In modern society, numerous organizations provide their clients with services and products. Quality is what makes these products different. Most customers demand good quality products (1). Health systems are no exception and the qualities of offered services and protections are of high importance (2).

Hospitals are a part of this system and offer diverse therapeutic services and supports to promote population health.

People value their health very much and the patients expect to receive health services of the highest quality (3). This has led to the establishment of numerous systems which aimed to promote the qualities of health support in recent years. Clinical Governance (CG) is one of the most important of these promoting care quality systems. CG was first devised in National Health Services of the United Kingdom.

The term itself is used to describe a systematized approach towards maintaining and promoting the quality of offered health services. With the establishment of the National Health Service in the UK in 1948, the first step was made in promoting health services quality (4). Clinical governance is a framework in which the organizations which offer health services are held responsible for their services quality and in this way, reaching high standards in services is ensured (5).  It is actually based on the following seven pillars: patient's safety and risk management, service user and public involvement, education and training, clinical information, clinical effectiveness, clinical audit, and staffing and staff management (6). From the first line of health care practice to the highest level of subspecialty, the quality of health services should be taken into consideration. In fact, clinical governance could be thought of as a new and extensive mechanism which guarantees permanent improvement of health services quality and maintaining health organizations standards (7). Considering the vital importance of improving the quality of health services in health system (8) and despite many endeavors recently done in this field, the status of the country national health system is far behind the expected national and worldwide standards. Our previous models for promotion of health services quality have each had their own strong and weak points. Unfortunately, undertaking different models and strategies has lead to a loss of integrity in the process of health service quality improvement (9). Clinical governance is the only system that has the true potential and does not interfere with peer strategies. It also aims to maintain a permanent improvement of health services quality.

Successful fulfillment of clinical governance is indebted to cultural/ organizational changes, reinforcement of supporting systems, and the establishment of cyclic quality surveillance and evaluation (10).

NHS has emphasized on matrons' roles in the implementation of clinical governance and introduced new roles for matrons from which one can mention strong leadership to ensure quality care and infection control for patients (8).

Despite the fact that clinical governance has been in action in Mashhad Hospitals three years ago, little is known about the relationship between matrons’ participation in this plan and hospitals' success in clinical governance fulfillment. Thus, this study was designed to investigate the relationship between matrons’ knowledge, attitude, and performance in clinical governance and Mashhad hospitals fulfillment of clinical governance.

Materials and Methods

This descriptive, cross-sectional analytic study was conducted in nine public hospitals of Mashhad. Due to the limited statistical population, a census method was used, and all nine hospitals implementing clinical governance were included. A researcher-made questionnaire was used to evaluate the knowledge, attitude and the performance of hospital matrons. This questionnaire consisted of four parts: section on matrons' demographic data, section on knowledge
(10 questions), section on attitude (10 questions) and section on performance (10 questions). The questionnaire was designed by clinical governance experts, and its validity was checked by the attendees and staff.

After complete corrections and final confirmation by the attendees, the questionnaire was completed by 15 personnel in a pilot study. Cronbach's alpha was 0.82 and 0.95 for the evaluation of attitude and performance, respectively, and in this way, the reliability of the questionnaire was assessed.

The questionnaires were sent to the nursery managers via email. The standard checklist of the health ministry, which includes seven pillars
(patient's safety and risk management, service user and public involvement, education and training, clinical information, clinical effectiveness, clinical audit, and staffing and staff management) was used to evaluate the performance of the hospitals in the domain of clinical governance. A single team carried out the evaluations on all of the studied hospitals. The assessors’ team consisted of four experts who had been trained in a one-week course on completing checklists.

All the collected data was analyzed with SPSS16 (Spearman's Correlation coefficient) for each hospital separately.

Results

In this study, five out of nine nursery managers were men. Mean age and mean work experience were 45.1±2.1 and 24.1 ± 4.01, respectively. Seven of our participants had a BSN, and the remaining two had MSN. All the managers were official recruits and had previously participated in clinical governance courses.

The mean score of the participants in the knowledge section was 5.51±1.01 of 10.

The mean scores of matrons' attitude and performance regarding clinical governance were 4.46±0.43 and 3.8±1.14, respectively (Table 1).

Spearman's Correlation coefficient test showed that there is no statistically significant relationship amongst knowledge/ attitude/ and performance of nursery managers and the hospital performance scores in clinical governance.

According to the data, average scores of matrons in knowledge, performance, and attitude sections were above mediocre level. Amongst all, matrons' attitude regarding clinical governance achieved the highest score (46.4).

Hospitals mean score in clinical governance was 625.75 (out of 1000). (Table 2)

Discussion

The results of this study showed that the knowledge of nursery managers is less favorable than their attitude and performance in clinical governance domain. In a study by Murray and colleagues which evaluated the level of knowledge, attitude, and performance of NHS staffs in the clinical governance domain, the results demonstrated a positive attitude and nonuniform levels of knowledge and performance (11). In another study dietitians reported a positive attitude regarding clinical governance (12). In a study by Sam on the physicians' responses to innovations of health systems in governance and, in particular, clinical governance, it was shown that physicians did not have a high opinion of clinical governance and were not willing to contribute to the process since they thought of this strategy as something purely managerial with no practical gains (13). Our study focuses on the matrons: Although the matrons' mean knowledge score was above mediocre, one must note that hospital nursery managers play a very important role in solidifying the clinical governance and still higher levels of knowledge are needed.

Devising more instructive courses with new teaching methods and making use of multiple educational tools to improve matrons' knowledge of clinical governance seems a must. On the other hand, no significant relationship was found between the matrons’ knowledge, attitude, and performance in the clinical governance domain and the overall score of the pertaining hospitals in fulfilling clinical governance.

We could not find any similar studies to compare the results. However, in a study by Feng the relationship between the nursery management commitment to safety and the patients' safety culture was found to be significant (14). These results are not exactly consistent with ours and may be due to the small sample size. It must be noted that beside matrons, hospital managers and personnel, whose opinions and attitudes were not evaluated in our study, may also play an important role in clinical governance fulfillment.

Conclusion

Clinical governance is an opportunity to drive health system personnel to a more active and challenging atmosphere. This approach may be a true turning point for health systems and bring us a rich culture free from reproach and based on ration.

Clinical governance has been in action since 2010 and we investigated the relationship between the matrons’ knowledge/ attitude/ performance in clinical governance domain and hospitals score in executing clinical governance. According to our present study, the knowledge, attitude, and performance of matrons are all above mediocre level, but the matrons' knowledge must be still improved.

Also, no significant relationship was found between the matrons' knowledge, attitude, and performance in the clinical governance domain and the scores of the pertaining hospitals, which may be due to the study small sample size.