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Nurses’ attitudes toward quality improvement in hospitals: Implications for nursing management systems

Available online at: http://npt.tums.ac.ir Background & Aim: Quality improvement in hospitals is a systematically widely used framework that improves patient care quality delivered by health care professionals. This study assessed the attitude of nurses toward Quality Improvement. Methods & Materials: A quantitative research approach was used. A total of 361 nurses working in two government hospitals and two private hospitals in the Philippines were selected using convenience sampling. The data collected using a self-administered questionnaire was started in March-April 2019. To identify the association between nurse demographic characteristics and perceived quality improvement, an independent sample t-test, a one-way analysis of variance with a post-hoc Tukey HSD test, and a Pearson’s product-moment correlation were conducted using SPSS. Results: Nurses have high positive quality improvement attitude scores. The age, salary, and hospital type, influence quality improvement attitude scores. Conclusion: Nurses have a positive attitude towards qualitative improvement. In addition, nurses’ age, salary, and public hospitals' work have a positive qualitative improvement than nurses working in private hospitals.


Introduction
During the past decades, the importance and momentum of hospital quality improvement (QI) has dramatically increased internationally. In health care, QI is a systematically widely used framework that improves patient care quality delivered by health care professionals (1). QI involves unceasing efforts in achieving steady and established process results for both patients and the health care institution (2). The implementation of QI in a health care organization has several benefits, including improved patient health, decreased morbidity and mortality, (1) effective and efficient managerial processes, and decreased medical errors and failures (2,3).
In health care systems, QI is used to improve patient quality care (2). Also, health care professionals have an important role in refining the quality of care in hospitals. Like other professionals, nurses play a pivotal role in improving quality care services, since they are the primary patient care providers and the part of health care teams concerned with patient safety (3). This might be the reason why nurses play a significant role in improving overall hospital quality.
In connection to this, the Philippines is acknowledged as having a highly trained

Nursing Practice Today
Tehran University of Medical Sciences 2021; Volume 8, No 3, nursing workforce. Improving the country's quality of health care is on the government's health agenda (4). Consequently, hospitals in the country have to become more sophisticated in trailing activities that fundamentally contribute to hospital quality achievement and performance and patient safety (5). This increase in hospital sophistication could enhance the use of existing resources in carrying out work tasks. Meanwhile, the country's private health care system offers more constant care and better facilities compared to public hospitals (6). Because of these higher-quality private hospitals' issues, staff nurses from public hospitals intend to leave their workplaces (4).
Private hospitals demonstrated better performance in comparison to the public hospital towards environment control and nurses inter collaboration. Also, if patients seek treatment, they will generally have more choice about the type of care they receive. It is most likely one reason for better performance of nurses for private hospitals (7). Meanwhile, there is an outcry in health care delivery services concerning the lack of quality patient care and the poor health care standard in public hospitals. For example, one integrative review reported concerning working conditions in public hospitals that affects QI. These are increased patients' workloads, longer working hours, lack of staff, limited health equipment, and budgetary constraints (8).
This might affect nurses not engaging in hospital QI in public hospitals. An unsatisfied employee increases its absenteeism and turnover rates affecting rendering quality improvement care. Thus, improving QI is therefore critical if we want to accelerate quality patient care. Meanwhile, several kinds of research noted that the necessity of nurses' attitude affects its QI permeates health care. The rationale for measuring the nurse's QI quality attitude is that good performance imitates good-quality care practice. Comparing performance among other health care providers could inspire better performance. (9). To put on perspective, if nurses have put extra effort toward QI, have more positive fulfilling work, perceive trust and common values, and more engaging employees and potentially leading to higher nurse retention rate and improved quality of patient care.
This might result in nurses suffering from overload and understaffing as well as delayed patient treatment, thus affecting the quality of care provided. This challenge is significant, and, in some hospitals, the quality is deteriorating rather than improving (10). Hence, the hospital must value the nurses' potential contribution to carrying out QI processes. Better public health contributes to progress and development in different spheres of society.
Nevertheless, regardless of any healthcare institutions in the country, it has been carefully changing the health care system to progress the quality of care. These strengths are looked-for, particularly for the nurses who are the primary care provider is the best person to assess the patient's health status towards the delivery of health care services (8).
Professional nurses in QI's role constitutes of ability in carrying out organizational QI goals practices and QI assessment-improvement influencing patient outcomes related to nursing practices (3). In these QI roles, nurses' professional quality care standards could improve nurses' professional status and inspire nurses to pursue excellence in their practice. The QI services are thoroughly related to the attitude level relative to these services (7). So, it is noteworthy to note that if nurses have a positive attitude towards IQ, it creates a positive nurse-patient relationship, then improving patient outcomes. Therefore, the nursing administrator must configure the clinical setting to assist the staff nurse's ability to undertake QI action for care improvement Extensive research has shown that providing baseline data on the nurses' attitude pertaining to QI could improve healthcare quality. It is also extensively acknowledged that nurses' active involvement is vital for QI in any organizational setting (3,10,11). However, the Philippines' QI initiatives have not usually obtained the full engagement of nurses due to recent changes to QI policy. While several hospitals have considered nurses' role in QI as crucial, much uncertainty still exists about the relationship with QI attitudes among Filipino nurses. To date, there has been little agreement on what is the attitude of Filipino nurses pertaining to QI.
Given the scarcity of related studies in Filipino nurses' culture and context, this study assessed such attitudes; the present study was conducted to assess the attitude of nurses toward QI and the challenges they experience. This study can also offer significant insights into how hospitals can enhance human resources in improving quality care, nurses' empowerment, and QI initiatives moving forward. This study aimed to assess the attitude of nurses toward QI.

Study Design
A cross-sectional design of a qualityimprovement attitude among Filipino nurses was conducted in this study.

Settings and participants
A total of 361 nurses working in two government hospitals and two private hospitals in the Northern Philippines were selected using convenience sampling. These hospitals were all tertiary, and each had a bed capacity for 300 to 400 patients. The inclusion criteria were the following: a) being a registered nurse, b) working as a nurse in the current hospital for the past 6 months, and c) consenting to participate in the study. The data collected using a selfadministered questionnaire was started in March-April 2019. The surveys were then distributed to each nursing staff member along with a detailed cover letter. A blank manila envelope was left in the room for survey collection, and the researcher left the room while participants were filling out the surveys. Completed information from the survey was returned in specially marked envelopes placed in each clinical setting.
This study was carried out after receiving approval from the Ethics Review Committee of each health care institution. Verbal approval for this study was additionally obtained through the Private Hospital Nursing Research Council. Each department's manager approved permission to survey each department. Informed consent was implied by participation in the survey, and the confidentiality of information was discussed. Each survey also included a cover letter explaining the study purpose, the right to refuse to participate, and the fact that participation implied consent.

Questionnaire
Quality Improvement Nursing Attitude Scale (QINAS). The QINAS is a 35-item scale that assesses nurses' attitudes regarding quality competency values in QI based on their workplace practices (12). It contains a 5point Likert scale (strongly agree to strongly disagree), and the scores are summated to give a total ranging from 35 to 175. Higher QINAS scores indicate nurses' positive attitudes regarding quality competency values in QI and their workplace practices. The Cronbach's alpha reliability of the previous study was high at 0.97 (12). In this study, Cronbach's alpha is 0.91.

Statistical Analysis
The data were examined using Statistical Package for the Social Sciences (SPSS1) software (SPSS Inc., Chicago, IL, USA) version 24. To identify demographic characteristics associated with the QI scores, descriptive statistics such as frequency, percentage, mean, and standard deviation analyses generated descriptive statistics. To identify the association between nurse demographic characteristics and perceived QI, an independent sample t-test, a one-way analysis of variance with a post-hoc Tukey HSD test, and a Pearson's product-moment correlation were conducted. The p-value of<0.05 was defined as significant.

Results
A total of 445 questionnaires were distributed in four hospitals; however, only 361 questionnaires were retrieved due to incomplete ones (response rate=81.12%).
The nurses' demographic characteristics are shown in

Discussion
In this study, nurses reported high positive QI attitude nursing attitudes. This result is slightly higher than in previous studies conducted in Saudi Arabia (13). This might mean that different countries have different cultural backgrounds pertaining to the QI attitude approach. However, while all nurses in the Philippines consist of Filipino nurses, the majority of nurses in Saudi Arabia were expatriate nurses (e.g., Indian, Filipino, Egyptian, etc.). In addition, in the analysis of QI attitude, Alshehry et al. (14) described that each country has its own culture and population needs, which share a set of goals with the health care system. These unique cultural differences might contribute to the different QI attitudes of nurses. According to Fong et al. (15), a homogenous culture is defined as a set of behavioral expectations coupled with skills that can easily address issues and problems pertaining to QI. There are different reasons why distinct hospitals have varying types of QI attitude, and they can include leadership style, organizational culture (16), a lack of consensus (17), and resource constraints. However, factors affecting QI attitude and cultural differences were not discussed in this study. Thus, further research could be explored pertaining to the above factors.
The statement, "I enjoy being a part of a change in my unit to improve quality of care," was rated the highest (rank 1) among the QI statements. This implies that nurses might view themselves as part of a team, which could result in feeling a sense of ownership (17). Thus, it could also stimulate enthusiasm and teamwork, enhancing a positive QI attitude. In the study by Cruz et al. (4), nurses who felt part of a team strived to contribute positively and with enthusiasm and work proactively. In the analysis by Almazan et al. (18), the feeling of being part of a team increased the participants' motivation, initiative, and creativity. Therefore, teamwork and collaboration are vital in the quest for success in providing quality patient care.
The statement, "When I see a risk of compromised safety, I keep it to myself," was rated the lowest among the QI statements. This implies that nurses are assertive in promoting patient safety. In a previous study by Alshehry et al. (19), nurses were likely to show clinical excellence in bedside care when provided with clear direction and support by patients and the health care team. Nurses' assertiveness in notifying doctors and nursing administrators is also expected when they are unsure about nursing care, carrying out diagnoses, and patient treatment, in order to reduce risk and prevent major medical errors (20). Also, notifying higher authorities when nurses commit errors can immediately provide patients with appropriate care and prevent further harm (19).
Some demographic work characteristics of nurses significantly influence QI attitude. Specifically, age is associated with QI attitude. The average age in this study was 29.47 years old. This means that nurses of this age might have already acquired learning experience pertaining to QI. According to Wood et al. (21), this average age is considered the period of life in which an individual faces a large number of individual transition experiences. Regardless of whether they are negative or positive, these experiences improve individual well-being, which is expected to lead to optimism and taskfocused behavior (4). Also, once individuals have already gained experience, they can provide adaptive task-focused strategies, which lead to success (22), taking into account that individuals with experience have strategies and have been found to have high work achievement. However, a developmental context among nurses, relating to the age at which achievement strategies are developed, has not been examined in this study. Thus, further studies could explore the achievement strategies that nurses use during their developmental age.
Compensation plays a significant role in motivating and retaining nursing staff. In this study, salary is associated with QI attitude. This is worth considering since the greater the compensation that nurses receive, the better their work performance is (23). This might be because the salary brings a feeling of security and is a financial reward for the work.
Another study stated that compensation plays an important role in defining employees' job satisfaction levels and QI (10). For example, Alshehry et al.
(20) described that lower compensation could lead to job dissatisfaction, less motivation to work, higher absenteeism, and intent to leave. According to the Department of Labor and Employment (24) in the Philippines, the average monthly salary in this study is higher than the government's minimum. This might mean that the nurses studied have higher pay satisfaction and create more quality work improvements in the workplace.
Health care organizations have made considerable efforts to improve the quality of nursing services. In this study, hospital type is associated with and a predictor of QI attitude. Specifically, government hospitals have more QI attitudes than private hospitals. This is worth noting since the Philippines' health care services have undergone massive changes to improve the quality of health care and compete effectively with the private sector (5). This is similar to one previous study conducted in the Middle East, which specified that continuous training courses and nurses' skills and competencies were more established in government hospitals (25).
Meanwhile, public hospitals have a positive QI attitude than nurses working in private hospitals. This is worth noting since public hospital health services usually have a higher number of patients than private hospitals. They are found to have a stressful environment with inadequate conditions, where the nursing staff are overworked, there is a lack of drugs for the patients, and the professionals' physical and emotional exhaustion is favored, leading to increased absenteeism and work accidents (15). Thus, all of these might create less motivation and commitment to patients at work. Efforts are needed, and many nurses welcome the idea of QI. However, without reflecting on the attitudes towards QI, this can affect a quality standard in nursing care. Therefore, strategies towards QI standards to provide high quality and safe care is warranted. This could be clear communication in specifying the QI purpose and strategy, enabling the voicing of concerns throughout creating change process; Greater QI awareness and consistent practice in the health care setting, consistent QI training, and workshop, improvement of necessary equipment must be in place and properly maintained, warranting that everybody is heard and felt involved, and celebrating successes, no matter how small or big.

Limitations
The study was carried out in two private hospitals and two government hospitals in the Philippines, limiting the results' generalizability. A cross-sectional design was also used, which does not allow for causal inference with QI attitude. In addition, when using a self-administered questionnaire, participants may not feel encouraged to provide accurate, honest answers. The psychometric properties, including construct validity, were not measured in the study, affecting the results' overall validity.

Conclusion
This study assessed the attitude of nurses toward QI. Nurses attained high positive QI attitudes. Nurses have a positive attitude towards qualitative improvement. In addition, nurses' age, salary, and public hospitals' work have a positive qualitative improvement than nurses working in private hospitals. This study can also offer significant insights into how hospitals can enhance human resources in improving quality care, nurses' empowerment, and QI initiatives moving forward.
The basis in assessing QI attitude is the belief that noble performance mirrors good quality practice; thus, comparing nurses' performance could encourage better performance and quality care. These findings can serve as a guide in establishing approaches to awareness of and confidence improvements in nurses' QI attitude. Methods such as simulation techniques (e.g., case studies, mock equipment, standardized) can be used for QI attitude, involving complete practice and pertaining to teamwork across all ages. In addition, continuous professional development, such as courses, workshops, and training, can create a continuous reflection for ongoing improvement. Similarly, if staff nurses experience time constraints, one-to-one training could be recommended. Finally, benchmarking of the good practices in public and private hospitals could be promoted. This benchmarking can be used to evaluate quality performance.