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Employee organizational commitment and hospital performance

Baird, Kevin M.; Tung, Amy; Yu, Yanjie

doi: 10.1097/HMR.0000000000000181
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Background: There is widespread evidence of the purported benefits of employee organizational commitment (EOC) and its impact on both individual and organizational performance. This study contributes to this literature by providing a unique insight into this relationship, focusing on the interrelationship between EOC with hospital performance and the role of the provision of adequate facilities in eliciting EOC.

Purpose: The aim of this study was to introduce and empirically examine a new theoretical model in which it is argued that the performance of hospitals with regard to the provision of adequate facilities (medical facilities, support facilities, and staff resources) influences the level of EOC, which in turn influences hospital performance with regard to patient care and operational effectiveness.

Methodology/Approach: To examine the interrelationships between the provision of adequate facilities, EOC, and hospital performance, the study utilizes a survey of hospital managers.

Results: The findings support the theoretical model, with the provision of support facilities and staff resources positively indirectly associated with both patient care and operational effectiveness through their impact on EOC.

Conclusion: The findings highlight the importance of providing adequate facilities and EOC within hospitals and suggest that CEOs and general managers should try to enhance the provision of such resources in an attempt to elicit EOC within their hospitals.

Practice Implications: The findings suggest that managers should try to enhance their provision of adequate facilities in order to elicit EOC and enhance hospital performance. With regard to medical facilities, they should consider and incorporate the latest technology and up-to-date equipment. They should also provide adequate staff resources, including appropriate numbers of beds, nurses, and doctors, to prevent “fatigue” (West, 2001, p. 41) and provide adequate support facilities.

Kevin M. Baird, BEc (Hons), MCom, PhD, is Associate Professor, Department of Accounting and Corporate Governance, Macquarie University, Sydney, New South Wales, Australia. E-mail: kevin.baird@mq.edu.au.

Amy Tung, BBA with BCom (Hons), MIB, PhD, is Lecturer, Department of Accounting and Corporate Governance, Macquarie University, Sydney, New South Wales, Australia.

Yanjie Yu, MI (Acc & Fin), MRes, is Research Associate, Department of Accounting and Corporate Governance, Macquarie University, Sydney, New South Wales, Australia.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

There is increasing evidence to support the importance of employee engagement in enhancing the performance of hospitals. For instance, a study by West, Dawson, Admasachew, and Topakas (2011) conducted in England’s National Health Service reported a positive association between staff engagement with both the quality of patient care and financial performance, whereas Lowe (2012) found that higher engagement led to better patient-centered care, employee retention, and a better patient safety culture. Similarly, other studies refer to the importance of employees in managing hospital performance, in particular because of the scarcity of human resources and the fact that “knowledge intensive and service-based organizations are especially reliant on employee contribution and commitment for their effective operation” (Simmons, 2008, p. 463).

This study aims to contribute to the limited empirical literature examining the role of employee engagement in enhancing hospital performance, focusing on the organizational commitment aspect of employee engagement. In particular, the first objective of the study is to extend the contingency literature in this area by focusing on the association between employee organizational commitment (EOC), defined as an employee’s identification with the organization’s goals and values, their willingness to exert a great effort on behalf of the organization and their intent to stay with the organization (Porter, Steers, Mowdat, & Boulian, 1974), and hospital performance.

EOC is widely referred to in the literature because of its “linkage to behavioural consequences desirable at an organizational level” (McKinnon, Harrison, Chow, & Wu, 2003, p. 26). Thanacoody, Newman, and Fuchs (2014, p. 1841) highlight the importance of EOC in hospitals, stating that “in an environment characterised by constant institutional change and uncertainty, policy makers and academics have begun to recognise that an engaged, healthy and motivated workforce is vital to the delivery of high-quality healthcare.” Simmons (2008) suggests that the commitment of employees must be elicited by the organization rather than assumed, implying that organizations should try to be proactive in influencing the level of EOC within their organization. Accordingly, given its importance, many studies have focused on the antecedents of EOC (McKinnon et al., 2003; Su, Baird, & Blair, 2013).

However, little research has been conducted on the contingency factors influencing EOC in the public sector (Su et al., 2013) and even less in the health care industry. Therefore, given that the focus on EOC within the health care industry is becoming increasingly important (Top, Akdere, & Tarcan, 2015), the second objective of this study is to contribute to the contingency literature examining the factors influencing the level of EOC in the context of hospitals. In particular, amidst evidence that engaged employees, who are both capable and committed, can enhance hospital performance (Lowe, 2012; West et al., 2011), it is important to gain an insight into how to enhance the level of such engagement. In this respect, Su, Baird, and Schoch (2015) found that input controls (e.g., appropriate selection, training, and skill development activities) were associated with the level of EOC, with such controls used to manage the resources acquired by organizations, including employees’ knowledge and skills, to ensure that employees are capable of performing their jobs in the desired way (Cardinal, Sitkin, & Long, 2004). We extend this research in the following way. Specifically, whereas Su et al. (2015) focus on the capability aspect of engagement, in particular the role of input controls in managing the limited human resources available, we explore this contingency factor from a different perspective, focusing on the perceived availability of resources. Specifically, we focus on the association between the provision of adequate facilities (medical facilities, support facilities, and staff resources) and the level of EOC.

The focus on the provision of adequate facilities as a contingency factor influencing the level of EOC is considered pertinent for a number of reasons. First, there is constant scrutiny over the level of government funding provided within the health care sector with evidence of “a reduction in governmental funding, and a greater pressure to offer high-quality patient care with ever few resources” (Thanacoody et al., 2014, p. 1841). For example, in Australia there is “increased pressure for more infrastructure resources and improved clinical and information management technologies” (Townsend, Lawrence, & Wilkinson, 2013, p. 3062), concerns that it is difficult “to attract and retain suitably qualified staff in an aging workforce” (Townsend et al., 2013, p. 3062), and claims that “the availability of health-care professionals is insufficient to meet patient demands” (Thanacoody et al., 2014, p. 1844). In addition, in line with the New Public Management approach, there is increasing pressure on hospitals to be more efficient and effective in their operations with “greater pressure to offer high-quality patient care with limited resources” (Thanacoody et al., 2014, p. 1844). Finally, as depicted in the conservation of resources theory (Hobfoll, 1989), employees will engage in coping behavior in response to alterations in the provision of resources, and hence, knowledge concerning the impact of changes in the availability of resources on employee commitment is crucial.

In examining the association between EOC and hospital performance and the antecedents of EOC, the article introduces and empirically examines a new theoretical model, the Ontario Hospital Association Quality Healthcare Workplace model, which consists of three levels, the drivers of performance (the work environment, job characteristics, and organizational support), which influence individual outcomes (including engaged and capable employees) and subsequently influence organizational outcomes including quality and patient safety, staff recruitment and retention, employer reputation, and productivity and costs. The study reflects this model, focusing on the provision of adequate facilities (medical facilities, support facilities, and staff resources) as an indicator of the level of organizational support provided, EOC to reflect individual outcomes, and patient care and operational effectiveness (the extent to which patients get treatment in the most effective and efficient way) to reflect organizational outcomes. In particular, it is argued that the performance of hospitals with regard to the provision of adequate facilities (medical facilities, support facilities, and staff resources) influences the level of EOC, which in turn influences hospital performance with regard to patient care and operational effectiveness.

Hence, in summary, the specific aims of the study are to investigate the following:

  1. the association between the provision of adequate facilities and the level of EOC,
  2. the association between the level of EOC and hospital performance, and
  3. the mediating role of the level of EOC on the association between the provision of adequate facilities with hospital performance.
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Literature Review and Hypotheses Development

The Association Quality Healthcare Workplace Model

The Association Quality Healthcare Workplace model was created by the Ontario Hospital Association in an attempt to provide an insight into the factors influencing performance in the health care industry. The model maintains that the achievement of specific organizational outcomes is dependent on both the drivers of performance (including characteristics of the work environment and the level of organizational support provided) and the achievement of individual employee outcomes, with the latter influenced by the drivers of performance. Hence, the model consists of three levels with the drivers of performance influencing the achievement of individual outcomes, which in turn are expected to influence the achievement of desired organizational outcomes. The achievement of individual outcomes, specifically engaged and capable employees, is central to this model with Lowe (2012, p. 29), maintaining that “managers increasingly understand that employee engagement is a prerequisite for high performance.” In particular, engaged employees are essential because of their commitment to achieving organizational goals and evidence of the positive association between employee engagement with other desirable human resource goals including job retention, individual job performance, and absenteeism (Lowe, 2012). In addition, because of the importance of employee engagement, it is equally appropriate for hospital managers to focus on the factors that contribute to the enhancement of employee engagement. Hence, the model also focuses on the factors contributing to a healthy and productive workplace, specifically the work environment, job characteristics, and/or level of organizational support provided.

The study provides an empirical insight into this model, focusing on the interrelationships between the level of organizational support, operationalized with regard to the provision of adequate facilities (medical facilities, support facilities, and staff resources), employee engagement, specifically the level of EOC, and hospital performance, operationalized with regard to the level of patient care and operational effectiveness. As depicted in the Association Quality Healthcare Workplace model, we hypothesize that the provision of adequate facilities will influence hospital performance indirectly through the level of EOC. Specifically, although an enhancement in the provision of facilities is expected to influence hospital performance, this effect takes place because of the positive impact that the provision of the facilities has on EOC, with the enhanced level of EOC resulting in better performance. Hence, as discussed in the subsections below, the provision of adequate facilities exhibits a positive association with EOC, which in turn exhibits a positive association with hospital performance, and hence, the level of EOC mediates the relationship between the provision of adequate facilities and hospital performance.

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Employee Engagement

“Engaged employees are committed to their employer, satisfied with their work and willing to give extra effort to achieve the organization’s goals” (Lowe, 2012, p. 33). Higher engagement is desirable both from an individual and organizational perspective. First, from the individual employee perspective, social identity theory maintains that individuals seek to identify with relevant social groups, and hence, their identification with, engagement with, and/or commitment to an organization represents part of their self-concept and/or self-value. Consequently, the identification with and/or commitment to an organization is something that is sought by employees. Second, from the organizational perspective, higher engagement is desirable because of the positive association between employee engagement and the achievement of other desirable human resources-related goals.

Lowe (2012) focused on three dimensions of employee engagement: emotional, rational, and behavioral. This study focuses on a particular aspect of employee engagement, organizational commitment, specifically the level of EOC. O'Reilly (1989) defines EOC as an employee’s psychological attachment to the organization. In line with this definition, EOC is measured as an “employees’ emotional attachment to, identification with, and involvement in the organization” (Meyer & Allen, 1997, p. 11) using Cook and Wall’s (1980) nine-item measure (see Appendix).

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The Association Between the Provision of Adequate Facilities and EOC

As previously discussed, following the introduction of the New Public Management approach, the focus on the provision of resources is considered important because hospitals face increasing accountability requirements and are expected to maintain high patient care standards with fewer resources (Laschinger, Finegan, & Shamian, 2001). The focus on providing adequate facilities is also important because of the “importance of hospital facilities in improving outcomes, economic performance, [and] productivity” (Becker & Parsons, 2007, p. 263). Although hospital staff are responsible for providing a high level of patient care, the impetus is on managers to provide sufficient resources to facilitate such care. In particular, Laschinger et al. state that “if managers cannot provide these resources due to staff shortages, fiscal restraint, breakdown of ageing equipment, or inadequate supplies, staff nurses may not be able to keep their side of the agreement” (Laschinger et al., 2001, p. 19). Hence, although it is expected that the provision of resources (medical facilities, support facilities, and staff resources) will impact the performance of hospitals, we argue that this effect transpires through the impact of the provision of resources on employees, specifically their level of EOC.

The association between the provision of adequate facilities and EOC is alluded to by Gregory, Way, LeFort, Barrett, and Parfrey (2007, p. 119), who refer to evidence that “the presence or absence of supportive work environments helps explain the differences observed in employee attitudes and turnover intentions.” Similarly, Lowe (2012) found evidence that the provision of adequate resources was one of the top 10 drivers of engagement among employees.

In theorizing the association between the provision of adequate facilities and EOC, we rely on Kanter’s (1977) theory of organizational empowerment and the conservation of resources theory. First, with regard to Kanter’s theory, it is argued that the provision of sufficient resources evokes a sense of empowerment among employees because they are provided with the flexibility and autonomy to perform their duties in a responsible and timely manner. Accordingly, “having access to [the] resources necessary to do the job” results in more satisfied employees who are more committed to the organization (Laschinger et al., 2001, p. 8).

Alternatively, when insufficient resources are provided, it is expected that this will result in increased workload expectations, and “healthcare professionals [will] exhibit lower levels of commitment” (Thanacoody et al., 2014, p. 1841). The conservation of resources theory can explain this situation. This theory maintains that “people strive to retain, protect and build resources and that what is threatening to them is the potential or actual loss of these valued resources” (Hobfoll, 1989, p. 513). Hobfoll (1989) maintains that insufficient resources affect stress, which results in specific behavioral responses. Similarly, Sherif (1958) refers to the influence of too few resources in promoting intergroup conflicts and the need to resolve such situations. Hence, Hobfoll and others argue that “individuals will protect their valued resources from being depleted by engaging in some coping behaviours (that is by reducing their efforts and withdrawing from work) in order to prevent a further loss of resources” (Thanacoody et al., 2014, p. 1842). Specifically, although employees will still complete the necessary tasks to care for patients, they may choose to reduce their effort in an attempt to “preserve the limited resources available to them and reduce a further depletion of resources” (Thanacoody et al., 2014, p. 1844).

H1: The provision of adequate hospital facilities is positively associated with EOC.

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The Association Between EOC and Hospital Performance

Many authors make reference to the positive impact of EOC on individual and organizational performance (Takeuchi, Chen, & Lepak, 2009). Alternatively, a lack of commitment is expected to result in poorer performance levels (Guleryuz, Guney, Aydin, & Asan, 2008). Committed employees are “satisfied with their work and willing to give extra effort to achieve the organization’s goals” with such engagement deemed to be a requirement for high performance (Lowe, 2012, pp. 29–30). Accordingly, many authors have reported a positive association between organizational commitment and job performance (Al-Ahmadi, 2009). Similarly, West et al. (2011) found that hospitals in England reported better financial performance when staff were more engaged. Therefore, “organisational commitment is a variable affecting organisational effectiveness and efficiency” (Guleryuz et al., 2008, p. 1625), and it is expected that the level of EOC will be positively associated with hospital performance.

H2: EOC is positively associated with hospital performance.

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The Mediating Role of EOC on the Association Between the Provision of Adequate Hospital Facilities and Hospital Performance

In line with the above discussion, which maintains a positive association between the provision of adequate facilities and EOC and a positive association between EOC and hospital performance, it is argued that the level of EOC plays a mediating role in the association between the provision of adequate facilities and hospital performance. Specifically, it is implied that when employees “do not have adequate resources to deal with the work demands required from them” (Thanacoody et al., 2014, p. 1843), this will have a negative impact on hospital performance as employees will devote less time and energy to their work when they feel that sufficient resources are not available. This effect may be attributable to a general poor attitude following the perceived lack of organizational support, demonstrated through the inadequate provision of facilities, and/or in line with the conservation of resources theory represent a deliberate act in an attempt to protect the remaining resources. Either way, it is argued that the performance of hospitals (i.e., the quality of patient care and operational effectiveness) is related to the “the quality of life experienced by staff at work” (West, 2001, p. 41), in particular whether they feel that they are supported through adequate medical and support facilities and adequate staffing resources, and hence, if hospital staff feel that there is a decline in the provision of such facilities, they will react by decreasing their level of EOC, which will subsequently have a negative impact on hospital performance. Of course alternatively, we argue that the impact of any increases in the provision of adequate facilities on hospital performance occurs indirectly through EOC, with the provision of adequate facilities enhancing the level of EOC, which in turn enhances hospital performance.

H3: EOC mediates the association between the provision of adequate hospital facilities and hospital performance.

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Method

The study focuses on hospitals because of their importance to the community, with over 10 million users of the health care system having a significant impact on the economy ($203.1 billion or 10.1% of the GDP in 2014–2015; Australian Bureau of Statistics, 2015). Using Cohen’s (1988) approach to determine sample size for regression analysis and assuming a response rate of 14% based on the average response rate of previous health care industry studies (13%, Clinton & Nelson, 2004; 15%, Kondo, Nishii, & Aihara, 2013), a mail survey questionnaire was distributed to 487 hospitals in Australia in an attempt to collect data on the provision of adequate facilities (medical facilities, support facilities, and staffing resources), EOC, and hospital performance (patient care and operational effectiveness).

The questionnaires were distributed to a variety of managers in order to obtain responses from different types of hospital employees. Specifically, the questionnaires were sent to the Directors of Nursing (lower-level management), who have an insight into day-to-day operational activities; Financial Managers and Health Service Managers (middle-level management); and CEOs and General Managers (higher-level management). This approach was appropriate, given evidence in Su et al. (2013) that the level of EOC varies across different levels of management. Each of the identified managers was deemed to have the requisite knowledge to complete the questionnaire.

The One Source database was used to identify potential respondents from the listed hospitals across Australia. To avoid duplication of data, only one respondent was randomly selected from each hospital. The initial distribution resulted in 76 (15.6%) questionnaires being returned with an additional 67 (13.8%) returned following the follow-up mail out, which was conducted 3 weeks following the initial mail out. Hence, a total of 143 (29.4%) questionnaires were returned, 38 completed by lower-level managers, 45 by middle-level managers, and 59 by higher-level managers, with one respondent failing to indicate their position. Although a larger sample size is desirable to conduct structural equation modeling (SEM), the literature suggests that such a sample size (100–200) is adequate to draw conclusions from small-to-medium size SEM models (Smith & Langfield-Smith, 2004).

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Measurement of Variables

The provision of adequate facilities

Following a review of the relevant literature (Grosskopf & Valdmanis, 1987; Organization & Hospital, 2008; Voelker, Rakich, & French, 2001) and the indicators launched by the Australian Institute of Health and Welfare (AIHW, 2015), a 10-item self-developed measure was used to measure employees’ perception of the provision of adequate facilities. Respondents were required to evaluate their hospital’s performance with regard to each of the 10 items using a 7-point Likert scale with anchors of 1 = extremely poor and 7 = excellent. Factor analysis (varimax rotation) of the measure resulted in three dimensions, the first of which focused on the “Nurse–Doctor ratio,” the “Bed–Nurse ratio,” and the “Patient–Doctor” ratio. Accordingly, this item was labeled “Staff Resources.” The second dimension included five items, including “The cleanliness of wards,” “Hospital security,” “The quality of IT facilities,” “The provision of patient support facilities,” and “The provision of staff training.” Given that this dimension included a range of different support activities, we labeled this dimension as “Support Facilities.” Finally, the third dimension included “The quality of medical facilities” and “The provision of medical facilities” and hence was labeled “Medical Facilities.” Each dimension was measured as the average score of the loading items with higher (lower) scores representing the provision of more (less) adequate facilities.

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The level of EOC

Cook and Wall’s (1980) nine-item measure of affective commitment was used to measure EOC (see Appendix). The scale includes items on organizational identification, organizational involvement, and organizational loyalty and has been found to be a reliable measure in previous studies (Su, Baird, and Blair, 2009). Respondents were required to indicate the extent to which they agreed with the nine statements using scales of 1 = strongly disagree and 7 = strongly agree. EOC was measured as the average score of the nine items with higher (lower) scores representing a higher (lower) level of EOC.

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Hospital performance

The measure of hospital performance was self-developed based on a review of the relevant literature (AIHW, 2015; Grosskopf & Valdmanis, 1987; Organization & Hospital, 2008; Voelker et al., 2001). Emphasis was placed on patient care, as the “quality of patient care is an important performance outcome for health care” (Bartram, Karimi, Leggat, & Stanton, 2014, p. 2407), and effectiveness due to the increased focus on effectiveness and efficiency in public sector organizations. A seven-item measure was developed with respondents required to indicate their perception of their hospitals’ performance with regard to each item using a 7-point Likert scale with anchors of 1 = extremely poor and 7 = excellent.

Factor analysis (varimax rotation) resulted in two dimensions, which reflected the two emphasized aspects of perceived hospital performance. Specifically, the first dimension included “The quality of patient care” and “The overall satisfaction of patients” and hence was labeled, “Patient Care.” The second dimension included “The efficiency of the patient admission/discharge process,” “Average emergency waiting times,” “Surgery waiting times,” “Managing the length of patient stay,” and “Managing patient complaints.” These items refer to both the efficiency of hospital operations (in particular the first four items) and goal attainment, that is, the effectiveness with regard to managing patient complaints. Accordingly, we labeled this dimension as “Operational Effectiveness,” reflecting the achievement of the goal of managing patient complaints and improving the efficiency of hospital operations. Perceived hospital performance was measured based on the average scores of the items loading on these two dimensions, with higher (lower) scores representing higher (lower) perceived hospital performance.

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Results

Descriptive Statistics

Table 1 provides the descriptive statistics including the mean, standard deviation, and the minimum and maximum values for each of the independent and dependent variables. Table 1 also shows the reliability and convergent validity of the measures with the Cronbach’s alpha and composite reliability scores for all variables exceeding the required cutoff point (0.7; Fornell & Larcker, 1981; Nunnally, 1978). Table 2 provides the correlations between the variables.

The mean score of the provision of adequate medical facilities (5.76) is slightly higher than the mean scores for support facilities (5.49) and staff resources (5.57), indicating that greater focus is placed on providing adequate medical facilities in hospitals. The provision of adequate medical facilities and staff resources was significantly less in public hospitals when compared to private hospitals. The mean score of EOC (6.12) lies toward the higher end of scale, indicating that there is a relatively high level of EOC in hospitals. With regard to hospital performance, whereas the mean score of both dimensions exceeds the mid-point of the range, the mean score of patient care (6.21) is higher than the mean score of operational effectiveness (5.62), suggesting that performance outcomes in relation to patient care were achieved to a greater extent. In addition, an ANOVA analysis further revealed that the perception of higher levels of management was that hospital performance was significantly higher than that of middle and lower levels of management.

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Path Analysis

SEM was used to examine the hypotheses with the initial model consisting of unidirectional paths between the three provision of adequate facilities variables (medical facilities, support facilities, and staff resources) and three control variables (organizational size, staff position, and years worked by employees) with the level of EOC, and between the level of EOC and hospital performance (patient care and operational effectiveness). The model also considered the direct relationship between the provision of adequate facilities and the three control variables with hospital performance with all parameters (i.e., unidirectional paths) estimated. We then sequentially removed paths that were not statistically significant until all remaining paths in the model were significant and the overall (reduced) model was a good fit. Such an approach enables a model to determine the most parsimonious explanation of variation in variables. The BC bootstrap method was then used to examine the mediation effect.

The results of the SEM (see Figure 1) revealed that none of the three control variables were associated with the level of EOC, whereas only one of these factors (organizational size) was related to hospital performance (operational effectiveness; β = −0.15, p = 0.03), although this relationship was negative, indicating that larger hospitals performed worse with regard to operational effectiveness. The three benchmark fit indices (CMIN/DF = 1.14, CFI = 0.99, RMSEA = 0.03) indicate a good fit of the model. Although no associations were found between the provision of adequate medical facilities and the level of EOC, the findings provide partial support for Hypothesis 1, with both the provision of support facilities (β = 0.18, p = .01) and staff resources (β = 0.24; p = .00) found to be positively associated with the level of EOC.

Figure 1

Figure 1

Table 1

Table 1

Table 2

Table 2

The level of EOC was found to be positively associated with both patient care (β = 0.22, p = .01) and operational effectiveness (β = 0.25, p = .01), providing support for H2. In addition, the findings revealed that the provision of adequate facilities exhibited a direct impact on hospital performance. Specifically, the provision of adequate medical facilities was found to be positively associated with patient care (β = 0.13, p = .02), and the provision of adequate support facilities was found to be positively associated with “patient care” (β = 0.20, p = .01) and operational effectiveness (β = 0.46, p = .00).

Table 3 presents the evidence of the mediation in the model. The results indicate that the level of EOC mediates the positive association between the provision of adequate support facilities and hospital performance as the range of the confidence interval (CI) between the upper and lower limits does not cross zero (patient care, CI [0.01, 0.12] and operational effectiveness, CI [0.01, 0.11]). Similarly, the results indicate that the level of EOC mediates the positive association between the provision of adequate staff resources and hospital performance (patient care, CI [0.01, 0.13] and operational effectiveness, CI [0.01, 0.12]).

Table 3

Table 3

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Discussion

This study aimed to examine the association between employee engagement, in particular EOC, and hospital performance, and the role of the provision of adequate facilities as an antecedent of EOC. Specifically, it was hypothesized that a hospital’s performance with regard to providing adequate facilities (medical, support, and staff) would influence the level of EOC, which in turn would have a positive influence on the overall level of hospital performance, operationalized with regard to the level of patient care and operational effectiveness. The findings support the hypotheses, highlighting the important role of EOC in enhancing hospital performance and the role of providing adequate facilities in enhancing the level of EOC within hospitals.

The level of EOC was found to be positively associated with both the level of patient care and operational effectiveness. Such findings support the literature highlighting the importance of EOC in enhancing performance (Al-Ahmadi, 2009; West et al., 2011) and imply that managers should try to implement whatever processes, rewards, and working conditions are necessary to enhance the level of EOC of their employees. In particular, in line with the Association Quality Healthcare Workplace model, managers should focus on ensuring that the work environment, job characteristics, and level of organizational support provided are conducive to facilitating the enhancement of EOC.

Our findings provide an initial insight into this relationship, highlighting the important role of providing adequate facilities in enhancing the level of EOC within hospitals. In particular, it was found that the provision of adequate staff resources and support facilities exhibited a positive indirect influence on both patient care and operational effectiveness through their influence on EOC. Such findings highlight the significant role of EOC as a mediator of the relationship between the provision of adequate resources and hospital performance. Hence, it is implied that CEOs and general managers should try to enhance the provision of such resources within their hospitals due to the significant impact that the provision of resources has on the level of EOC. This is more pertinent within public hospitals where the results indicate that the provision of adequate medical facilities and staff resources was significantly lower than their private sector counterparts.

Although it is acknowledged that the ability of the managers of public sector hospitals to provide adequate resources is more constrained because of the limited availability of financial resources, the findings are poignant in alerting such managers of the importance of providing adequate facilities. Further evidence regarding the positive direct influence that the provision of adequate support facilities exhibited with regard to both dimensions of hospital performance (patient care and operational effectiveness), and that the provision of medical facilities exhibited with regard to patient care, provide further reason for managers to focus on providing adequate facilities. Such findings may provide the impetus for such managers to strive to negotiate with the government to increase their financial resource allocations and/or strengthen their attempts to allocate their limited resources in a more efficient and effective manner.

Although this study highlights the significance of the provision of adequate facilities in enhancing the level of EOC, future studies may choose to examine the influence of other drivers of performance. For instance, as recommended in the Association Quality Healthcare Workplace model, future studies can consider examining the role of specific job characteristics and/or other aspect of the work environment and organizational support in enhancing EOC. In particular, as suggested by Gregory et al. (2007, p. 119), organizations should work toward identifying and implementing the “policies and interventions aimed at creating more supportive work environments.”

The study contributes to the contingency-based literature by examining the factors influencing the level of EOC and hospital performance. Specifically, the study contributes to this literature by providing empirical evidence in support of the Association Quality Healthcare Workplace model, providing evidence that the drivers of performance (the provision of adequate facilities) facilitate improvements in both individual outcomes (EOC) and subsequently organizational outcomes, that is, hospital performance (patient care and operational effectiveness). In doing so, the study highlights the important role of human capital, elicited through the level of EOC, with regard to enhancing hospital performance. Such findings are consistent with and provide empirical evidence to support the claims of Simmons (2008), p. 470) that “human capital is less visible, well understood and measurable than financial capital; but is the main driver of organisational success.” Furthermore, the study provides an initial insight into the antecedents of EOC within a hospital context, highlighting the integral role of the provision of adequate facilities in enhancing EOC and providing the impetus for future empirical research with regard to other potential factors that may influence EOC.

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Practical Implications

From a practical perspective, the findings provide managers with an insight into how to proceed to manage hospital performance. In particular, it is suggested that managers should try to enhance their provision of adequate facilities in order to enhance hospital performance, either through their direct impact or the indirect impact that transpires due to their influence on enhancing the level of EOC. The observed importance of providing adequate facilities is in line with recent claims that “hospital administrators are under pressure to invest their limited resources in facility designs” (Becker & Parsons, 2007, p. 265) and suggestions that hospital managers should liaise with clinicians regarding the provision of adequate facilities (West, 2001). Hence, managers should focus on providing adequate facilities. With regard to medical facilities, they should consider and incorporate the latest technology and up-to-date equipment. They should also ensure that they provide adequate staff resources, including appropriate numbers of beds, nurses, and doctors to prevent “fatigue” (West, 2001, p. 41), and adequate support facilities, including employee training and organizational support.

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Limitations

Although the mail survey approach inhibits the establishment of causal relationships and has potential for common method bias, we rely on Harman’s single-factor test, which indicated that the total variance explained by a single factor (29.2%) was below the 50% threshold, indicative of common method bias problems (Podsakoff, MacKenzie, Lee, & Podsakoff, 2003). Furthermore, we acknowledge that we have used self-reported perception-based measures of the adequacy of resources, EOC, and hospital performance, whereas the use of senior managers may have also biased the findings given that it is anticipated that such employees will have more positive perceptions of organizational climates compared to frontline health care workers. Consequently, although the study serves the purpose of providing a preliminary insight into the model, it is recommended that future studies may incorporate more objective measures; survey a broader sample of health care workers, in particular frontline workers; and/or incorporate alternative methods to gain a more detailed insight into these relationships. Future studies may also provide a more detailed insight into the hypothesized relationships by using longitudinal data and/or incorporating a larger sample to accommodate the use of SEM. Finally, future studies may explore the influence of additional contingency factors with regard to the enhancement of the EOC of hospital employees and provide a more detailed insight into the issues affecting the provision of adequate facilities within hospitals.

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References

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        Appendix

        Measure of the level of EOC

        Please indicate the extent to which you agree with the following statements

        1. I am quite proud to be able to tell people who it is I work for.
        2. I feel that I am a part of the organization.
        3. I would not advise a close friend to join my organization. (Reverse scored)
        4. I am not willing to put myself out just to help the organization. (Reverse scored)
        5. In my work I like to feel I am applying some effort not just for myself but for the organization as well.
        6. I am determined to make a contribution for the good of my organization.
        7. I sometimes feel like leaving this employment for good. (Reverse scored)
        8. Even if my organization was not doing well financially, I would be reluctant to change to another employer.
        9. The offer of a small increase in remuneration by another employer would not seriously make me think of changing my job.
        Keywords:

        employee organizational commitment; facilities; hospital; organizational; performance

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