Abstract
Background:
The purpose of this study is to design, implement, and evaluate the impact of a total quality management intervention on job performance and commitment among Jordanian nurses working in government hospitals.
Methods:
A quasi-experimental multiple time series was conducted starting in September 2017 and ending in June 2018. 140 nurses were sampled using the proportionate stratified random sampling technique; 132 were completed the study 67 the intervention group, while 65 in the control group.
Results:
There were no significant differences in nurses’ job performance or commitment between the 2 groups (control and intervention). A repeated measure MANOVA test for both groups revealed that the interaction between group and time was statistically significant (F (4, 127) = 144.841; P = .001; Wilk’s Λ = 0.180; η2 = .820), indicating that groups had a significantly different pattern of job performance and commitment over time. A repeated test The MANCOVA test for both groups across time revealed significant differences in nurses’ job performance and nurses’ commitment at a less than 0.05 significance level (F (2127) = 320.724; P = .001; Wilk’s Λ = 0.165; η2 = 0.835), and the overall effect of time was significant for all dependent variables (F (4125) = 36.879; P = .001; Wilk’s Λ = 0.459; η2 = 0.541).
Conclusion:
The educational intervention was effective in improving nursing job performance among the study sample. The improved commitment of respondents in the intervention group was attributed to the improvement in job performance.
Keywords: commitment, nurses, performance, total quality management
1. Introduction
Guaranteeing people’s healthy lives and patient and personnel safety and improving healthcare quality to create an effective healthcare system is crucial for maintaining high living standards.[1,2] Given the technological revolution in the healthcare industry and the need to meet health quality standards for maintaining high-quality services.[3] Healthcare services management has become challenging in this setting.[4] With hospitals operating in a competitive, complex, and dynamic environment, providing healthcare services has become increasingly difficult for hospital leadership, employees, and suppliers.[5,6] The situation could worsen owing to a lack of employee organizational commitment which is a significant driving force of employee turnover intention in several sectors.[7,8]
Although nurses are crucial partners in the healthcare sector and among the frontline healthcare practitioners required to achieve effective healthcare-related programs, numerous challenges confronting hospitals today are frequently attributed to a lack of nurses’ commitment and performance, given that nurse commitment is a critical issue in achieving overall hospital performance and pursuing the delivery of an effective healthcare system.[9–12] Commitment is strongly related to performance because committed nurses engage in more extra-role activities and behaviors such as creativity and innovation.[13] Nurses’ dedication and performance have long been recognized as quality service determinants for patients admitted to hospitals. Thus, increasing nurses’ commitment and performance cannot be overstated.[14]
Performance in nursing profession can simply be the ability of a nurse to accomplish a given task, responsibilities and roles efficiently.[10,15] Larrabee et al also reported a strong positive relationship between nurses’ performance and retention to stay in the hospital among working welfare recipients.[16] Performance and commitment of a nurse has been found to be strongly associated.[17,18] Commitment of nurses is also linked to their job performance and turnover.[19] Age and gender, education, heavy workload and burnout factors has been reported to affect nurse commitment.[20–22]
One practical approach to enhance nurses’ commitment and performance is connected with intervention programs like total quality management total quality management (TQM). TQM is recognized for continuous quality improvement, quality improvement, quality management, and total quality control.[23] TQM, as an intervention, can deal with all of the challenges that hospitals face and solve the majority of the problems that health organizations face.[24] TQM is used in the medical sector to embed quality orientation in all processes and procedures involved in providing health care, and it is widely assumed that the higher the level of TQM implementation, the higher the level of nurse performance and commitment to the assigned tasks.[25]
In Jordan, a lack of commitment could cause nurses migration and, consequently, a nursing shortage. According to Al Momani, a nursing shortage has created a healthcare crisis and adversely affected nursing care quality.[26] Nevertheless, quite few studies have examined specific TQM principles related to nurse performance, particularly the aspect of continuous quality improvement. Furthermore, commitment research on nurse commitment and performance is limited because organizational commitment among Jordanian nurses has not been well studied.[4] In light of the discussion above, the purpose of this study was to evaluate, and implement an effective TQM intervention to improve the commitment and performance of nurses in government hospitals in Jordan. According to the researchers’ knowledge, this is the first intervention study to introduce and design a TQM program to improve nurse commitment and performance in the Jordanian healthcare system. The primary goal of this study was to investigate the impact of TQM as an intervention program on nurse commitment and performance in a sample of Jordanian hospitals. This study is based on a research gap identified in the literature regarding nurse commitment and performance. As a result, the following 2 null hypotheses were proposed to guide the research.
H1: There will be a significant difference in the level of nurse commitment between and within the intervention and control hospitals before the intervention, as well as 1 month and 6 months after the intervention, in the 2 selected hospitals.
H2: There will be a significant difference in nurse performance between and within the intervention and control hospitals in the 2 selected hospitals before the intervention, as well as 1 month and 6 months after the intervention.
2. Materials and Methods
2.1. Research design and sample
This research adopted a quasi-experimental time series research design. Only 2 of the 8 hospitals were chosen for the current study because their capacities and human re-sources are comparable. The participants were nurses from the emergency and intensive care units, surgical, medical, obstetrics and gynecology, and pediatric wards at Irbid’s two government hospitals. G*Power software was used to calculate the sample size. Based on an estimated medium effect size (f2) = 0.15, α = 0.05, power = 0.95, to run logistic regression with 2 independent variables, the required sample size was estimated to be 140. Nurses were sampled using the proportionate stratified random sampling technique; 70 nurses from Al-ramtha hospital served as the intervention group, while 70 nurses from Alraea hospital served as the control group.
2.2. TQM intervention
The interventional group’s TQM intervention used the 5S-KAIZEN principle, which was developed in the Japanese manufacturing sector. A 5S-KAIZEN principle seeks to organize and manage the workplace in order to improve working conditions.[27] The term “5S” is an acronym for 5 Japanese terms that all begin with the letter S. These are Seiri, Seiton, Seisou, Seiketsu, and Shitsuke, which translate as Sort, Set, Shine, Standardize, and Sustain in English.[27,28] KAIZEN is a Japanese concept that concentrates on the philosophy of activity improvement.[29] KAIZEN is a CQI process that uses a continuous process to improve the standard of the work environment and service contents and keep them as user-friendly and convenient as possible.[29] The focus of KAIZEN in the hospital context is the hospital’s output in terms of improvement in working processes such as productivity, quality, service delivery, safety, staff morale, and cost control. The TQM intervention was divided into 4 stages: The preparatory stage, which occurred prior to the implementation stage, during which awareness of the importance of TQM was raised and the situation in the hospital prior to implementation was assessed; the introductory phase that involved training of health workers on the concepts, principles, and application of TQM; the implementation phase that related to the adoption and application of TQM on the day-to-day operations of the hospital; and the maintenance phase that dealt with the continuous use and sustainability of TQM.
2.3. Instruments
Contingent upon an all-inclusive literature survey, items addressing nurse commitment and performance instruments were adapted. Nurse commitment is theorized as a psychological state that represents the positive relationships of nurses with the hospital, making the employees desire to remain in the same organization.[30,31] The scale was used to assess commitment with 18 items. Affective commitment, continuance commitment, and normative commitment are the 3 subdomains of nurse commitment measurement. The instruments of nurse performance were carefully adapted from Park et al, and consisted of 46 items. The 46 items, which reflect TQM principles, constituted 3 major subdomains/dimensions: organization management, information management, and quality management. All concepts’ instruments were evaluated reflectively and on a 5-point Likert scale ranging from 1 = not at all to 5 = very well. The instrument showed very good internal consistency and reliability with Cronbach’s α of 0.8. The English version were used in the instruments.
2.4. Data collection
2.4.1. Pre-phase.
In 2017, data was collected through a concurrent pre-intervention assessment in which the performance of both groups was evaluated using a pre-tested questionnaire. The exam took approximately 30 minutes to complete.
2.4.2. Intra-phase.
Following the pre-intervention assessment in month November 2017, intervention materials were distributed to the intervention group by lecture, after 1 month of intervention. The intervention instructional material that were distributed to the respondents were divided into 6 sections. The material discussed how the 5S-KAIZEN approach could be tailored toward TQM actualization and used to improve nurses’ commitment and performance. The first section focused on SORT in the context of 5S, emphasizing the importance of separating essential items, materials, and tools needed in the workplace from those that aren’t and keeping only those that are. The second section focused on SET, which emphasized efficiency by organizing the sorted items, materials, and tools to promote workflow flow. Section 3 focused on SHINE, which advocated for keeping the workplace clean and neat; section 4 on STANDARD-IZE, which advocated for consistency of work practices in a standardized manner; and section 5 on SUSTAIN, which advocated for making compliance with all of the previous 4S an automatic habit. The sixth section discussed KAIZEN, which means “improvement” or “change for the better.” Each session contained lectures ranging from 15 to 25 minutes. After that, the instructor began a discussion, dividing participant’s into small groups of 3 to 5 participants. Six sequential weeks of the study were conducted to complete the intervention instructional material. Respondents could choose between the Arabic and English versions of the module. In addition, to improve material readability, the intervention module/materials were made concise and straightforward. The nurses were provided with the training facilities and training materials involving a training module based on applying 5S-KAIZEN-TQM in all hospital units and wards, including emergencies, surgical, medical, orthopedic, and ICU units.
2.4.3. The posttest phases.
Questionnaires were distributed to nurses to assess the intervention’s immediate effect. The same procedure was repeated 6 months later in May 2018, to examine the differences or similarities between the intervention group and the control group, as well as the effect of the intervention program on the intervention group.
2.4.4. Control group.
2.4.4.1. Pre-phase.
The teaching duration, pre-&post-test, instructor, and time were the same as those in the intervention group, but on a different day of the week.
2.4.4.2. Intra-phase.
The control group received no intervention.
2.4.4.3. Posttest phase.
The pretest exam was repeated.
2.5. Ethical approval
This work was thoroughly reviewed granted an approval by Ethical Committee on Human Research (JKEUPM), Faculty of Medicine and Health Sciences of the Universiti Putra Malaysia with ethics number: (FPSK-P064) 2017. Ethical clearance from the hospitals were obtained. Informed consent was obtained from the study participants. In this study guidelines outlined in the Declaration of Helsinki were followed.
2.6. Statistical analysis
This study’s data analysis was divided into 2 parts: descriptive and inferential analyses. The respondents’ profiles and demographic backgrounds were included in the descriptive analysis. In the inferential data analysis, the statistical assumptions of RM-MANOA were evaluated This was followed by estimating repeated measure RM-MANOVA for comparing groups for research variables and RM-MANOVA/ RM-MANCOVA to test the research hypotheses and education and experience. Two dependent variables commitment and performance were test by MANOVA. The significance threshold was set at = 0.05, and all hypotheses were tested using two-tailed hypotheses. IBM SPSS version 25 and AMOS were used as statistical programs.
3. Results
All the 140 questionnaires distributed to the participants in the 2 hospitals, 67 (96%) and 65 (94%) of the control and intervention groups completed the study. More than half were female in both the intervention (53.7%) and the control group (64.6%) respectively. Baseline comparison of socio-demographic characteristics between intervention and control groups demonstrated a non-significant difference in terms of gender (χ2 = 1.617, P = .204), education (χ2 = 1.519, P = .218), age (χ2 = 2.918, P = .713), experience (χ2 = 9.355, P = .096), attendance (χ2 = 1.211, P = .271), and wards (χ2 = 1.337, P = .855). Therefore, this comparison of socio-demographic characteristics of the respondents between intervention and control groups is an indication that there is an effective subjects selectivity since no difference was discerned. Table 1 shows the overall summary of the result.
Table 1.
Demographic characteristics of nurses in the intervention and control groups (N = 132).
| Variable | Level | Intervention | Control | χ2 | P value |
|---|---|---|---|---|---|
| Gender | Male | 31 (46.3) | 23 (35.4) | 1.617 | .204 |
| Female | 36 (53.7) | 42 (64.6) | |||
| Education | Bachelor | 56 (83.6) | 59 (90.8) | 1.519 | .218 |
| Master | 11 (16.4) | 6 (9.2) | |||
| Age | 20–24 yr | 0 | 1 (1.5) | 2.918 | .713 |
| 25–29 yr | 11 (16.4) | 9 (13.8) | |||
| 30–34 yr | 25 (37.3) | 19 (29.2) | |||
| 35–39 yr | 11 (16.4) | 14 (21.5) | |||
| 40–44 yr | 13 (19.4) | 12 (18.5) | |||
| 45 > | 7 (10.4) | 10 (15.4) | |||
| Experience | 1–5 yr | 9 (13.4) | 4 (6.2) | 9.355 | .096 |
| 6–10 yr | 8 (11.9) | 17 (26.2) | |||
| 11–15 yr | 25 (37.3) | 16 (24.6) | |||
| 16–20 yr | 17 (25.4) | 19 (29.2) | |||
| 21–25 yr | 7 (10.4) | 5 (7.7) | |||
| 26–30 yr | 1 (1.5) | 4 (6.2) | |||
| Attendance | Yes | 37 (55.2) | 42 (64.6) | 1.211 | .271 |
| No | 30 (44.8) | 23 (35.4) | |||
| Ward | Paediatric | 11 (16.4) | 7 (10.8) | 1.337 | .855 |
| Surgical | 19 (28.4) | 19 (29.2) | |||
| Medical | 15 (22.4) | 13 (20) | |||
| Obstetrics and Gynaecology | 10 (14.9) | 12 (18.5) | |||
| ICU | 12 (17.9) | 14 (21.5) |
The results of the MANCOVA pretest (F (2127) = 1.174. P = .312; Wilk’s = 0.982) revealed no significant differences in nurses’ commitment and job performance between the 2 groups (control and intervention) at the 0.05 level of significance. According to the results of repeated measure MANCOVA (RM-MANCOVA), there were significant differences between the 2 groups (control and intervention) on nurses’ commitment and job performance at the 0.05 level of significance (F (2127) = 320.724, P = 0.001; Wilk’s Λ = 0.165, η2 = 0.835). The overall effect of time on all nurses’ commitment and performance was also significant (F (4125) = 36.879. p 0.001; Wilk’s Λ = 0.459, η2 = 0.541). The interaction between the 2 groups and time was also statistically significant (F (4, 125) = 175.979, P = .001, Wilk’s Λ = 0.151, η2 = .849) (Table 2).
Table 2.
RM-MANCOVA results comparing between groups across time.
| Effect | Wilks’ Lambda | F | Hypothesis df | Error df | P value | η2p |
|---|---|---|---|---|---|---|
| Group | 0.165 | 320.724 | 2 | 127 | <.001 | 0.835 |
| Time | 0.459 | 36.879 | 4 | 125 | <.001 | 0.541 |
| Time * group | 0.151 | 175.979 | 4 | 125 | <.001 | 0.849 |
| Edu | 0.870 | 9.483 | 2 | 127 | <.001 | 0.130 |
| EXP | 0.991 | 0.570 | 2 | 127 | .567 | 0.009 |
Because there was statistical significance at the multivariate analysis level, the researchers ran the univariate analysis (Table 3) involving the RM-ANCOVA test. The results indicated that the main effect of the 2 groups (intervention and control) on job performance was statistically significant F (1, 128) = 378.439, P < .001, η2 = 0.747), and the effect of repeated measures across the time (test) for job performance was significant (F (1.87, 239.39) = 43.497. P < .001, η2 = 0.254) indicating that the interaction between the groups was statistically significant (F (1.87,239.39) = 146.979. P < .001, η2 = 0.535). This result signified that the 2 groups exhibited different patterns over time (pre, post, and follow-up tests) for job performance after controlling for education and experience. Likewise, the results showed that the main effect of the 2 groups (intervention and control) was statistically significant (F (1, 128) = 312.761, P < .001, η2 = 0.710). The results regarding the effect of repeated measures over time (test) for nurses’ commitment was significant (F (1.67, 214.7) = 12.722. P < .001, η2 = 0.090) indicated that the interaction between the 2 groups for nurses’ commitment was statistically significant F (1.67, 214.7) = 90.205. P < .001, η2 = 0.413, which means the level of nurses’ commitment between the 2 groups exhibited a different pattern over time (pre, post, and follow-up tests) after controlling for education and experience (Table 3).
Table 3.
RM-ANCOVA for all dependent variables (univariate analysis).
| Source | Variable | Df | MS | F | P value | η2 |
|---|---|---|---|---|---|---|
| Group | PF | 1 | 25168.99 | 378.493 | <.001 | 0.747 |
| CM | 1 | 3629.592 | 312.761 | <.001 | 0.710 | |
| Time | PF | 1.870 | 1960.395 | 43.497 | <.001 | 0.254 |
| CM | 1.677 | 131.571 | 12.722 | <.001 | 0.090 | |
| Time * group | PF | 1.870 | 6624.245 | 146.979 | <.001 | 0.535 |
| CM | 1.677 | 932.877 | 90.205 | <.001 | 0.413 |
A post hoc test (Bonferroni) was used to test the hypotheses (Table 4). The differences in nurses’ commitment and job performance between the pretest and post-test, as well as between the post-test and follow-up test, in the intervention groups were statistically significant (P = .01). Conversely, after controlling for education and experience, nurses’ commitment and job performance did not change significantly over time (P > .05) in the control group. The difference in nurses’ commitment and job performance between the pretest and post-test, as well as between the post-test and follow-up test, was statistically significant (P = .01) in the intervention group, but not in the control group (P > .05) after controlling for education and experience (Table 4).
Table 4.
Pairwise comparison across time for both control and intervention.
| Variable | Group | (J) Test | (I) Test | Mean Diff. | SE | P value | 95% CI for difference | |
|---|---|---|---|---|---|---|---|---|
| LB | UB | |||||||
| PF | Intervention | 2 | 1 | −22.964* | 1.113 | <.001 | −25.665 | −20.264 |
| 3 | 1 | −28.152* | 1.254 | <.001 | −31.193 | −25.111 | ||
| 3 | 2 | −5.188* | 0.998 | <.001 | −7.607 | −2.768 | ||
| Control | 2 | 1 | −2.514 | 1.13 | .084 | −5.256 | 0.228 | |
| 3 | 1 | −1.828 | 1.273 | .46 | −4.916 | 1.26 | ||
| 3 | 2 | 0.686 | 1.013 | 1 | −1.771 | 3.143 | ||
| CM | Intervention | 2 | 1 | −7.519* | 0.437 | <.001 | −8.58 | −6.458 |
| 3 | 1 | −8.623* | 0.466 | <.001 | −9.754 | −7.492 | ||
| 3 | 2 | −1.104 | 0.612 | .221 | −2.588 | 0.381 | ||
| Control | 2 | 1 | 0.95 | 0.444 | .103 | −0.127 | 2.028 | |
| 3 | 1 | −0.081 | 0.473 | 1 | −1.229 | 1.067 | ||
| 3 | 2 | −1.031 | 0.621 | .298 | −2.539 | 0.476 | ||
As shown in Table 5, the Bonferroni test revealed that the differences in nurses’ commitment and job performance between the experimental and control groups in the pretest were not statistically significant (P > .05), whereas the differences in nurses’ commitment and job performance between the experimental and control groups were significant in the post-test and follow-up test (P > .05).
Table 5.
Pairwise comparison between control and intervention at 3 different times.
| Variable | Test | (I) group | (J) group | Mean Diff. | SE | P value | 95% CI for difference | |
|---|---|---|---|---|---|---|---|---|
| LB | UB | |||||||
| CM | Pretest | Control | Intervention | 0.436 | 0.313 | .166 | −0.183 | 1.056 |
| Post-test | Control | Intervention | 8.906* | 0.529 | <.001 | 7.86 | 9.952 | |
| Follow-up | Control | Intervention | 8.978* | 0.718 | <.001 | 7.558 | 10.398 | |
| PM | Pretest | Control | Intervention | 0.49 | 1.362 | .72 | −2.205 | 3.185 |
| Post-test | Control | Intervention | 20.940* | 0.958 | <.001 | 19.045 | 22.835 | |
| Follow-up | Control | Intervention | 26.813* | 1.37 | <.001 | 24.103 | 29.524 | |
4. Discussion
The overarching results indicate that the level of nurses’ commitment and performance differed statistically between the pretest and post-test and between the post-test and follow-up tests in the intervention group, but not in the control group. These results confirm the positive effects of TQM interventions (measured by 5S KAIZEN) on nurses’ commitment and performance in the intervention group in the selected Jordanian hospitals. The repeated measure MANOVA test revealed significant differences between the 2 groups (control and intervention) on job performance and nurses’ commitment at the 0.05 significance level after 1 month of the intervention. This was due to the fact that the TQM intervention program was a comprehensive education program that was delivered effectively and conveyed key messages more frequently and with greater emphasis.[32] These findings imply that TQM as an educational intervention could improve nurse commitment and performance if employed in the healthcare sector.[33] This study’s findings are consistent with other experimental research. In their quasi-experimental research on 5S lean intervention, Al Dhaafri et al,[34] discovered that the intervention group reported higher satisfaction with a large effect size for the logical arrangement and product availability than the control group. The researchers concluded that the 5s lean intervention impacted some staff ratings of patient care quality.
This study’s findings regarding the effective role of providing TQM intervention are consistent with the results of other studies, among which is the experimental research of Bader et al,[35] on post-intervention measurement. They found improvement in performance and commitment in the intervention group with an effect size of 0.26. The interventional/operational research of El-Sherbiny and Elsary,[8] assessed the application of the 5S-KAIZEN-TQM approach in improving the quality of care provision in Egyptian hospitals. After implementing the 5S-KAIZEN approach, they discovered that the patient-hospital cycle time was reduced by more than 50%. Furthermore, after the 5S-KAIZEN-TQM educational intervention, healthcare professionals believed that using the 5S-KAIZEN approach saved them time, money, and effort while decreasing their daily workload and stress. Depending on this, the researchers noted that the 5S-KAIZEN approach could improve healthcare work environment standards, promote safe practices that result in high-quality, efficient care services, boost productivity at a low cost, and increase healthcare staff satisfaction with their professional image and communication with other personnel.
Take et al,[36] investigated the effect of 5S-KAIZEN-TQM practices on staff motivation and patient waiting time in Ugandan General Hospitals in another related interventional study. The study’s findings revealed that 5S-KAIZEN-TQM practices improved staff motivation in terms of commitment and waiting time in the dispensary in 10 hospitals that used 5S-KAIZEN-TQM practices. Moreover, the findings of the current study partially corroborated Sinha and Dhall’s, study on the relationship between TQM intervention and performance in India, their findings revealed that TQM interventions positively and significantly affected performance (P > .05), indicating that TQM interventions should be aligned with organizational culture, which will boost performance and help an organization improve global competitiveness.[37] Iqbal and Asrar-ul-Haq, discovered that TQM was positively and significantly related to employee performance with (S.E = 0.078, t = 4.593, and P = .01).[38]
Prasad and Prabhudesai,[39] discovered that TQM practices were significant and positive predictors of better employee performance in the Indian educational sector in a study of TQM practices and their influence on employee satisfaction and performance in India. Similarly, Carmona-Márquez et al,[40] used partial least squares (PLS) structural equation modeling to test their research model and hypotheses, and their findings indicated that TQM significantly and positively affected overall performance based on efficiency. TQM could significantly help promote continuous improvements in advancing safe, health, patient-centered, timely, efficient, and cost-effective quality care through nurses’ commitment and job performance involving in-role and extra-role work behaviors, according to the overall findings of the current study.[41] TQM’s 5S methodology could aid in the improvement of working processes involving productivity, quality, service delivery, safety, employee morale, and cost control.[42] TQM would eliminate waste and ensure the most efficient use of resources at the hospital. Furthermore, it could be argued that TQM’s 5S-KAIZEN is best suited to the hospital environment because it ensures work standardization within health organizations.[43] It also ensures that standards for organizing, cleaning, developing, and maintaining a productive workplace are met. TQM centered on human resource management based on leadership, teamwork, training, and employee involvement principles could improve commitment and, as a result, workforce performance in any health-care organization.[44]
The findings of this study emphasize that 5S-KAIZEN-TQM intervention is a systemic, continuous approach that should be used to improve nurses’ and health workers’ commitment, productivity, quality, and performance. This is due to the fact that the 5S-KAIZEN has been recognized as a problem-solving technique based on a plan-do-check-adjust (PDCA) quality cycle and the practices required for continuous improvement.[45] Furthermore, because the study did not only describe the problem, but it also offers reasonable solutions to the problems of low-level commitment and performance, the findings of this research can serve as a practical solution to enhancing employee commitment and attendant performance. The study’s design and interventions allowed nurses to enhance their knowledge and awareness about enhanced commitment and performance, and this led to greater adherence to recommended practices, which achieved the desired change. A quasi-experimental design generates reliable evidence and can guide decision-makers to implement educational interventions to improve nurses’ commitment and performance. Likewise, this research provides practical solutions for the health care managers on how to apply 5S-KAIZEN TQM educational intervention to improve service quality and nurses’ outcomes. It also helps to increase the knowledge on how to increase healthcare practitioners’ adherence to delivered interventions that aim to improve service outcomes.[46–48]
5. Conclusions
With its findings that TQM intervention may help promote continuous improvements in advancing cost-effective quality care, this study enriched the existing body of knowledge in the TQM, nursing, and health management research field. Although this research achieved its objectives and expanded the existing scope of knowledge, there were limitations. The participating hospitals in this experimental research were public-oriented. In the managerial aspect, this study offers guidelines for the stakeholders, hospital managers, and policymakers, which will benefit the sustained enhancement of nurses’ commitment and performance. The results showed that nurses’ commitment and performance levels grew with an increase in the educational level and working experience of the nurses. One reason is that nurses with high education and many years of working experience would have developed their practice knowledge, skills, and abilities required for enhanced commitment and performance. Therefore, privately-owned hospitals could be included in future research to extend the findings. Also, the duration of follow-up may be inadequate to assess the long-term effects of TQM educational intervention due to resource constraints on the researcher and time constraints on the participants. Therefore, future experimental research could consider a more extended follow-up period. On the whole, this study has made significant contributions to the body of knowledge and has significant implications for stakeholders and policymakers. The findings of the study have broadened the scope of knowledge in the existing literature.
Acknowledgments
The authors extend their appreciation to Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2023R279), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.
Author contributions
Conceptualization: Majdi M. Alzoubi.
Data curation: Khalid AL-Mugheed.
Formal analysis: Majdi M. Alzoubi, Khaled M. Al-Zoubi.
Funding acquisition: Samira A. Alsenany.
Project administration: Hayati KS.
Resources: Khalid AL-Mugheed, Samira A. Alsenany.
Supervision: Rosliza AM.
Visualization: Rosliza AM.
Writing – original draft: Majdi M. Alzoubi, Sally M.F. Abdelaliem.
Writing – review & editing: Isalm Oweidat, Sally M.F. Abdelaliem.
Abbreviations:
- TQM
- total quality management
The research was funded by Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2023R279), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Alzoubi MM, KS H, AM R, Al-Zoubi KM, AL-Mugheed K, Alsenany SA, Oweidat I, Abdelaliem SMF. Effect of total quality management intervention on nurse commitment and nurse performance: A quasi-experimental study. Medicine 2023;102:40(e35390).
References
- [1].Abdelaliem SMF, Alsenany SA. Factors affecting patient safety culture from nurses’ perspectives for sustainable nursing practice. Healthcare (Basel, Switzerland). 2022;10:1889. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [2].AL-Mugheed K, Bayraktar N, Al-Bsheish M, et al. Patient safety attitudes among doctors and nurses: associations with workload, adverse events, experience. Healthcare (Basel, Switzerland). 2022;10:631. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Chang CS, Chen SY, Lan YT. Service quality, trust, and patient satisfaction in interpersonal-based medical service encounters. BMC Health Serv Res. 2013;13:22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [4].Saleh A, Darawad M, Al-Hussami M. Organizational commitment and work satisfaction among Jordanian nurses: a comparative study. Life Sci J. 2014;11:31–6. [Google Scholar]
- [5].Aoun M, Hasnan N, Al-Aaraj H. Relationship between lean practices, soft total quality management and innovation skills in Lebanese hospitals. East Mediterr Health J. 2018;24:269–76. [DOI] [PubMed] [Google Scholar]
- [6].Al-Mugheed K, Bayraktar N. Patient safety attitudes among critical care nurses: a case study in North Cyprus. Int J Health Plan Manag. 2020;35:910–21. [DOI] [PubMed] [Google Scholar]
- [7].Van DJ, Coetzee M. Retention factors in relation to organisational commitment in medical and information technology services. SA J Hum Res Mana. 2012;2:1–11. [Google Scholar]
- [8].El-Sherbiny NA, Elsary AY. Physical activity levels among Fayoum governorate population (Egypt): Community-based survey. J Public Health Epidemiol. 2018;10:69–76. [Google Scholar]
- [9].Ismail AI, Majid AH, Zakaria M, et al. Factors predicting health practitioners’ awareness of UNHS program in Malaysian non-public hospitals. Int J Pediatr Otorhinolaryngol. 2018;109:78–84. [DOI] [PubMed] [Google Scholar]
- [10].Awases MH, Bezuidenhout MC, Roos JH. Factors affecting the performance of professional nurses in Namibia. Curationis. 2013;36:1–8. [DOI] [PubMed] [Google Scholar]
- [11].Loes CN, Tobin MB. Does empowerment enhance nurses’ organizational commitment? J Nurs Manag. 2022;30:3123–30. [DOI] [PubMed] [Google Scholar]
- [12].Alzoubi MM, Al-Mahasneh A, Al-Mugheed K, et al. Medication administration error perceptions among critical care nurses: a cross-sectional, descriptive study. J Multidiscip Healthc. 2023;16:1503–12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [13].Loes CN, Tobin MB. Organizational trust, psychological empowerment, and organizational commitment among licensed practical nurses. Nurs Adm Q. 2020;44:179–87. [DOI] [PubMed] [Google Scholar]
- [14].Alzoubi MM, Hayati KS, Rosliza AM, et al. Total quality management intervention for enhancing nursing commitment and performance in Jordanian Hospital: protocol of a Quasi-Experimental study. Int J Adv Sci Res Dev. 2018;5:01–2. [Google Scholar]
- [15].Mehmet T. Organizational variables on nurses’ job performance in Turkey: nursing assessments. Iran J Public Health. 2013;42:261. [PMC free article] [PubMed] [Google Scholar]
- [16].Larrabee JH, Wu Y, Persily CA, et al. Influence of stress resiliency on RN job satisfaction and intent to stay. West J Nurs Res. 2010;32:81–102. [DOI] [PubMed] [Google Scholar]
- [17].Oh EH, Chung BY. The effect of empowerment on nursing performance, job satisfaction, organizational commitment, and turnover intention in hospital nurses. J Korean Acad Nurs Adm. 2011;17:391–401. [Google Scholar]
- [18].Somers MJ. The combined influence of affective, continuance and normative commitment on employee withdrawal. J Vocat Behav. 2009;74:75–81. [Google Scholar]
- [19].Kelarijani S, Heidarian AR, Jamshidi R, et al. Length of service and commitment of nurses in hospitals of Social Security Organization (SSO) in Tehran. Caspian J Intern Med. 2014;5:94. [PMC free article] [PubMed] [Google Scholar]
- [20].Li A, Early SF, Mahrer NE, et al. Group cohesion and organizational commitment: protective factors for nurse residents’ job satisfaction, compassion fatigue, compassion satisfaction, and burnout. J Prof Nurs. 2014;30:89–99. [DOI] [PubMed] [Google Scholar]
- [21].Al-Ahmadi H. Factors affecting performance of hospital nurses in Riyadh Region, Saudi Arabia. Int J Health Care Qual Assur. 2009;22:40–54. [DOI] [PubMed] [Google Scholar]
- [22].Chan ZC, Tam WS, Lung MK, et al. A systematic literature review of nurse shortage and the intention to leave. J Nurs Manag. 2013;21:605–13. [DOI] [PubMed] [Google Scholar]
- [23].Sallis E. Total Quality Management in Education. Routledge; 2014. [Google Scholar]
- [24].Hamidi Y, Moghadam S, Hazavehei S, et al. Effect of TQM educational interventions on the management policy standard of health promoting hospitals. Health Promot Int. 2021;36:397–405. [DOI] [PubMed] [Google Scholar]
- [25].El-Tohamy AE, Al Raoush AT. The impact of applying total quality management principles on the overall hospital effectiveness: an empirical study on the HCAC accredited governmental hospitals in Jordan. Eur Sci J. 2015;11. [Google Scholar]
- [26].Al-Momani MM. Improving nurse retention in Jordanian public hospitals. Topic Adv Pract Nurs J. 2008;8:121–8. [Google Scholar]
- [27].Ishijima H, Eliakimu E, Takahashi S, et al. Factors influencing national rollout of quality improvement approaches to public hospitals in Tanzania. Clin Governance. 2014;19:137–52. [Google Scholar]
- [28].Ishijima H, Eliakimu E, Mshana JM. The “5S” approach to improve a working environment can reduce waiting time: Findings from hospitals in Northern Tanzania. TQM J. 2016;28:664–80. [Google Scholar]
- [29].MoHSW T. Implementation Guidelines for 5S-KAIZEN-TQM approaches in Tanzania, Foundation of all Quality Improvement Programs. 3rd ed. 2013. [Google Scholar]
- [30].Meyer JP, Allen NJ, Allen NJ. Commitment in the Workplace. Theory, Research, and Application Sage Publications; 1997. [Google Scholar]
- [31].Park JE, Kim SS. Development of a nursing competency scale according to a clinical ladder system for intensive care nurses. J Korean Acad Nurs Adm. 2013;19:501–12. [Google Scholar]
- [32].Shen J, Guo Y, Chen X, et al. Male nurses’ work performance: a cross sectional study. Medicine (Baltimore). 2022;101:e29977. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [33].Sibandze BT, Scafide KN. Among nurses, how does education level impact professional values? A systematic review. Int Nurs Rev. 2018;65:65–77. [DOI] [PubMed] [Google Scholar]
- [34].Al Dhaafri HS, Yusoff B, Al Swidi K. The relationship between enterprise resource planning, total quality management, organizational excellence, and organizational performance-the mediating role of total quality management and organizational excellence. Asian Soc Sci. 2014;10:158–78. [Google Scholar]
- [35].Bader MK, Palmer S, Stalcup C, et al. Using a FOCUS-PDCA quality improvement model for applying the severe traumatic brain injury guidelines to practice: process and outcomes. Evidence-Based Nurs. 2003;6:6–8. [PubMed] [Google Scholar]
- [36].Take N, Byakika S, Tasei H, et al. The effect of 5S-Continuous quality improvement-total quality management approach on staff motivation, patients’ waiting time and patient satisfaction with services at hospitals in Uganda. J Public Health Afr. 2015;6:486. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [37].Sinha N, Dhall N. Mediating effect of TQM on relationship between organisational culture and performance: evidence from Indian SMEs. Total Qual. Manag Bus Excell. 2018;31:1841–65. [Google Scholar]
- [38].Anam I, Asrar-ul-Haq M. Establishing relationship between TQM practices and employee performance: the mediating role of change readiness. Int J Prod Econ. 2018;203:62–8. [Google Scholar]
- [39].Prasad CV, Prabhudesai R. An empirical study on TQM practices and its influence on employee satisfaction and performance in technical institutions: teachers’ perspectives. J Mgt Mkt Rev. 2018;3:169–78. [Google Scholar]
- [40].Carmona-Márquez FJ, Leal-Rodriguez AL, Leal-Millán A, et al. TQM implementation: from institutionalization to superior performance attainment. Acad Manag Proceed. 2018;2018:14475. [Google Scholar]
- [41].Talib F, Rahman Z, Azam M. Best practices of total quality management implementation in health care settings. Health Mark Q. 2011;28:232–52. [DOI] [PubMed] [Google Scholar]
- [42].Anderson R, Eriksson H, Torstensson H. “Smililarities and differences between TQM, six sigma and lean,”. TQM Magazine. 2006;18:282–96. [Google Scholar]
- [43].Janjić V, Todorović M, Domanović V. “TQM and KAIZEN for continuous quality management,” Economics and Organization, 2018, 15, 1, 43-55. Available at: http://casopisi.junis.ni.ac.rs/index.php/FUEconOrg/article/view/3120 [access date November 20, 2018].
- [44].Kanamori S, Shibanumba A, Jimba M. Applicability of the 5S management method for quality improvement in healthcare facilities: a review. Trop Med Health. 2016;21:1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [45].Kanamori S, Castro MC, Sow S, et al. Impact of the Japanese 5S management method on patients’ and caretakers’ satisfaction: a quasi-experimental study in Senegal. Glob Health Action. 2016;9:1–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [46].Mazzocato P, Stenfors-Hayes T, Thiele SU, et al. Kaizen practice in healthcare: a qualitative analysis of hospital employees’ suggestions for improvement. BMJ Open. 2016;6:7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [47].Suleiman K, Hijazi Z, Al Kalaldeh M, et al. Quality of nursing work life and related factors among emergency nurses in Jordan. J Occup Health. 2019;61:398–406. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [48].AlNawafleh AH, Muwafaq AM, Alhalaiqa F. Patient safety education: a perspective of Southern Jordan Nursing Students’. Nat App Sci Series. 2022;37. [Google Scholar]