Nursing Staff Awareness Regarding Challenges for Applying Total Quality Management

Introduction

Healthcare organizations face some serious challenges, particularly concerning effectiveness, efficiency, and quality. Therefore, there is a pressing need for a new approach in managing healthcare organizations to become more cost-effective in the delivery of high-quality healthcare services (Mosadeghrad, 2014). 

Quality management constitutes an appropriate response to these challenges. It is a potential way to improve systems and procedures as effective as possible by using scientific methods to achieve an optimum outcome. Total quality management as a quality management strategy aims to enhance customer satisfaction and subsequently organizational performance by providing high-quality products and services through the participation and collaboration of all stakeholders, teamwork, customer-driven quality and continuously improving the performance of inputs and processes by applying quality management techniques and tools (Najm,    Yousif & Al-Ensour, 2017).

Nowadays, several hospitals and service managers try to look at the best ways and means to improve the administrative quality of their products. Many are wondering what successful leaders should do to improve their organizations to lead them to excellence among global organizations. Such questions reflect the aspirations of the vast majority of contemporary business organizations and highlight the importance of finding the most appropriate means to achieve this level (Hao & Yazdanifard, 2015).

Advantages of implementing total quality management: Improving the organization's reputation faults and problems are identified quickly (the "zero defects"); Significant improvement in quality of products or services; Customer satisfaction increase, which leads to additional sales; A significant decrease of resources waste; Increased productivity because the staff uses the time more efficiently; Increasing the market share on the long term; The workforce is motivated by additional responsibilities, teamwork, and involvement in decision-making on total quality management; Lower costs; Focus on continuous improvement (Wamuyu, 2015). 

Elewa & Elkattan, (2017) conducted a survey for a hospital to identify the major obstacles to total quality management implementation in health care organization as; Organizational structure; Leadership style; Organizational culture; Professional autonomy; Lack of Consensus; Internal requirement domination; Efficiency-oriented; And manpower shortfall.

Aim of the study:

The aim of the current study is to assess nursing staff awareness regarding challenges for applying total quality management at Assuit University Hospital. 

Research question:

What are the challenges that hinder the application of total quality management at Assuit University Hospital?

Subjects and Method

Study Design:

A descriptive research design was used to achieve the aim of the current study.

Sample:

A convenience sample of studied nursing staff at Assuit University Hospital. 

Setting:

The study was conducted in General Surgical, Special Surgical, General Medical, and Special Medical departments at Assuit University Hospital. 

Subjects: 

The present study included all head nurses and staff nurses who worked in the previous settings, which contains head nurses (no= 17) and (no= 202) staff nurses which were distributed as follows. General Surgical and Special Surgical departments number of head nurses (n= 8) and (no= 80) number of staff nurses and General Medical and Special Medical departments number of head nurses (no= 9) and (no= 122) number of staff nurses.   

Study tools:

Self-administered questionnaire namely Total Quality Management Challenges Questionnaire. It includes two parts:

• 1^stpart Personal Data; it was including information about head nurses and staff nurses. The data included items related to age, gender, unit, educational qualification, years of experience, and attended training courses.
•  2^ndpart Total Quality Management Challenges questionnaire; this tool was developed by Korani, (2017). This tool was adopted and included (26 items) total quality management challenges. The researcher added one open question about the other challenges not mentioned in the questionnaire.       

The scoring system of the study tool is 5 points Likert scale ranged from to Strongly Disagree (1), Disagree (2) Neutral(3), Agree (4) to Strongly Agree(5).

Validity of the tool:

Tool was tested for the face and content validity by a jury of (five) experts in the field of Nursing Administration and necessary modifications were done. The jury composed of one Professor from Faculty of Nursing, Ain-shams University; one Professor from Faculty of Nursing, Cairo University; and three Professors from Faculty of Nursing, Assuit University. Each of the expert panel was asked to examine the instruments for content coverage, clarity, wording, length, format and overall appearance. 

Reliability of the tool

The internal consistency measured to identify the extent to which the items of the tool measure the same concept and correlate with each other by Cronbach’s alpha test and it was proven test for each part according to the following formula:

Reliability of the tool was performed to confirm consistency of the tool Total Quality Management Challenges Questionnaire witch found equal α o.849

Operational Design

The operational design for this study included three phases namely: Preparatory phase, Pilot study, and Data collection:

Preparatory Phase:

             This phase took around three months from April to the end of Jun (2019). Reviewing the available related literatures and studies concerning the study topic, and an Arabic translation of the study tool was done.

Pilot Study:  

A pilot study was conducted on 10% of head nurses (no=2) and 10% of staff nurses (no=20) before beginning the field of data collection to obtain information which could improve the research plan and facilitate the execution of the study. The main purposes of the pilot study were to test the data collection tool regarding the phrasing, the order, and the need for adding or omitting questions or items that included in the tool, determine what kinds of difficulties could arise and how to deal with them and estimate the time required to complete the tool. It was taken about 20- 25min for filling the sheet. 

Data Collection:

Official approvals to obtain data were introduced to administrative authorities; and approvals included a brief explanation of the objectives of the study. Arabic translation of the study tool was done by the researchers. Oral consent was obtained from all head nurses and staff nurses agreed to participate in the study. For the head nurses and staff nurses, the researchers interviewed them and provided a brief explanation about the purpose and the nature of the study to them. The researchers interviewed with head nurses and staff nurses in morning shift during the working days and waited with them during their working hours to fill it and it was collected after filling. The duration of data collection was lasted on three months from the beginning of September to the end of November (2019).

Administrative design:

A written initial approval was obtained from the Research Ethics Committee of the Faculty of Nursing, Minia University. Official letters were obtained from the director of the hospital and the nursing manager.

Ethical Considerations: 

The studied subjects were informed that their participation in the study was completely voluntary and there was no harm if they are not participating in the study. Oral consent was obtained from the head nurses and staff nurses participating in the study after explaining the nature, purposes, and benefits of the study. Each assessment sheet was coded and participants' names were not appearing on the sheets for anonymity and confidentiality. 

Statistical Design:  

Data entry and statistical analysis were done using SPSS version 20.0 (Statistical Soft Ware Package). Data were presented using descriptive statistics in the form of frequency, mean, standard deviation, and range. Pearson correlation analysis was used for the assessment of the inter-relationships among quantitative variables. Statistical significance was considered at p-value ≤ 0.05.

Results:

 Table (1): Percentage distribution of personal characteristics of the studied nursing staff at Assuit University Hospital (N=219).

≠ More than one answer

Table (1): Indicates that the age of the studied nursing staff one-quarter of them (25.1%) age less than 30 years old, less than half of them (42.5%) age from 30 to 40 years old respectively, and more than one-third of them (32.4%) age more than 30 years old with mean age (36.06 ± 8.88). The majority of them (92.0%) are a staff nurse. Educational qualification more than three quarters (76.7%) were a secondary school of nursing, while less than quarter of them (16.0%) have a technical institute of nursing, and the lowest percentage of them (7.3%) Faculty of Nursing from the table for years of experience less than half of them (43.4%) have twenty years of experience, while more than one-third of them (37.4%) have less than twenty years of experience, and less than quarter of them (19.2%) had more than years of experience respectively with a mean (17.11 ± 8.69), more than half of them attended training courses (50.7%), which classified according to training courses about (81.1%) have infection control training courses, and less than a quarter of them (18.0%) have training on quality courses.

Figure (1): Percentage distribution of gender of the studied nursing staff at Assuit University Hospital (N=219).

Fig (1):  shows that the majority (84.9%) of studied nursing staff are females.

Figure (2): Percentage distribution of work place among studied nursing staff at Assuit University Hospital (N=219).

Fig(2): Illustrates that about the place of work more than a quarter of the studied nursing staff in General Surgery ( 26.0%), while less than quarter of the studied nursing staff in Internal Medicine ( 20.5%), and the lowest percentage (5.5 %) working in Plastic Surgery and Blood Disease respectively.

Table (2): Percentage distribution of challenges of applying quality management as reported by studied nursing staff at Assuit University Hospital (N=219).

Table (2): Shows that less than half of studied nursing staff agrees about the items (central decision-making in the hospital; no advertising for the total quality system in the health director; lack of adequate encouragement from senior management in the application of TQM; lack of an effective incentive system; the inability of training programs to carry out their work; lack of good and up-to-date information systems; prevents stagnation of the policies and procedure of the application of TQM in hospital; lake to delegate responsibilities and lake of tasks distribution; and lack of focus on patient satisfaction) ranged from (46.1% to 41.1%). While more than one-third of them strongly agree for the items (resistance of some workers to change in hospital; no available resources to apply TQM; no advertising for the total quality system in the health director; and lack of qualified personnel to implement TQM) ranged from (38.8% to 31.1%) respectively.

Table (3): Percentage distribution of open ended question about other challenges for the application of total quality management as reported by studied nursing staff at Assuit University Hospital(N=219).  

-Unavailable meetings with nurses to discuss work obstacles and nursing problems.

Table (3): Clarifies that other challenges facing the studied nursing staff for the application of total quality management for the items (there are no training courses about quality for nursing personnel in different departments (7.3%), there is no patient examination room in different departments (1.8%) respectively.

Table (4): Relation between total quality management challenges with personal characteristics as reported by studied nursing staff at Assuit University Hospital(N=219).

Table (4): Shows that the highest mean scores are in challenges of total quality management; educational qualification (102.89 ± 13.48), age (102.00 ± 13.48), gender (100.01 ± 16.73), years of experience (101.71 ± 16.65), attended training courses (100.44 ± 16.77), workplace (99.85 ± 16.93), occupation (99.53 ± 22.92), with no statistically significant differences with personal characteristics.