2.1 Study design and sample
This cross-sectional design is a subset of a broad multisite project (15, 18–21). The project’s overall aim is to use BSC perspectives and dimensions to include a wide range of stakeholders in the strategic improvement of Palestinian hospitals’ performance. This article focuses on engaging Palestinian health care workers, particularly physicians and nurses. The reporting of this study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria (31).
2.2 Sample calculation
Due to geographical and logistical limitations, we were only able to choose 18 hospitals in OPT for this research. However, we took into consideration the fact that our hospital sample consists of hospitals with various sizes, locations, and administrative styles. Maximum variation sampling was used for this objective (6). The number of hospitals and beds in each administrative category and governorate were considered while selecting a sample of hospitals. Patient samples were also picked easily. HCWs in the selected departments were approached during the visit and asked if they would be interested in participating in the study. The sample size was determined using the Steven K. Thompson sample size Eq. (32), where n is the sample size, N is the population size, p is the estimated population variability (0.5), d is the margin of error (0.05), and the z score is at the 95 percent confidence interval (1.96). The research indicates that there are 36,809 HCWs employed in Palestinian hospitals (33). Hence, the minimum sample size needed was found to be 381 HCW. The authors were worried about the low response rate as a result of the pandemic's effect on hospitals and the HCWs' heavy workload, a perception shared by other studies (34, 35). In addition, there is a poor response rate of physicians relative to the rest of the population (36, 37). Therefore, 800 questionnaires were delivered as a result.
2.3 Measures
We employed a validated survey designed to engage HCWs in the PE of hospitals based on BSC perspectives and dimensions (BSC-HCW1). The Arabic version was utilized. The validation of BSC-HCW1 at Palestinian hospitals resulted in 28 items and 9 factors. The six experience factors are the management performance evaluation (MGMTEVAL), the financial incentives (FIN), the quality and development initiatives (QUALDEV), the technology (TECH) factor, HCWs’ engagement (ENG), and the work life balance and time management (WTLB). The three HCWs’ attitudes are the HCWs’ loyalty (LOY), the perceived patient respect and trust of HCWs, and the trust of HCWs toward their direct managers (MTR).
2.4 Data collection
The first author and four medical students from An Najah National University were responsible for the data collection. Before beginning data collection, the main author led a training session for the medical students that lasted for three hours and covered a brief about BSC, guidelines for data collection, and ethical considerations. The team members were assigned duties and hospitals depending on where they resided: eastern Jerusalem, northern, middle, and southern West Bank. The Gaza Strip was omitted for political and pragmatic inaccessibility reasons. In addition, five institutions were omitted from the list: two military hospitals that had not yet opened, one mental hospital, and two rehabilitation hospitals.
To prevent nonresponse bias, between January and October 2021, printed surveys were given to respondents instead of emailing the questionnaires (38). To avoid response bias (38), the "I do not know (neutral)" option was introduced, given that experiences and attitudes might sometimes be ambiguous (39). Second, to guarantee that the number of missing responses had been reduced to a minimum, the data collectors reviewed the retrieved surveys. In the case of missing items, they drew the participant's attention to record a response. If any missing responses were discovered during data input, they were recorded as I do not know. The inclusion and exclusion criteria were a Palestinian doctor or nurse of either gender who had worked at any of the evaluated hospitals for at least three months. Emergency medicine, internal medicine, surgery, gynecology, and pediatrics were among the departments covered.
2.5 Statistical analysis
The first author coded the data, and then the normality of the data was examined using the Shapiro–Wilk test. In addition, frequency calculations were carried out for the categorical patient sociodemographic items. On the 3-point Likert scale, "No" responses were scored as 0, "Yes" responses as 100, and "I do not know" responses as 50. Each question's frequency was determined. Then, the mean score and standard deviation (SD) of each factor in both the physician and nurse categories were determined by calculating the average score for the underlying questions (40). After piloting, Cronbach's alphas for the scale, subscales, and factors were computed.
We used the Mann‒Whitney U test to test the differences between the physicians’ and nurses’ evaluations of the BSC-HCW1 factors. The strength of the relationship between the independent variables or between the dependent and independent factors was examined using Pearson's correlation (r). Then, r was defined as negligible when r < 0.2, low when r = 0.2–0.49, moderate when r = 0.5–0.69, high when r = 0.7–0.85, and very high when r = 0.86–1.00 (41).
Multiple linear regression was used to examine the causation link of the independent variable factors on each dependent variable factor, with a P value less than 0.05 for statistical significance and 95% confidence interval (CI). The residual plots were examined for normal distribution and linearity. The Durbin-Watson test was used to examine autocorrelation, also known as serial correlation (42). A score between 1.5 and 2.5 was deemed acceptable since it suggests that the residuals had relative independence and no serial correlation. In addition, we investigated the model's multicollinearity. Multicollinearity occurs when independent variables in a regression model are correlated, which is problematic since independent variables should be unrelated. Multicollinearity was identified if any of the threshold values shown below (43, 44) were exceeded: 1- the Pearson correlation between variables was greater than 0.70, 2- a variance inflation factor (VIF) greater than ten, 3- a condition index greater than 30, and 4- a variance decomposition proportion (VDP) for two or more predictors that was more than 0.80.
Finally, path analysis is considered a method for enhancing conceptual comprehension and illustration of regression findings, particularly in complicated models (64). Therefore, to develop the strategic map of BSC factors from the HCWs' perspective, we conducted a path analysis for the dependent and independent variables of BSC-HCW1 collectively. To arrive at the best fit model, we kept the regressions that were significant, utilized the modification indices, and used the most used fit indices of the competing models; a minimum discrepancy divided by its degrees of freedom (χ2/df) less than five and closer to zero, a P value more than 0.05, the goodness-of-fit index (GFI), the comparative fit index (CFI), the Tucker–Lewis index (TLI), and cutoff values of approximately 0.95. Additionally, a root mean square error of approximation (RMSEA) value less than 0.06 and a standardized root mean square residual (SRMR) value less than 0.08 were sought (45, 46). Based on the final resulting best fit model, we assessed the standardized direct and indirect impacts of factors on each other. Statistical Package for the Social Sciences (SPSS) version 21.0 was used for all the tests except the path analysis, which we did with IBM Amos Graphics version 23.0. Additionally, R version (3.1.0) was used to create the correlogram.
2.6 Ethical considerations
The Research and Ethics Committee of An Najah National University's Faculty of Medicine and Health Sciences issued the Institutional Review Board (IRB) with a reference code number on May 31, 2020 (Mas, May/20/16). After that, we obtained permission from the Palestinian Ministry of Health to perform the study at public hospitals. The request was then sent to each hospital separately. Requests were made to 15 West Bank hospitals and three Jerusalem hospitals between June and December 2020. In accordance with the ethical standards outlined in the Declaration of Helsinki, all of the HCWs gave written, informed permission to participate in the research (47). The confidentiality and anonymity of the data were guaranteed to the HCWs. Participation in the research was optional, and all HCWs were made aware of this fact and given the opportunity to withdraw at any time.