Relationships Between Core Factors of Knowledge Management in Hospital Nursing Organisations and Outcomes of Nursing Performance

ORIGINAL ARTICLE Relationships between core factors of knowledge management in hospital nursing organisations and outcomes of nursing performance

Eun Ju Lee, Hong Soon Kim and Hye Young Kim

Aims and objectives. The study was conducted to investigate the levels of implementation of knowledge management and outcomes of nursing performance, to What does this paper contribute examine the relationships between core knowledge management factors and nurs- to the wider global clinical ing performance outcomes and to identify core knowledge management factors community? affecting these outcomes. • This study contributes to the Background. Effective knowledge management is very important to achieve development of effective and efﬁ- strong organisational performance. The success or failure of knowledge manage- cient KM systems and strategies for improving both the produc- ment depends on how effectively an organisation’s members share and use their tivity and competitiveness of knowledge. Because knowledge management plays a key role in enhancing nurs- healthcare organisations. ing performance, identifying the core factors and investigating the level of knowl- • This study’s results will be basic edge management in a given hospital are priorities to ensure a high quality of data to ensure high quality of nursing for patients. nursing for patients through Design. The study employed a descriptive research procedure. identifying the core factors and investigating the level of KM in Participants. The study sample consisted of 192 nurses registered in three large healthcare organisations. healthcare organisations in South Korea. Method. The variables demographic characteristics, implementation of core knowledge management factors and outcomes of nursing performance were examined and analysed in this study. Results. The relationships between the core knowledge management factors and outcomes of nursing performance as well as the factors affecting the performance outcomes were investigated. A knowledge-sharing culture and organisational learning were found to be core factors affecting nursing performance. Conclusion. The study results provide basic data that can be used to formulate effective knowledge management strategies for enhancing nursing performance in hospital nursing organisations. In particular, prioritising the adoption of a knowledge-sharing culture and organisational learning in knowledge management systems might be one method for organisations to more effectively manage their knowledge resources and thus to enhance the outcomes of nursing performance and achieve greater business competitiveness. Relevance to clinical practice. The study results can contribute to the development of effective and efﬁcient knowledge management systems and strategies for enhancing knowledge-sharing culture and organisational learning that can improve both the productivity and competitiveness of healthcare organisations.

Authors: Eun Ju Lee, PhD, RN, Researcher, Research Institute of Correspondence: Eun Ju Lee, Researcher, Research Institute of Nursing Science, Keimyung University, Deagu; Hong Soon Kim, Nursing Science, Keimyung University, Sindang-dong, Dalseo-gu, RN, Professor, Department of Nursing, Andong Science College, Daegu 704-701, Korea. Telephone: +82 54 855 0671. Andong-si, Gyeongbuk; Hye Young Kim, PhD, RN, Professor, E-mail: [email protected] College of Nursing, Keimyung University, Daegu, Korea

Key words: knowledge management, nursing organisation, outcome of nursing performance

Accepted for publication: 20 February 2014

given hospital should result in improved organisational per- Introduction formance. At this time, studies are needed to investigate the In the information society of the 21st century, knowledge is levels of KM achieved in Korean healthcare organisations the leading strategic element for enhancing the international where varying KM practices are conducted and to deter- competitive power of organisations (Solow 1997, Stewart mine how much practical impact the core KM factors have 1998), and knowledge is being emphasised as the most had on nursing performance. important resource for an enterprise to survive and become Studies of KM in healthcare organisations have been con- more robust (Lee 2006). Therefore, effective management of ducted to investigate the effects of the development and knowledge is very important to achieve strong organisational application of informatics systems (Hsia et al. 2006, Ghosh performance (Chun-Ming et al. 2012Knowledge manage- & Scott 2007, Juarez et al. 2009, Wu et al. 2010), to con- ment (KM) can promote such organisational performance sider the necessity for and methods of KM (Dreher 2009), only when members of an organisation actively share and use to identify factors affecting healthcare KM (Chen et al. their knowledge (Shih-Hsiung & Gwo-Guang 2013). 2011), to examine effective levels of KM implemented by In a healthcare organisation, the quality of the nursing team leaders and care providers (Sanchez-Polo & Cegarra- workforce, which constitutes the greatest portion of health- Navarro 2008) and to explore the relationship between care staff, strongly impacts the productivity of the institu- KM and nursing competence (Hwang 2011). However, few tion (Oh & Chung 2011). In particular, nurses must be recent studies have attempted to identify the relationships extremely knowledgeable as primary professional healthcare between KM and outcomes of nursing performance. There- providers. To improve nurses’ productivity, nursing depart- fore, this study was undertaken to investigate the levels of ments have tried to implement effective KM in ongoing implementation of KM and outcomes of nursing perfor- patient assessments and scientific nursing care as well as in mance, to examine the relationships between core KM fac- hundreds of professional guidelines and protocols (Bohmer€ tors and nursing performance outcomes and to identify 2009). In South Korea, most large hospitals – those with core KM factors affecting these outcomes. more than 300 beds – are using hospital information systems (HIS) incorporating nursing job manuals and clinical Background pathways and guidelines provided by the Korea Institute for Healthcare Accreditation (KIHA) to improve the quality Knowledge management of nursing care. In one approach to improving KM for clinical nurses, the Korea Nurses Association (KNA) has ‘Knowledge management’ is a term that was newly intro- applied web-based learning, cyber-learning, web-based duced by Nonaka, who originated the concept of a ‘knowl- medication instruction developed by Samsung Seoul Hospi- edge-creating organization’ in 1991 (Nonaka 1991), and it tal and other educational methods. is defined as organisational activities related to exploring However, the effectiveness of the KM approach varies what knowledge is and how to create, transfer and use it for each hospital (Choi 2005). The reason for this variation (Davenport et al. 1998). KM is a management method used might be that KM has recently been focusing on the use of to rapidly improve the problem-solving skills within an information technology (IT) systems that facilitate storage, organisation by discovering the knowledge and know-how retrieval and application of knowledge to enhance nurses’ of organisation members and sharing them throughout the competence (Hsia et al. 2006, Wu et al. 2010, Chen et al. organisation (Nonaka 1991). 2011). However, KM practices should combine core ele- For effective KM to be performed, the core factors con- ments of technical infrastructure such as IT with a culture stituting KM had to be identified. The core factors are the that facilitates and drives the KM process, an organisation- essential contents to be included in KM systems. In cases al system that supports and rewards sharing of knowledge, where these factors for enhancing organisational perfor- encouragement of group learning and the presence of mance are overlooked, the probability of the success of KM responsible team leaders (Sanchez-Polo & Cegarra-Navarro is low (Guak 2011). The core factors of KM have been 2008). A suitable combination of these KM factors at a somewhat differently identified in previous studies.

According to a study by Sanchez-Polo and when nursing leaders make accurate estimates of the Cegarra-Navarro (2008), KM practices have four core capacity, attitude and level of knowledge of their nursing factors: technical infrastructure, people to facilitate and staff members (Choi 2005). drive the KM process, a system that supports and Outcomes of nursing performance can be evaluated by rewards sharing of knowledge, and the presence of good considering the quality and quantity of nursing perfor- leadership. Ghosh and Scott (2007) identified the core mance, usage of time and resources, and other factors factors of KM as organisational structure, organisational (Jeffs et al. 2011). In the study of Ko et al. (2007), four culture and organisational technology. Their study measurement categories for outcomes of nursing perfor- suggested that a KM process for a nursing organisation mance were identified: the capacity of nursing perfor- should include making knowledge visible and showing mance, attitude of nursing performance, improvement of the role of knowledge in the organisation, developing a the performance level and application of the nursing pro- knowledge-sharing culture by encouraging and cess. In addition, recent studies have shown the relation- aggregating behaviours that involve seeking and offering ships of nursing performance to empowerment (Ryu knowledge, and building a knowledge infrastructure to 2009), leadership (Bae 2007, Ryu 2009, Brady & Cum- allow organisation members to interact and collaborate. mings 2010), work satisfaction (Bae 2007) and KM (Choi Finally, Choi’s (2005) study suggested that to investigate 2005). However, the research into KM for nursing in the level of nursing KM in a healthcare organisation, one healthcare organisations is in its early stages, and the must examine the level of sharing culture, the use of a studies that investigate the relationships between KM and nursing KM system, the presence of effective leadership, the outcomes of nursing performance are few. Therefore, the level of organisational learning and the presence of a the purpose of this study was to investigate the levels of reward system based on business performance as core implementation of KM and outcomes of nursing perfor- factors. mance, to examine the relationships between core KM Based on previous studies, the core KM factors can be factors and nursing performance outcomes and to identify viewed as including culture and people, the KM technical core KM factors affecting these outcomes. The study system, leadership, the strategic organisational system, results provide basic data that can be used to formulate and organisational learning. Therefore, these five factors effective KM strategies for enhancing nursing performance were the focus of this study. Because KM plays a key in hospital nursing organisations. role in enhancing nursing performance, assessing the core factors and identifying the level of KM in a given hospi- Methods tal are priorities to ensure a high quality of nursing for patients. Design

This study used a cross-sectional survey design to describe Outcomes of nursing performance the relationships between implementation of core KM fac- The outcomes of nursing performance mean the level of the tors and levels of nursing performance in healthcare organi- achievement of healthcare organisational goals through sations as well as to determine the core factors most nurses who are members of the organisation and who per- strongly affecting nursing performance. form reasonable roles based on professional nursing (Yoon 1995). Research questions In a modern healthcare organisation, the outcomes of nursing performance are determined by the quality of In this study, research questions are as follows. nursing care for patients, which is mainly measured • What are the levels of implementation of KM and the according to patient outcomes and the achievement of outcomes of nursing performance with respect to gen- organisational goals (Morrison et al. 1997). Recently, eral nurse characteristics, and what are the total levels competition among healthcare organisations has become of these among nurses in hospital nursing organisations? ﬁerce, and this competition has resulted in strong efforts • What is the relationship between core KM factors and to enhance nursing performance. To attain a high quality nursing performance outcomes in hospital nursing of nursing service, nurses must have the ability to carry organisations? out their professional responsibilities based on scientiﬁc • What are core KM factors affecting nursing perfor- knowledge and the needs of patients. This is possible only mance outcomes in hospital nursing organisations?

Outcomes of nursing performance Sample The outcomes of nursing performance were assessed using For this study, we recruited nurses registered in three large the performance measurement scale (PMS) developed by Ko healthcare organisations – all having more than 300 beds – et al. (2007). This questionnaire contains a total of 17 in Kyungbuk Province in South Korea. During the recruit- items and uses a five-point Likert scale. The 17 items are ing process, posters were displayed in each nursing depart- grouped in the four categories of performance competency ment to attract study participants. (seven items), performance attitude (four items), willingness The sample size was calculated using G POWER 3 ANALYSIS to improve performance (three items) and application of SOFTWARE (Heinrich Heine University, Dusseldorf,€ Ger- the nursing process (three items). The higher the score many). In order to have an effect size of 0Á2, have a achieved, the higher the level of nursing performance. In power of 0Á8 and apply correlation analysis, 191 subjects the study of Ko et al. (2007), the reliability of this ques- were needed for the study (Faul et al. 2007). Assuming tionnaire was established with a Cronbach’s a of 0Á92. In a 10% attrition rate for study participants, a total of 210 our study, the Cronbach’s a was 0Á94. nurses who were interested in the study and who attended an introductory presentation on the study were recruited. Procedure Of the 210 nurses, a total of 192 ultimately participated in the study (18 nurses failed to complete the study sur- After being reviewed for any potential ethical problems vey). with the study process and being approved by hospital To be eligible for the study, participants had to meet the committees, this study was conducted in August and Sep- following inclusion criteria: they had to (1) possess at least tember 2010. Three research assistants (three graduate stu- one year of nursing experience, (2) be working at a health- dents in a nursing college) received two hours of training care organisation with more than 300 beds and (3) sign about the study questionnaires’ contents and how to collect informed consent forms for participation in the study. the study data. During the recruitment process, the research assistants explained the purpose and methodology of the study to potential participants and guaranteed their ano- Instruments nymity, and then, signed informed consent forms were Based on previous investigations in the KM and nursing obtained from all the participants. performance areas (Choi 2005, Ko et al. 2007), the following variables were examined: demographic characteristics, Analysis implementation of core KM factors and outcomes of nursing performance. The data were analysed using SPSS, version 20.0 (SPSS, Chi- cago, IL, USA). To examine the levels of implementation of Demographic characteristics core KM factors and the levels of outcomes of nursing perfor- The demographic characteristics examined included age, mance, mean and standard variation scores were calculated sex, marital status, religion, educational level, work area, using the mean test. An independent t-test and ANOVA were total years of nursing experience and professional position. used to examine the differences between the levels of implementation of core KM factors and outcomes of nursing per- Implementation of core KM factors formance based on general demographic characteristics. In The level of implementation of core KM factors was addition, Scheffe’s test was used as a post-hoc test. The corre- assessed using the questionnaire addressing implementation lation between the levels of implementation of core KM fac- of core KM factors developed by Choi (2005). This ques- tors and outcomes of nursing performance was calculated tionnaire contains a total of 23 items and uses a five-point using Pearson’s correlation coefficient. To identify the core Likert scale. The 23 items consist of five items for knowl- factors most strongly affecting nursing performance, the data edge-sharing culture, six items for the nursing management were analysed using stepwise multiple regression. system, four items for innovative management leadership, five items for organisational learning and three items for a Results reward system for performance outcomes. The higher the score achieved, the higher the level of implementation of The study results with respect to demographic characteris- KM. In our study, the Cronbach’s a for the reliability of tics, core KM factors and nursing performance outcomes the questionnaire was 0Á93. are presented below.

which was the highest score. The mean score for organisa- Demographic characteristics of study participants tional learning was 3Á3, the mean score for innovative The nurses were predominantly female (95Á8%), college management leadership was 3Á16, the mean score for the graduates (80Á7%), atheists (61Á3%) and single (60Á3%). nursing management system was 3Á12, and the mean score Their mean age was 28Á7 Æ 5Á2 years, and 65Á4% were for the reward system for performance outcomes was under 29 years of age. Of the nurses, 54Á8% were working 3Á05. in general wards, and 83Á8% were general nurses. Regard- ing their length of nursing experience, 40Á1% of the nurses Comparison of implementation of core KM factors with had five years or less and 36Á5% had between 5–10 years respect to general nurse characteristics of experience. As shown in Table 2, when the data for the total implementation scores for core KM factors were compared with Levels of implementation of core KM factors the general characteristics of nurses, the results indicated The total mean score for implementation of KM was significant differences only between nurse managers and 3Á21, as shown in Table 1. For the five core KM factors, general nurses in terms of position (t = 3Á49, p = 0Á001). the mean score for knowledge-sharing culture was 3Á44, The total implementation scores for core KM factors for

Table 1 Implementation scores for core KM factors among nurses, n = 192

Core KM factors Content Mean Æ SD

Knowledge-sharing Sharing ideas and resources with members 3Á57 Æ 0Á70 culture Active exchange of information with other ward workers 3Á21 Æ 0Á70 Head of the nursing department understanding the importance of exchanging information 3Á63 Æ 0Á77 among wards Nursing department setting a high value on applying new ideas 3Á41 Æ 0Á81 Knowledge-creating activities, knowledge sharing and applying knowledge related to nursing 3Á36 Æ 0Á85 work Subtotal 3Á44 Æ 0Á56 Nursing management Presence of a technology system for sharing knowledge 3Á38 Æ 0Á97 system Management of a database of new information, know-how and other items that nurses need for 3Á16 Æ 0Á85 work Accessibility of knowledge that nurses need for work 3Á02 Æ 0Á85 Establishment of a search method for accumulated information and knowledge 3Á03 Æ 0Á92 Establishment of an evaluation system for accumulated information and knowledge 3Á01 Æ 0Á85 Usefulness of information and knowledge that are applied by a nursing department through the 3Á13 Æ 0Á91 homepage, electronic board or electronic mail of the nursing department Subtotal 3Á12 Æ 0Á71 Innovative management The willingness of the head of the nursing department to apply KM 3Á32 Æ 0Á93 leadership Promoting innovative strategies for nursing work and change 3Á22 Æ 0Á96 Treating nurses as equal members of the healthcare team 2Á77 Æ 0Á96 Presence of a coordinator or manager for KM in the nursing department 3Á35 Æ 0Á89 Subtotal 3Á16 Æ 0Á73 Organisational learning Knowledge serving as a basis for improving the quality of nursing 3Á67 Æ 0Á81 Recognising ‘core knowledge’ related to nursing work and continuously applying it 3Á24 Æ 0Á68 Implementing educational programmes within the nursing department 3Á22 Æ 0Á84 Assessing the usefulness of education and training to nursing work 3Á31 Æ 0Á82 Actively supporting nurses who try to learn 3Á13 Æ 0Á95 Subtotal 3Á31 Æ 0Á61 Reward system for Fair and objective evaluation of nurses’ performance 3Á02 Æ 0Á94 performance outcomes Evaluation system partially based on nurses’ education/training efforts and knowledge sharing 3Á20 Æ 0Á90 Monetary or nonmonetary compensation for nurses based on the evaluation results 2Á94 Æ 1Á03 Subtotal 3Á05 Æ 0Á83 Total 3Á21 Æ 0Á57

KM, knowledge management.

Table 2 Comparison of implementation of core knowledge management factors with respect to general characteristics of nurses

Knowledge- Nursing Innovative Reward system General sharing management management Organisational for performance Total characteristics culture system leadership learning outcomes (n = 192) of nurses Mean Æ SD Mean Æ SD Mean Æ SD Mean Æ SD Mean Æ SD Mean Æ SD

Age ≤30 3Á39 Æ 0Á51 3Á09 Æ 0Á69 3Á10 Æ 0Á71 3Á28 Æ 0Á60 3Á01 Æ 0Á84 3Á17 Æ 0Á55 31–40 3Á50 Æ 0Á68 3Á15 Æ 0Á79 3Á25 Æ 0Á80 3Á33 Æ 0Á65 3Á10 Æ 0Á82 3Á27 Æ 0Á64 ≥41 3Á68 Æ 0Á44 3Á28 Æ 0Á54 3Á58 Æ 0Á49 3Á60 Æ 0Á45 3Á30 Æ 0Á85 3Á49 Æ 0Á47 F 1Á69 0Á40 2Á45 1Á28 0Á68 1Á71 p 0Á187 0Á671 0Á089 0Á281 0Á508 0Á183 Scheffe –– – – – – Education College 3Á41 Æ 0Á56 3Á08 Æ 0Á71 3Á10 Æ 0Á75 3Á27 Æ 0Á59 3Á03 Æ 0Á82 3Á18 Æ 0Á57 University 3Á50 Æ 0Á55 3Á22 Æ 0Á64 3Á39 Æ 0Á49 3Á47 Æ 0Á66 3Á06 Æ 0Á88 3Á35 Æ 0Á52 t 1Á29 1Á70 2Á94 2Á11 0Á91 1Á67 p 0Á278 0Á168 0Á034 0Á101 0Á437 0Á176 Workplace General warda 3Á47 Æ 0Á54 3Á17 Æ 0Á74 3Á24 Æ 0Á71 3Á36 Æ 0Á63 3Á03 Æ 0Á90 3Á26 Æ 0Á59 ICUb 3Á14 Æ 0Á59 2Á73 Æ 0Á65 2Á84 Æ 0Á70 3Á21 Æ 0Á52 2Á98 Æ 0Á84 2Á98 Æ 0Á45 Special clinicc 3Á42 Æ 0Á58 3Á18 Æ 0Á59 3Á17 Æ 0Á76 3Á23 Æ 0Á61 3Á07 Æ 0Á73 3Á21 Æ 0Á55 Outpatient clinicd 3Á74 Æ 0Á51 3Á11 Æ 0Á90 3Á11 Æ 0Á83 3Á46 Æ 0Á62 3Á19 Æ 0Á83 3Á30 Æ 0Á65 F 3Á42 2Á23 1Á65 0Á91 0Á19 1Á34 p 0Á018 0Á086 0Á180 0Á435 0Á904 0Á263 Scheffe b < a ––– – – Total years of work experience <53Á35 Æ 0Á52 3Á15 Æ 0Á69 3Á11 Æ 0Á68 3Á29 Æ 0Á59 3Á09 Æ 0Á76 3Á20 Æ 0Á53 5–10 3Á44 Æ 0Á60 3Á03 Æ 0Á72 3Á11 Æ 0Á82 3Á28 Æ 0Á66 2Á98 Æ 0Á95 3Á16 Æ 0Á62 >10 3Á55 Æ 0Á55 3Á20 Æ 0Á73 3Á30 Æ 0Á65 3Á38 Æ 0Á56 3Á08 Æ 0Á76 3Á33 Æ 0Á54 F 1Á67 0Á84 1Á02 0Á34 0Á36 1Á06 p 0Á192 0Á434 0Á363 0Á714 0Á698 0Á350 Scheffe –– – – – – Position Nurse manager 3Á79 Æ 0Á48 3Á46 Æ 0Á63 3Á59 Æ 0Á53 3Á58 Æ 0Á51 3Á23 Æ 0Á76 3Á54 Æ 0Á49 General nurse 3Á36 Æ 0Á54 3Á05 Æ 0Á70 3Á07 Æ 0Á73 3Á25 Æ 0Á61 3Á01 Æ 0Á84 3Á15 Æ 0Á56 t 3Á94 2Á99 3Á68 2Á73 1Á33 3Á49 p 0Á000 0Á003 0Á000 0Á007 0Á185 0Á001 Gender Female 3Á39 Æ 0Á51 3Á08 Æ 0Á67 3Á09 Æ 0Á72 3Á26 Æ 0Á60 3Á01 Æ 0Á84 3Á16 Æ 0Á56 Male 3Á51 Æ 0Á64 3Á18 Æ 0Á76 3Á26 Æ 0Á73 3Á39 Æ 0Á61 3Á09 Æ 0Á80 3Á29 Æ 0Á58 t À1Á45 À0Á95 À1Á62 À1Á49 À0Á58 À1Á47 p 0Á150 0Á341 0Á107 0Á138 0Á563 0Á142 nurse managers (3Á54 Æ 0Á49) were higher than those for mean score for application of the nursing process was general nurses (3Á15 Æ 0Á56). 3Á44 Æ 0Á65.

Levels of outcomes of nursing performance Comparison of nursing performance outcomes with respect to general nurse characteristics The total mean score for outcomes of nursing performance was 3Á68 Æ 0Á55, as shown in Table 3. Among the four As shown in Table 4, when the data for the total outcome subcategories of nursing performance outcomes, the mean scores for nursing performance were compared with the score for performance competency was 3Á83 Æ 0Á61, general characteristics of nurses, the results indicated signif- which was the highest score. The mean score for perfor- icant differences between ages (F = 3Á63, p = 0Á028), mance attitude was 3Á71 Æ 0Á62, the mean score for will- between workplaces (F = 3Á54, p = 0Á018), between total ingness to improve performance was 3Á54 Æ 0Á66, and the years of work experience (F = 8Á01, p < 0Á001), and

Table 3 Levels of outcomes of nursing performance, n = 192

Subcategories Content Mean Æ SD

Performance competency Understanding prescription content and performing appropriate 3Á75 Æ 0Á85 tasks without errors or omissions within a given period of time Dealing with and performing many tasks within a reasonable time 3Á82 Æ 0Á87 limit Performing accurately according to the guiding principles of 3Á97 Æ 0Á83 medication management Possessing the knowledge and skills needed to carry out tasks 3Á79 Æ 0Á70 Accurately taking control of patients’ information during shift 3Á93 Æ 0Á78 changes Accurately recording data according to nursing guidelines 3Á78 Æ 0Á73 Managing nursing jobs correctly 3Á77 Æ 0Á76 Subtotal 3Á83 Æ 0Á61 Performance attitude Showing concern and a receptive attitude towards patients and their 3Á90 Æ 0Á75 families Encouraging harmony among health team members within the 3Á70 Æ 0Á78 department and promoting a climate of mutual trust and respect Showing trust in others 3Á75 Æ 0Á72 Taking the initiative and setting an example for others, often by 3Á51 Æ 0Á80 seeking additional responsibility Subtotal 3Á71 Æ 0Á62 Willingness to improve Monitoring for and reporting missing items and faulty equipment 3Á65 Æ 0Á77 performance and facilities Completing learning credits by participating in continuing education 3Á48 Æ 0Á81 and pursuing competency development and improvement Identifying the aetiology of problems and applying appropriate 3Á49 Æ 0Á76 problem-solving methods Subtotal 3Á54 Æ 0Á66 Application of nursing Implementing nursing assessments accurately using instruments 3Á37 Æ 0Á75 process identified on nursing information forms After assessing patients, planning and implementing nursing care 3Á51 Æ 0Á77 according to order of priority Demonstrating and teaching self-care skills to patients and their 3Á44 Æ 0Á71 families Subtotal 3Á44 Æ 0Á65 Total 3Á68 Æ 0Á55 between nurse managers and general nurses (t = 2Á65, outcome scores for nursing performance (r = 0Á38) and for p < 0Á001). the subcategories of performance competency (r = 0Á33), In post-hoc analysis, the total outcome scores for nursing performance attitude (r = 0Á32), willingness to improve per- performance showed no significant difference between ages. formance (r = 0Á36) and application of the nursing process However, workplaces showed significant differences between (r = 0Á35). The total outcome scores for nursing perfor- the general ward (3Á62 Æ 0Á56) and outpatient clinic mance showed positive correlations with the implementa- (3Á13 Æ 0Á48), and total years of work experience showed tion scores for the core KM factors: knowledge-sharing significant differences between below five years (3Á50 Æ 0Á49) culture (r = 0Á42), nursing management system (r = 0Á29), and 5–10 years (3Á74 Æ 0Á55) and between below five years innovative management leadership (r = 0Á31), organisation- (3Á50 Æ 0Á49) and above 10 years (3Á90 Æ 0Á56). al learning (r = 0Á38) and reward system for performance outcomes (r = 0Á23) (see Table 5).

Correlations between implementation scores for core KM factors and outcome scores for nursing performance Factors affecting the outcomes of nursing performance

The total implementation scores for core KM factors Stepwise regression analysis was conducted to analyse fac- showed signiﬁcant positive correlations with the total tors affecting the outcomes of nursing performance for

Table 4 Comparison of outcomes of nursing performance with respect to general characteristics of nurses

General Performance Performance Willingness to Application of Total characteristics competency attitude improve performance nursing process (n = 192) of nurses Mean Æ SD Mean Æ SD Mean Æ SD Mean Æ SD Mean Æ SD

Age ≤30 3Á75 Æ 0Á58 3Á62 Æ 0Á58 3Á47 Æ 0Á63 3Á42 Æ 0Á63 3Á61 Æ 0Á51 31–40 3Á96 Æ 0Á68 3Á85 Æ 0Á67 3Á66 Æ 0Á74 3Á49 Æ 0Á71 3Á81 Æ 0Á62 ≥41 4Á14 Æ 0Á42 4Á10 Æ 0Á47 3Á74 Æ 0Á32 3Á59 Æ 0Á57 3Á94 Æ 0Á36 F 3Á465 4Á624 1Á985 0Á458 3Á63 p 0Á033 0Á011 0Á140 0Á633 0Á028 Scheffe ––– – – Education College 3Á77 Æ 0Á59 3Á66 Æ 0Á60 3Á48 Æ 0Á65 3Á43 Æ 0Á63 3Á63 Æ 0Á53 University 4Á09 Æ 0Á65 3Á91 Æ 0Á67 3Á79 Æ 0Á64 3Á50 Æ 0Á75 3Á78 Æ 0Á60 t À2Á89 À2Á162 À2Á592 À0Á541 À1Á326 p 0Á004 0Á032 0Á010 0Á589 0Á186 Scheffe ––– – – Workplace General warda 3Á75 Æ 0Á62 3Á65 Æ 0Á63 3Á44 Æ 0Á64 3Á44 Æ 0Á65 3Á62 Æ 0Á56 ICUb 3Á77 Æ 0Á69 3Á71 Æ 0Á61 3Á66 Æ 0Á75 3Á56 Æ 0Á68 3Á70 Æ 0Á60 Special clinicc 3Á88 Æ 0Á52 3Á73 Æ 0Á55 3Á64 Æ 0Á64 3Á37 Æ 0Á65 3Á72 Æ 0Á50 Outpatient clinicd 4Á40 Æ 0Á51 4Á28 Æ 0Á55 3Á89 Æ 0Á56 3Á74 Æ 0Á65 3Á13 Æ 0Á48 F 4Á642 4Á233 2Á71 1Á255 3Á548 p 0Á004 0Á006 0Á047 0Á291 0Á018 Scheffe a,b,c < d a,b,c < d ––a > d Total years of work experience <5a 3Á59 Æ 0Á55 3Á54 Æ 0Á58 3Á44 Æ 0Á60 3Á36 Æ 0Á59 3Á50 Æ 0Á49 5–10b 3Á94 Æ 0Á60 3Á77 Æ 0Á57 3Á53 Æ 0Á70 3Á45 Æ 0Á72 3Á74 Æ 0Á55 >10c 4Á06 Æ 0Á62 3Á91 Æ 0Á68 3Á71 Æ 0Á68 3Á57 Æ 0Á62 3Á90 Æ 0Á56 F 10Á72 5Á726 2Á251 1Á491 8Á014 p <0Á001 0Á004 0Á108 0Á228 <0Á001 Scheffe a < b, c a < c ––a < b, c Position Nurse manager 4Á28 Æ 0Á51 4Á14 Æ 0Á58 3Á90 Æ 0Á65 3Á73 Æ 0Á66 4Á10 Æ 0Á50 General nurse 3Á74 Æ 0Á60 3Á63 Æ 0Á59 3Á47 Æ 0Á64 3Á39 Æ 0Á63 3Á60 Æ 0Á52 t 5Á141 4Á502 3Á382 2Á605 4Á650 p <0Á001 <0Á001 0Á002 0Á013 <0Á001

Table 5 Correlations between implementation scores for core KM factors and outcome scores for nursing performance, n = 192

Knowledge- Nursing Innovative Reward system Total scores for sharing management management Organisational for performance implementation culture system leadership learning outcomes of KM

Performance competency 0Á38** 0Á25** 0Á26** 0Á34** 0Á16* 0Á33** Performance attitude 0Á37** 0Á21** 0Á25** 0Á33** 0Á21** 0Á32** Willingness to improve 0Á37** 0Á27** 0Á31** 0Á34** 0Á24** 0Á36** performance Application of nursing 0Á34** 0Á29** 0Á27** 0Á33** 0Á26** 0Á35** process Total of outcome scores 0Á42** 0Á29** 0Á31** 0Á38** 0Á23** 0Á38** for nursing performance

KM, knowledge management. *p < 0Á05; **p < 0Á001.

© 2014 John Wiley & Sons Ltd 8 Journal of Clinical Nursing Original article Core factors of knowledge management nurses in healthcare organisations. To satisfy the conditions followed by the scores for innovative management leader- for the use of stepwise regression analysis, nine enabling ship, knowledge-sharing culture, nursing management sys- variables were investigated to analyse the factors affecting tem and reward system for performance outcomes. The the nursing performance outcomes: (1) age, (2) workplace, reasons that our study’s result for knowledge-sharing cul- (3) total years of work experience, (4) position, which had ture differed from the results of those studies might be that significantly different effects on the outcomes, and (5 the results reflect different organisational cultures and char- through 9) implementation of the five core KM factors, acteristics, different employee perceptions of the quality of which showed significant positive correlations with the out- the work environments and different organisational comes. For the stepwise regression analysis, categorical attitudes towards knowledge-sharing (Shih-Hsiung & Gwo- variables were recorded as dummy variables. Guang 2013). All of our study’s mean implementation In summary, only four of the variables were found to be scores for the five core KM factors were higher than the significant, and the model explained 27Á7% of the variance middle score. This indicates that in the information society in the outcome scores for nursing performance among the of the 21st century, nurses in healthcare organisations are nurses. As shown in Table 6, knowledge-sharing culture participating in KM to improve their problem-solving skills was found to be the strongest factor affecting nursing by discovering the knowledge and know-how of other orga- performance outcomes (b = 0Á28, p = 0Á001), followed by nisation members and sharing them throughout the organi- workplace (b = 0Á02, p = 0Á028), total years of work expe- sation. rience (b = 0Á01, p = 0Á001) and organisational learning In our study, when the total mean implementation scores (b = 0Á17, p=0Á018). for core KM factors were compared with the general characteristics of the nurses who participated, the scores for nurse managers were higher than those for general nurses. Discussion The attitudes of nurse managers with respect to the imple- As stated above, this study was a descriptive research effort mentation of core KM factors could support the success of to investigate the levels of implementation of KM and out- their general nurses’ knowledge-sharing efforts because comes of nursing performance, to examine the relationships nurse managers could serve as role models encouraging a between core KM factors and nursing performance out- problem-solving and knowledge-seeking environment in comes and to identify core factors affecting these outcomes. their units (Sanchez-Polo & Cegarra-Navarro 2008). From Regarding the levels of KM implementation, the total this perspective, we could say that the core KM factor mean score obtained in the study was 3Á21. This result was implementation scores for nurse managers being higher similar to the total mean scores of 3Á44 obtained in the than those for general nurses indicated the possibility of study of Hwang (2011) and 3Á27 obtained in the study of strong support for KM development among the general Choi (2005), both of which involved nurses at healthcare nurses in their organisations. organisations and which used the same measurements for Regarding the levels of outcomes of nursing performance, KM implementation. In our study, of the five core KM fac- the total mean score was 3Á68. This result corresponded tors, knowledge-sharing culture had the highest mean score closely with the mean score of 3Á69 obtained by Ryu of 3Á44, followed by organisational learning with a score of (2009), who identified levels of nursing performance out- 3Á33, innovative management leadership with a score of comes using the same instrument as was used in our study. 3Á16, the nursing management system with a score of 3Á12 With respect to the four subcategories of nursing perfor- and the reward system for performance outcomes with a mance outcomes, in both our study and the Ryu study, per- score of 3Á05. These results differed somewhat from those formance competency had the highest mean score, followed of Choi (2005) and Hwang (2011). In each of those studies, by performance attitude, willingness to improve perfor- the mean score for organisational learning was the highest, mance and application of the nursing process. Recently, a

Table 6 Factors affecting the outcomes of nursing performance, n = 192

Variable b tpCum R2 R2 Adjusted R2 Fp

Knowledge-sharing culture 0Á28 3Á393 0Á001 0Á176 0Á277 0Á259 15Á615 <0Á001 Workplace 0Á02 2Á219 0Á028 0Á227 Total years of work experience 0Á01 3Á437 0Á001 0Á255 Organisational learning 0Á17 2Á388 0Á018 0Á277

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing 9 EJ Lee et al. growing interest in service to healthcare customers is caus- knowledge- sharing environment by implementing personal- ing significant changes in the overall healthcare environ- isation strategies such as incentive programmes because ment. For this reason, nursing departments have engaged in knowledge creation and knowledge sharing are intangible multilateral efforts to enhance the quality of nursing care, a activities (Chang 2011). Development of strategies to goal that can be achieved only through application of the enhance knowledge-sharing culture could strengthen organi- scientific nursing process (Brady & Cummings 2010). sations’ competitiveness by reducing their nursing labour Therefore, the fact that application of the nursing process costs and working hours. had the lowest mean score in both our study and that of Organisational learning, which was identified as a core fac- Ryu (2009) indicates that improvement in this activity tor affecting the outcomes of nursing performance in our among nurses must be a priority to enhance their overall study, was found to play a major role in KM by Choi (2005). professional performance. In addition, Guak (2011) and Noruzy et al. (2013) found The levels of outcomes of nursing performance with that among the five core KM factors, organisational learning respect to the general characteristics of nurses showed sig- facilitated organisational innovation and consequently nificant differences between ages, between workplaces, improved organisational performance. Even though in our between total years of work experience, and between nurse study, the effects of organisational learning on the outcomes managers and general nurses. Similarly, in Bae’s (2007) of nursing performance were limited, organisational learning study, the levels of nursing performance outcomes showed could support achievement of sustained organisational significant differences between ages and between total years growth through promotion of continuous learning, field edu- of work experience of nurses. The findings of both our cation and job training. In this regard, nursing departments study and Bae’s can be explained by improvements in nurs- should provide continuous support for the development of ing knowledge and skills related to increased work experi- nursing educational systems and programmes to encourage ence over time. Based on these findings, enhancement of nurses’ professional improvement, and individual nurses nursing performance within nursing departments may should take advantage of these opportunities. require development of special systems such as manpower Based on these results, the practical implications of this management programmes for long-term employees. study would be of consideration to basic data in developing In our study, the factor most strongly affecting the out- the KM programme for enhancement of the outcome of comes of nursing performance was knowledge-sharing cul- nursing performance, and it can also contribute to improv- ture, followed by workplace, total years of work experience ing both the productivity and competitiveness of healthcare and organisational learning. The levels of implementation organisations. of the five core KM factors and the nursing performance outcomes showed significant positive correlations among all Conclusion variables. However, only two core KM factors, knowledge- sharing culture and organisational learning, were identified Effective nursing requires many complex and knowledge- as affecting the outcomes of nursing performance. Choi’s intensive professional skills. For a healthcare organisation (2005) study, which investigated the factors affecting the to enhance its overall nursing performance, the knowledge outcomes of nursing performance in healthcare organisa- and experiences of its individual nurses should be identified tions, identified only organisational learning as a core KM and shared throughout the organisation. Therefore, identi- factor affecting the outcomes. But the importance of a fying core KM factors that can be used to effectively man- knowledge-sharing culture has been emphasised in the stud- age and share nursing knowledge is vital to improving the ies of Shih-Hsiung and Gwo-Guang (2013) and of Thom outcomes of nursing performance. (2007), who investigated organisational cultures and con- This study identified the relationships between five core cluded that shared knowledge, experience and values are KM factors and outcomes of nursing performance, and two critical enablers and success factors for KM implementa- factors – knowledge-sharing culture and organisational tion. Mustapha (2012) indicated that the ultimate goal of learning – were found to affect nursing performance out- KM is to create a learning organisation in a knowledge- comes. Therefore, prioritising the adoption of a knowledge- sharing atmosphere. A knowledge-sharing organisational sharing culture and organisational learning in KM systems atmosphere has been found to make a large impact on the might be one method for organisations to more effectively organisation members’ propensity to create knowledge and manage their knowledge resources and thus to enhance the share it with other members (Ghosh & Scott 2007). There- outcomes of nursing performance and achieve greater busi- fore, nursing leaders have a responsibility to create a ness competitiveness.

Few recent studies have attempted to identify the rela- The study results can contribute to the development of tionships between KM and outcomes of nursing perfor- effective and efficient KM systems and strategies for mance. Therefore, the greatest strength of our study is that enhancing knowledge-sharing culture and organisational it investigated the levels of implementation of KM and out- learning that can improve both the productivity and com- comes of nursing performance, examined the relationships petitiveness of healthcare organisations. between core KM factors and nursing performance outcomes and identified core KM factors affecting these out- Acknowledgements comes. Even though our study provided useful findings that can The authors thank Mr. Jon Mann for editing the manu- be applied to KM in healthcare organisations, one limita- script of this article for submission for publication. tion is that a cross-sectional study design was employed. Therefore, caution was needed in interpreting the causal Disclosure relationships between core KM factors and outcomes of nursing performance. In future studies, researchers should The authors have confirmed that all authors meet the consider using a longitudinal study design to evaluate the ICMJE criteria for authorship credit (www.icmje.org/ effects of core KM factors on nursing performance out- ethical_1author.html), as follows: (1) substantial contribu- comes. tions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, Relevance to clinical practice and (3) final approval of the version to be published. Effective management of knowledge is very important to achieve strong nursing performance within healthcare or- Conflict of interest ganisations. This study demonstrates that a knowledge- sharing culture and organisational learning are vital core All the authors report no conflicts of interest relevant to KM factors affecting the outcomes of nursing performance. this article.

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