Strategic alignment, meaningful work, and employee engagement among teaching hospital’s workforce in 2017

Background: Human resource management plays a vital role in providing quality services to patients in hospitals. Objective: This study aimed to determine strategic alignment, meaningful work, and employee engagement of teaching hospitals employees. Methods: This cross-sectional study conducted in teaching hospitals. Stringer questionnaire applied for data collection. Linear regression analysis used to determine the effect of demographic variables. Pearson and multiple regression analysis used in STATA to evaluate the correlation between strategic alignment, meaningful work, and employee engagement. Results: Totally 516 participants included in the study. Strategic alignment in the hospitals had a desired situation (54% well level), while it was in a weaker position than employee engagement and meaningful work (18% to 15%-13%). The strategic alignment can be a predictor of meaningful work (r=37%) and employee engagement (r=38.1%). Also, the two variables of strategic alignment and meaningful work together have a stronger effect in explaining employee engagement (r=50.1%). Conclusions: According to the direct impact of strategic alignment on the meaningful work, employee engagement, and their performance, health policymakers need to pay more attention to these factors finally.


INTRODUCTION
Healthcare is faced with a wide range of challenges including service delivery, increased health care costs, and the ever-increasing need for scientific achievements. 1 It is necessary that hospital administrators ensure their organization is effective and efficient as well as do their best to achieve the highest successes with the minimum available resources. 2 The provision of healthcare considered a unique industry whose achievements directly depend on the competencies and technical abilities of its staff. Thus, the hospitals can maintain their dynamism when their human resources are sufficiently familiar with their duties and fulfill their obligations. 3,4 In fact, considering the conditions governing such organizations, they cannot survive without quality employees. 5 Hence, human resource management plays a vital role in providing quality services to patients in hospitals. 6 Based on this approach, strategic human resources management and planning is one of the most critical skills of managers of health centers in pursuit of organizational goals. 7, 8 However, many hospitals, especially in the Middle East, suffer from weaknesses in human resources management and planning and application of appropriate strategies. 9 The effectiveness in an organization will be realized when that organization achieves its predetermined goals about the needs of stakeholders. 10 This goal will not be achieved unless the employees are aware of their organizational goals and responsibilities for these goals. The staff of an organization should be able to answer the following questions: What works are they expected to do? How is the quality of the works they are expected to do? How much are they involved in organizational processes?
Assuming that employees are paid well (salary, wages, and benefits) and creating a suitable working environment, the staff will be able to work hard to answer these questions in order to fulfill their duties and comply with organizational norms. In other words, employees will be able to apply their efforts to achieve organizational goals and adapt to them or adapt to, correct, and change their work-place to accomplish its objectives. Otherwise, organizations and their constituents will face many problems in obtaining the desired level of "strategic alignment" (familiarity of employees with organizational goals and awareness of their responsibility for these goals). 11 Another important factor contributing to the ability of employees to create passion and interest in their work is the "meaningful work". All those who have investigated the relationship between work conditions and job satisfaction point out that value-giving or meaningful work leads to an increase in the physical, psychological, and social health of individual. 12, 13 Additionally, "employee engagement" is another job-related feedback. Employee engagement will occur in an organization when employees act beyond their occupational expectations and communicate with their job both physically and mentally. 14, 15 Previous studies have shown that different levels of occupational engagement are positively associated with functional dimensions of different units in the organization (satisfaction, organizational loyalty, profitability, and safety). 16 Existing studies indicate that organizations can increase the level of employee engagement by improving the level of strategic alignment and thereby pave the way for employees' collaboration and participation in organizational processes. [17][18][19] The present research aims to determine strategic alignment, meaningful work and employee engagement of teaching hospitals employees. The findings of this study can potentially pave the way for improvement of organizational performance of hospitals and provide managerial strategies to increase productivity and promote the administration of hospitals.

MATERIALS AND METHODS
A cross-sectional study in 2017 with a regression method approach was used to identify and analyze the current status of Strategic Alignment, meaningful work and employee engagement among hospital workforces ( Figure 1). Based on the accreditation scores of 16 teaching-specialty hospitals in the capital of Iran (Tehran), three hospitals were selected. Hospitals were chosen in three groups: the highest, the middle and the lowest hospitals regarding with accreditation score. Then, according to the number of personnel in each hospital, using Morgan table, the sample size of each hospital was determined. Total of 563 samples among the highest (N = 360, S = 186), the middle (N = 400, S = 196), and the lowest (N = 340, S = 181) obtained.
The data were collected through an English questionnaire extracted from a study conducted in the US whose reliability and validity were confirmed using the method of Banville et al. 20 In summary, those were translated into Farsi by two translators and then two other researchers and translators who were familiar with the subject again translated it into English (without access to the original English version of this tool). In the next step, English and Farsi versions were compared to each other to resolve the differences. Finally, the corrected Farsi version was sent to two experts on the research subject to elicit their comments and views. Accordingly, the questionnaire validity was confirmed without deleting any question. It was handed out to 30 employees of the studied units and its Cronbach's alpha was obtained equal to 0.87 to assess the reliability of this questionnaire.
The first part of the questionnaire included 6 demographic items. The second part dealt with strategic alignment and contained 8 items. 11 At least, it consists of 8 items about meaningful work. The fourth part of this questionnaire consisted of 14 items to measure occupational engagement. They were scored based on a 5-point Likert scale (totally disagree: 1, disagree: 2, no comment: 3, agree: 4, and totally agree: 5). Furthermore, some items, such as "thinking of other things when working", that are conceptually negative, were scored inversely. Accordingly, the scores above than percentile 70, between 40 and 70, below 40 were evaluated optimum, moderate, and weak, respectively. Therefore, in terms of strategic alignment and meaningful work, scores above than 28, between 16 and 28, and below 16 were considered optimum, moderate, and weak, respectively. Also, in the field of employee engagement, scores above 49, between 28 and 49, and below 28 were classified as optimum, moderate, and weak, respectively. 21 As to comply with the confidentiality of information, numerical codes were used to identify questionnaires. The only inclusion criterion was employment in one of the desired occupational groups (nursing, logistics, administrative-financial, and paramedical). Since individuals with less than two years of experience cannot have a clear understanding of organizational objectives, 11 the only exclusion criterion was a working experience of fewer than two years in the hospital. Linear regression analysis was used to examine the relationship of the considered variables with scores of strategic alignment, meaningful work, and employee engagement. To evaluate the correlation between the main variables, Pearson, linear and multiple regression analysis were used. Also, we used backward elimination method to remove inefficient variables form model in order to obtain the most parsimonies model. 22 In this research, STATA was used for data analysis.

RESULTS
After eliminating defective and incomplete items, the data of 516 questionnaires were used

ORIGINAL ARTICLE
for further analysis. 357 (69.2%) were women and most of the participants were in the age group of 25 to 34 years old with 297 (59.3%). Bachelor participants with the highest number of 108 (62.8%) were the most and also, 195 (41.8%) of them had a work experience of less than 10 years. Regarding with employment status, most of the people with a total of 194 (39.5%) were temporary (Table 1). Table 2 shows, 73% of the participants had a desirable level of engagement, which was the highest compared to strategic alignment and meaningful work. While 17.80% of the participants had weak strategic alignment status, this was the lowest among the three variables studied. Based on strategic alignment, men had a higher score than women (β = 2.345, P = 0.001). Of the increasing education level, strategic alignment score rates declined (P ≤ 0.05). Regarding other variables, employees with a work experience of 10 to 15 years (β = 2.33, P = 0.006) with contractual employment status (β = 1.481, P = 0.026) and auxiliary staff (β = 2.43, P = 0.001) has the highest rate of the aforementioned variable. In the case of meaningful work, men (β = 1.477, P = 0.001) had a higher level of an aforementioned variable than women. Regarding other variables, employees over 55 years of age (β = 2.56, P = 0.011), auxiliary staff (β = 2.43, P = 0.001) showed higher levels of the meaningful work ( Table 3). As well as, men (β = 2.35, P = 0.001), employees with a work experience of 10 to 15 years (β = 4.36, P = 0.001), employees with contractual employment status (β = 4.52, P = 0.001) and auxiliary employees (β = 4.47, P = 0.001) had a higher level of engagement.
Based on the results of Figure 1, the value of r 2 indicates that strategic alignment and meaningful work can explain employee engagement. Also, the relationship between meaningful work and employee engagement was higher than the relationship between strategic alignment and employee engagement even strategic alignment and meaningful work. There are also two variables of strategic adjustment and job involvement. Also, the two variables of strategic alignment and meaningful

Figure 1
The relationship between strategic alignment, meaningful work and employee engagement

DISCUSSION
The scores earned from the study show that each of the items strategic alignment, meaningful work and employee engagement they were in excellent condition. The strategic alignment in the hospitals had a desired situation, while it was in a weaker position than employee engagement and meaningful work. This is probably due to the novelty of strategic planning issues in Tehran's hospitals.
The results of this study show that strategic alignment can be a predictor of both employee engagement and meaningful work. Both of them can predict employee engagement. Stringer stated that it is a factor which improves their status in an organization. 11 In the study of Gagnon in the US evaluated different levels of strategic alignment and concluded that there is a significant relationship between of them. The findings indicate that increased employees' understanding of organizational strategies leads to improved organizational commitment, job satisfaction, and trust among employees. 23 Considering the results of this study which indicate the role of strategic alignment in the improvement of employee engagement in the hospital, it can be stated that the findings of these two studies are consistent with each other. Boswell also indicates that the level of performance is higher among the employees who have a better understanding of organizational strategies and responsibilities. 24 Moreover, such individuals enjoy a higher level of motivation, job satisfaction, organizational commitment than other employees.
Also, the results showed that auxiliary staff had the highest level in all three variables of strategic adjustment, meaningful work, and employee engagement. These findings are probably due to the higher involvement of this group of staff in hospital management training programs. Same as our study, in the study of Mirhashemi, there is a significant and positive relationship between some demographic variables, such as gender, work experience, and educational attainment, and employee engagement. 25 By contrast in stringer study, there was no significant relationship between demographic variables and occupational engagement. 11 This difference in the results can be attributed to the study populations.

CONCLUSION
In general, the present study, although limited by the lack of similar studies for the first time in Iran, showed that strategy could ultimately increase the performance of labor. The organizational objectives are determined in a way that employees accept then considering the individual and environmental conditions. It is essential to recommend practical strategies to be developed to guide employees in line with the realization of organizational objectives the employees be precisely and accurately communicated on the strategic and goals of the hospital. And the last, the mechanisms such as participation in targeting and challenging objective should be included in goal-setting.