, promise, and goodness that customers expect or feel.When trust is established, the commitment to the relationship between the hospital and the customer can be mutually beneficial.(According to Robinson, 1996) 3. The effect of effective communication on the culture of patient safety.
In this study, the effect of testing the effect of effective communication (X2) on patient safety culture (Y), which had a path coefficient of 0.279 with T-statistics of 3,573 and P-value of 0.000.Because the T-statistic value > T table (1.652) and P-value < 0.05, there was a positive and significant influence of 27.9% between the influential communication variable (X2) on patient safety culture (Y).Thus, the research hypothesis that effective communication positively and significantly affects patient safety culture is "accepted." From the results of this study, it was found that the most significant dimension describing the variable of effective communication was context by 86.8%, where nurses conveyed information according to the context of what should be done and what should not be done by the patient after I finished doing the action and also explained every start of medical action to be done to the patient.The highest indicator of the talent optimization dimension that describes effective communication is that nurses can create a familiar and comfortable atmosphere in communicating with patients by 94.7%.Then the aspect that needs to be improved again for friendly and friendly nurses by 75.3%, always smile, greet, greet, greet, polite and polite to patients and can create a familiar and comfortable atmosphere in communicating with patients and culture never gets reprimanded because of ethics and manners in communicating by 88.7%.
From the results of this study, it was found that the most significant dimension describing the variable of patient safety culture was the dimension of non-punitive response to error for incidents of 79.6%, where nurses received a positive response when reporting patient safety incidents and would not receive punishment.The highest indicator of the talent optimization dimension that describes patient safety culture is training related to patient safety intensively and periodically, then learning from each other and sharing experiences about patient safety by 99.1%.Moreover, aspects of personnel management and cooperation between teams must be improved again so that services and work are completed quickly by 65.3%.This is to Berlo's theory of effective communication, namely the exchange of information, ideas, and feelings that produce changes in attitude so that a good relationship is established between the messenger and the recipient of the message, where there are eight dimensions and indicators (direct, firm, friendly and friendly, clarity, accuracy, context, flow, culture).Effective communication is conveyed verbally or nonverbally, concretely and symbolically.When communicating, the individual expresses himself through words, movements, the intonation of voice, facial expressions and distance.This element works harmoniously to increase messages or conflicts to produce contradictions (Perry & Potter, 2010).
The Agency of Health Care Research and Quality's theory of patient safety culture is an effort to reduce the risk of unexpected injury in health care to the lowest acceptable value, where there are ten dimensions and indicators (Continuous improvement, giving priority to safety, nonpunitive response to errors, reporting errors and incidents, evaluating incidents, studying and making changes that have an effect, open communication, personnel management, staff education, and teamwork).A patient safety culture is the values shared among members of an organization about what is essential, their beliefs about how things operate within the organization, and the interaction of those values with work units and structural and organizational systems that together produce norms of behavior within the organization that promote safety (Arini, 2018).The three main components of safety culture are learning culture, fair culture, and reporting culture.A culture of fairness is a culture of trust, in which what is acceptable and unacceptable is defined and fairness and accountability are essential components.A reporting culture encourages and facilitates the reporting of errors and safety issues and is committed to fixing what is broken.A learning culture learns from mistakes, near misses, and other identified safety issues.The three components are interrelated.Without a fair culture, your reporting is minimal; without reporting, you do not have the opportunity to learn and grow (Ulrich & Kear, 2014).

The effect of effective communication on trust
In this study, an Effect of Effective Communication (X2) on Trust (Z) has a path coefficient of 0.412 with T-statistics of 3,520 and a P-value of 0.000.Because the Tstatistic value > T table (1.652) and P-value < 0.05, there was a positive and significant effect of 41.2% between the influential communication variable (X2) and trust (Z).Thus, the research hypothesis that effective communication positively and significantly affects trust is From the results of this study, it was found that the most significant dimension describing the variable of effective communication was context by 86.8%, where nurses conveyed information according to the context of what should be done and what should not be done by the patient after I finished doing the action and also explained every start of medical action to be done to the patient.The highest indicator of the talent optimization dimension that describes effective communication is that nurses can create a familiar and comfortable atmosphere in communicating with patients by 94.7%.The aspect that needs to be improved again for friendly and friendly nurses by 75.3% always smile, greet, greet, give greetings, courtesy and courtesy to patients and can create a familiar and comfortable atmosphere in communicating with patients and culture never gets reprimanded because of ethics and manners in communicating by 88.7%.
The results of this study found that the most significant dimension describing the variable of trust was the integrity dimension of 85.5%, where efforts to perform services according to standards in carrying out patient safety practices and devoting themselves to prioritizing patient safety in the hospital.The highest indicator of the talent optimization dimension that illustrates trust is adequate experience handling patient safety at 97.3%.Moreover, the aspect that needs to be improved again is predicting the risks that occur in hospitals related to patient safety by 88.1%.This is to Berlo's theory of effective communication, namely the exchange of information, ideas, and feelings that produce changes in attitude so that a good relationship is established between the messenger and the recipient of the message, where there are eight dimensions and indicators (direct, firm, friendly and friendly, clarity, accuracy, context, flow, culture).(Berlo, 1960).Effective communication is conveyed verbally or non-verbally, concretely and symbolically.When communicating, the individual expresses himself through words, movements, the intonation of voice, facial expressions and distance.This element works harmoniously to increase messages or conflicts to produce contradictions (Potter & Perry, 2010).
Mayer et al.'s theory of trust is the willingness of a person to be vulnerable to the actions of others based on the expectation that others will perform specific actions that are important to the trustor, regardless of the ability to monitor or control others, where there are four dimensions and indicators (integrity, benevolence, competency, predictability).Mayer et al. (1995).Trust is a person's expectations, assumptions or beliefs about the possibility that his actions are helpful, beneficial, or at least not detrimental to the interests of others.Trust is a hospital's reliability, promise, and goodness that customers expect or feel.When trust is established, the commitment of the relationship between the hospital and the customer can be mutually beneficial (According to Robinson, 1996). 5.The influence of trust on the culture of patient safety This study had confidence (Z) in patient safety culture (Y), which had a path coefficient of 0.442 with T-statistics of 5.145 and a P-value of 0.000.Because the Tstatistic value > T table (1.652) and P-value < 0.05, there was a positive and significant influence of 44.2% between the confidence variable (Z) on patient safety culture (Y).Thus, the research hypothesis that belief positively and significantly affects patient safety culture is "accepted." From the results of this study, it was found that the dimension that most describes the variable of trust is the integrity dimension of 85.5%, where efforts to provide services according to standards in carrying out patient safety practices and devote themselves to prioritizing patient safety in the hospital.The highest indicator of the talent optimization dimension that illustrates trust is adequate experience handling patient safety at 97.3%.Moreover, the aspect that needs to be improved again is predicting the risks that occur in hospitals related to patient safety by 88.1%.
From the results of this study, it was found that the most significant dimension describing the variable of patient safety culture was the dimension of non-punitive response to error for incidents of 79.6%, where nurses received a positive response when reporting patient safety incidents and would not receive punishment.The highest indicator of the talent optimization dimension that describes patient safety culture is training related to patient safety intensively and periodically, then learning from each other and sharing experiences about patient safety by 99.1%.Moreover, aspects of personnel management and cooperation between teams must be improved again so that services and work are completed quickly by 65.3%.This is to Mayer et al.'s theory of trust, namely the willingness of a person to be vulnerable to the actions of others based on the expectation that others will perform specific actions that are important to the trustor, regardless of the ability to monitor or control others, where there are four dimensions and indicators (integrity, benevolence, competency, predictability).(SUMANGKUT, Boham, & Marentek, 2019) Trust is a person's expectations, assumptions or beliefs about the possibility that his actions are helpful, beneficial, or at least not detrimental to the interests of others.Trust is a hospital's reliability, promise, and goodness that customers expect or feel.When trust is established, the commitment to the relationship between the hospital and the customer can be mutually beneficial.
The Agency of Health Care Research and Quality's theory of patient safety culture is an effort to reduce the risk of unexpected injury in health care to the lowest acceptable value, where there are ten dimensions and indicators (Continuous improvement, giving priority to safety, nonpunitive response to errors, reporting errors and incidents, evaluating incidents, studying and making changes that have an effect, open communication, personnel management, staff education, and teamwork).A patient safety culture is the values shared among members of an organization about what is essential, their beliefs about how things operate within the organization, and the interaction of those values with work units and structural and organizational systems that produce norms of behavior within the organization that promote safety.The three main components of safety culture are learning culture, fair culture, and reporting culture.A culture of fairness is a culture of trust, in which what is acceptable and unacceptable is defined and fairness and accountability are essential components.A reporting culture encourages and facilitates the reporting of errors and safety issues and is committed to fixing what is broken.A learning culture learns from mistakes, near misses, and other identified safety issues.The three components are interrelated.Without a fair culture, your reporting is minimal; without reporting, you do not have the opportunity to learn and grow (Ulrich & Kear, 2014).6. Influence transformational leadership and communicate effectively facing the patient's safety culture with trust as mediation.
In this study, transformational leadership (X1) was affected by patient safety culture (Y) with trust as mediation, having a path coefficient of 0.234 with T-statistics of 3.252 and a P-value of 0.001.Because the T-statistic value > T table (1.652) and P-value < 0.05, there was a positive and significant influence of 23.4% between the transformational leadership variable (X1) on patient safety culture (Y) and trust (Z) as mediation.Furthermore, testing the effect of effective communication (X2) on patient safety culture (Y) with trust (Z) as mediation has a path coefficient of 0.182 with Tstatistics of 2.937 and a P-value of 0.003.Because the T-statistic value > T table (1.652) and P-value < 0.05, there was a positive and significant influence of 18.2% between the influential communication variable (X2) on patient safety culture (Y) and trust (Z) as mediation.Thus, the research hypothesis that transformational leadership and effective communication positively and significantly affect patient safety culture with trust as mediation is "accepted." From the results of this study, it was found that the dimension that most describes the transformational leadership variable is the inspirational motivation dimension of 89.9%, where efforts to achieve common goals involve teams and are supported by nurses.The highest indicator of the talent optimization dimension that describes transformational leadership is that the leader provides encouragement and advice that prioritizes patient safety at work by 94.6% and aims to motivate nurses so that patient safety is a top priority.Aspects of intellectual stimulation need to be improved again, where leaders praise or appreciate nurses if they do an excellent job with patient safety procedures by 84.7%.
From the results of this study, it was found that the most significant dimension describing the variable of effective communication was context by 86.8%, where nurses conveyed information according to the context of what should be done and what should not be done by the patient after I finished doing the action and also explained every start of medical action to be done to the patient.The highest indicator of the talent optimization dimension that describes effective communication is that nurses can create a familiar and comfortable atmosphere in communicating with patients by 94.7%.The aspect that needs to be improved again for friendly and friendly nurses by 75.3% always smile, greet, greet, give greetings, courtesy and courtesy to patients and can create a familiar and comfortable atmosphere in communicating with patients and culture never gets reprimanded because of ethics and manners in communicating by 88.7%.
From the results of this study, it was found that the most significant dimension describing the variable of patient safety culture was the dimension of non-punitive response to error for incidents of 79.6%, where nurses received a positive response when reporting patient safety incidents and would not receive punishment.The highest indicator of the talent optimization dimension that describes patient safety culture is training related to patient safety intensively and periodically, then learning from each other and sharing experiences about patient safety by 99.1%.Moreover, aspects of personnel management and cooperation between teams must be improved again so that services and work are completed quickly by 65.3%.
From the results of this study, it was found that the dimension that most describes the variable of trust is the integrity dimension of 85.5%, where efforts to provide services according to standards in carrying out patient safety practices and devote themselves to prioritizing patient safety in the hospital.The highest indicator of the talent optimization dimension that illustrates trust is having adequate experience handling patient safety at 97.3%.Moreover, the aspect that needs to be improved again is predicting the risks that occur in hospitals related to patient safety by 88.1%.This is to Bass's theory of transformational leadership, namely the ability of a leader to change the work environment, work motivation, work patterns, and work values prepared by subordinates so that they can achieve organizational goals where there are four dimensions and indicators (ideal influence, inspirational motivation, intellectual starts, individual considerations).(Benard M. Bass, 1985).According to Berlo's theory of effective communication, namely the exchange of information, ideas, and feelings that produce changes in attitude so that a good relationship is established between the messenger and the recipient of the message, where there are eight dimensions and indicators (direct, firm, friendly and friendly, clarity, accuracy, context, flow, culture).(Berlo, 1960).According to Mayer et al.'s theory of trust, a person's willingness to be vulnerable to the actions of others is based on the expectation that others will perform specific actions that are important to the trustor, regardless of the ability to monitor or control others, of which there are four dimensions and indicators (integrity, benevolence, competency, predictability).(Mayer et al., 1995).The Agency of Health Care Research and Quality's theory of patient safety culture is an effort to reduce the risk of unexpected injury in health care to the lowest acceptable value, where there are ten dimensions and indicators (Continuous improvement, giving priority to safety, nonpunitive response to errors, reporting errors and incidents, evaluating incidents, studying and making changes that have an effect, open communication, personnel management, staff education, and teamwork) (AHRQ, 2014).
The results of the distribution of descriptive data from 4 dimensions with 10 transformational leadership indicators to 5 dimensions with 10 patient safety culture indicators through 4 dimensions with 10 trust variable indicators had a positive and significant effect of 23.4%.
The results of the distribution of descriptive data from 5 dimensions with 10 indicators of Effective communication to 5 dimensions with 10 indicators of patient safety culture through 4 dimensions with 10 indicators of trust variables had a positive and significant effect of 18.2%.

Conclusion
Based on the analysis conducted in this study, a conclusion that can be stated in this study is as follows: 1.There is a significant impact of transformational leadership on patient safety culture 2. There is a significant influence of transformational leadership on trust 3.There is a significant effect of effective communication on patient safety culture 4. There is a significant effect of effective communication on trust 5.There is a significant influence of trust on patient safety culture 6.There is a significant influence of transformational leadership and communication of effectiveness in facing the culture of patient safety with trust as mediation in nursing personnel in hospital X of population d = Desired significant level (set at 5% or 0.05)