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Using internal marketing to improve organizational commitment

and service quality
Yafang Tsai & Shih-Wang Wu

Accepted for publication 5 March 2011

Correspondence to Y. Tsai: T S A I Y . & W U S . - W . ( 2 0 1 1 ) Using internal marketing to improve organizational

e-mail:, commitment and service quality. Journal of Advanced Nursing 67(12), 2593–2604. doi: 10.1111/j.1365-2648.2011.05696.x

Yafang Tsai PhD

Associate Professor
Department of Health Policy and Aim. The purpose of this article was to explore the structural relationships among
Management, Chung Shan Medical internal marketing, organizational commitment and service quality and to practi-
University, Taiwan, cally apply the findings.
and Adviser, Background. Internal marketing is a way to assist hospitals in improving the
Department of Medical Research, quality of the services that they provide while executing highly labour-intensive
Chung Shan Medical tasks. Through internal marketing, a hospital can enhance the organizational
University Hospital, Taichung, Taiwan
commitment of its employees to attain higher service quality.
Method. This research uses a cross-sectional study to survey nursing staff per-
Shih-Wang Wu PhD
Assistant Professor ceptions about internal marketing, organizational commitment and service quality.
Department of Hospital and Health Care The results of the survey are evaluated using equation models. The sample includes
Administration, Chia Nan University of three regional hospitals in Taiwan. Three hundred and fifty questionnaires were
Pharmacy & Science, Tainan, Taiwan distributed and 288 valid questionnaires were returned, yielding a response rate of
82Æ3%. The survey process lasted from 1 February to 9 March 2007. The data were
analysed with SPSS 12Æ0, including descriptive statistics based on demographics. In
addition, the influence of demographics on internal marketing, organizational
commitment and service quality is examined using one-way ANOVA .
Results. The findings reveal that internal marketing plays a critical role in explaining
employee perceptions of organizational commitment and service quality. Organiza-
tional commitment is the mediator between internal marketing and service quality.
Conclusion. The results indicate that internal marketing has an impact on both
organizational commitment and service quality. Internal marketing should be
emphasized to influence frontline nursing staff, thereby helping to create better
organizational commitment and service quality.

Keywords: internal marketing, organizational commitment, service quality

care is becoming more difficult. As in many other countries,

hospital managers in Taiwan face the challenges of control-
Because the Bureau of National Health Insurance in Taiwan ling costs while maintaining service quality (SQ). As a result,
has focused on reducing its financial deficit for several years, hospital administration teams must now focus on patient
the predicament of hospitals and the administration of health satisfaction and employee organizational commitment (OC)
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Y. Tsai and S-W Wu

to ensure hospital development and stability in a competitive that affect job satisfaction and SQ (Edwards & Burnard
environment. 2003, Mélanie et al. 2005). Whether or not IM activities
Unlike physical products, service products involve real- are executed affects staff SQ and the presentation of
time interactions with customers. When customers pay for external promotional activities (Berry & Parasuraman
service products, they evaluate SQ according to their 1991). IM is based on the notion that organizations
predetermined expectations with respect to how service providing employment security are committed to their
employees should behave. Thus, the willingness of service workforce and that when internal customer needs are
employees to deliver quality service plays a significant role in fulfilled through IM, their satisfaction will increase. The
an organization’s attempts to satisfy customer expectations promotion of staff satisfaction should also increase, with
(Humborstad et al. 2008). good SQ resulting in promotional marking activities (Bansal
According to Greene et al. (1994), methods for efficiently et al. 2001).
improving SQ are pertinent to internal marketing (IM) Previous studies have revealed that employee OC is
because in offering a service, employees not only represent positively correlated with job satisfaction (Susskind et al.
the organization but also provide a crucial so-called ‘service 2000, Charles & Schwepker 2001). The work that organi-
encounter’ (Carr 1990, Tansuhaj et al. 1991). Kotler (1991) zations do to promote staff work satisfaction and elevate the
defines IM as a method that organizations use to hire and quality of services that staff provide to external customers
maintain employees and to motivate them to provide better also forms a virtuous cycle and promotes staff commitment
services to customers. Because most service organizations are (Kim et al. 2005). Makanjee et al. (2006) finds that IM is
highly labour intensive, IM can assist these organizations in positively related to employee OC. Makanjee et al. (2006)
attracting and retaining high-quality talent (Berry 1984). study four clinical diagnostic imaging radiographers from
Hospital managers who use IM can also improve employee Pretoria Academic Hospital in South Africa. However,
OC and job satisfaction (Bansal et al. 2001). depending on the cultural background of a given country,
Other international studies related to this research have the results that they identify may shift. We therefore propose
considered patient evaluations of the quality of nursing Hypothesis 1.
services and patient perceptions of nursing quality (Shaw
Hypothesis 1. Internal marketing is positively related to organiza-
1997, Persson et al. 2005, Staniszewska & Henderson 2005).
tional commitment.
Some studies of OC have explored the influence of employee
roles on OC (Lou et al. 2007), and still other studies explore
how OC influences employee turnover or consider the Organizational commitment and service quality
influence of leadership behaviour on employee OC (Loke
Frontline employees play a boundary role, not only repre-
2001). These studies all focus on the individual level; they
senting the firm by interacting with outside parties but also
explore the nursing behaviours, SQ and OC of employees. By
influencing the cognitions, attitudes and evaluations of
contrast, an IM approach considers the level of the organi-
customers (Woodside et al. 1989). Service organizations
zation. Specifically, IM is concerned with how organizational
deliver organizational goals and visions to customers through
management should develop educational training, explicitly
IM, which means that employee organizational fit has an
communicate organizational perspectives and create reward
impact on service delivery because it has impacts on
systems that improve employee service ability and satisfac-
organizational performance (Ostroff 1993). That is, the
tion with their work. Most previous studies from the IM
relative strength of an employee’s identification with the
approach have focused on for-profit sectors such as the
organization’s goals (Unzicker et al. 2000), vision and values
service sector (Boshoff & Tait 1996), airlines (Frost &
is reflected in employee service delivery. Identification with
Kumar 2001) and banks (Caruana & Calleya 1998, Sargeant
the goals and values of a company is referred to as OC
& Asif 1998). Notably, they have not focused on non-profit
(Mowday et al. 1982).
During a service encounter, the willingness of employees to
engage in discretionary efforts determines the level of SQ
Background delivered to customers, leading to customer satisfaction
(Zeithaml et al. 1990). The willingness of employees to
Internal marketing and organizational commitment accept and support organizational goals and behave in a
manner that is likely to promote these goals influences the
Problems related to retaining qualified and experienced staff
level of SQ delivered to the customer as well (Boshoff & Tait
have highlighted the need to review various aspects of work
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1996). For example, Malhotra and Mukherjee (2004) find employee ability to provide quality services to customers.
that the OC of employees plays an important role in Thus, we propose Hypothesis 3.
determining the level of SQ delivered to customers. Malhotra
Hypothesis 3. Organizational commitment is a mediator between
and Mukherjee (2004) study a major retail bank in the United
internal marketing and SQ.
Kingdom (UK). Of course, given the different cultural
characteristics and the for-profit nature of the UK bank, this
organization is different from hospitals in Taiwan, and the The study
results obtained may be different from our own. Neverthe-
less, we offer Hypothesis 2.
Hypothesis 2. Organizational commitment is positively related to SQ.
The purpose of this article was to explore the structural
relationships between IM, OC and SQ.
The relationships among internal marketing,
organizational commitment and service quality
Heskett et al. (1994) provide a model of a service profit chain
A cross-sectional study was conducted during 2007.
as a strategic variable, suggesting linkages among internal
SQ, employee satisfaction, productivity, external customer
satisfaction and organizational performance (Varey 1995). Participants
Because service delivery occurs through human interaction
The survey samples include nursing staff from three regional
between service providers and customers (Goran 2006), the
teaching hospitals in Taiwan.
service encounter during the service delivery process largely
determines the degree of SQ delivered to customers
(Malhotra & Mukherjee 2004). Bowen and Schneider The nursing profile of Taiwan
(1985) recognize that the work environment of service
employees has a strong impact on how customers experience There are many differences between the nursing education
the service provided to them. Human resource practices (such system in Taiwan and the United States of America (USA). In
as service training and reward practices) can ultimately Taiwan, the training system for nursing staff includes
influence the service experiences of customers (José & Garazo vocational nursing schools, nursing colleges and nursing
2006, Tsai & Tang 2008). Employees must satisfy customer departments at universities. Nursing staff under 20 years of
needs, and thus, customers are more satisfied when employees age are mostly graduates of vocational nursing schools
demonstrate an advanced skill level, advanced knowledge without college training; if they wish to serve in hospitals,
and strong abilities. they must qualify via the national nursing licence examina-
Internal marketing is the process of selling the concept of tion, thereby becoming designated as staff nurses. The
customer service to employees so that they internalize an nursing students who have graduated from a college or
appropriate set of values (Varey 1995). If employees identify university can take the national specialist examination and
with the organization and indicate their service commitment become nursing specialists. Staff nurses in Taiwan are the
to customers, they fulfill the goals of the organization. IM equivalent of licensed vocational nurses in the USA, whereas
should focus on properly educating employees both internally nursing specialists are Registered Nurses.
and externally about the organizational mission, strategic
mission and customer needs. They should subsequently Data collection
become more focused on satisfying those needs and contrib-
ute significantly to organizational effectiveness (Sargeant & Three hundred and fifty questionnaires were distributed and
Asif 1998). The aim of IM is to ensure that employees feel 288 valid questionnaires were received, yielding a response
that the management is concerned with them and that their rate of 81Æ13%. The survey period was from 1 February to 9
needs are met. When used successfully, IM creates positive March 2007.
employee attitudes, including OC, job involvement, work The questionnaire contained a range of closed statements.
motivation and job satisfaction (Tansuhaj et al. 1991). Thus, Respondents were asked to rate their level of agreement on a
a service organization can improve employee OC through IM 5-point Likert Scale (1 = ‘strongly disagree’ and 5 = ‘strongly
efforts such as training and motivation and thereby enhance agree’).

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Y. Tsai and S-W Wu

Internal marketing
The Proposed Model
This research used the 14-item scale designed by Money and
Foreman (1996), a commonly used assessment tool for the After the pilot study and the tests for construct validity and
concept of IM (Ewing & Caruana 1999). internal consistency, we developed our final conceptual
model (Figure 1).
Organizational commitment
The 15-item scale by Mowday et al. (1979) was used to
Ethical considerations
measure OC.
This survey is based on the agreement of volunteer exami-
Service quality nees. All responses were anonymous and the examinees and
This study used a 22-item self-report instrument called the researchers were not acquainted with each other. The
SERVQUAL to measure SQ. SERVQUAL is a concise, mul- researchers invited the examinees to participate in this
tiple-item scale with good reliability (Lewis & Mitchell 1990) research upon distributing the questionnaires. They were
that has been widely accepted as a valid instrument for also informed that all information was to be provided on a
measuring SQ (O’Connor et al. 2000, Frost & Kumar 2001). voluntary basis and would be used for research purposes
only. Because names were not required on the data collection
forms, privacy and anonymity were ensured. To guarantee
Pilot study
the privacy of the examinees, the questionnaires were sealed
First, the content of the questionnaires was developed by after they were retrieved to keep their contents secure and
consulting relevant literature and then slightly modifying anonymous. The questionnaire has been verified that it is
existing items to create initial questionnaires based on the unnecessary be approved by ethical committee.
research purpose and specific industry features. Then, three
directors or supervisors from the medical centre were invited
Data analysis
to perform an expert validation of the questionnaire, after
which it was further revised. Next, a pilot run of the Structural equation modelling (SEM) with latent variables was
questionnaire was administered to 50 nurses. The pilot results used to analyse the data in this study. The parameters of the
indicated that all item-total correlations were >0Æ40 and that models were estimated via maximum-likelihood (ML) estima-
all Cronbach’s coefficients of the subscales and scales tion using AMOS 7Æ0 (SPSS Inc., Chicago, IL, USA). Indirect
exceeded 0Æ65; therefore, none of the items was deleted effects were tested using a bootstrap framework based on
(Hair et al. 1998). Shrout and Bolger’s (2002) techniques with 500 bootstrap
samples (re-sampled from the original dataset) to derive less
biased standard errors and achieve a 95% confidence interval
Validity and reliability
(CI). A bias-corrected 95% CI (BC 95% CI) is also reported.
Two hundred and eighty-eight valid questionnaires were The current study also used several indices to evaluate
collected during the formal study. Table 1 shows descriptive overall model fit, including the chi-squared ratio (v2/d.f.), the
statistics, exploratory factor analysis and internal consistency adjusted goodness-of-fix index (AGFI), the standardized root-
(Cronbach’s coefficient) for all variables. mean-squared residual (SRMR), the comparative fit index
Principal component analysis was used to extract major (CFI) and the root-mean-square error of approximation
contributing factors, and Promax rotation (non-orthogonal) (RMSEA). v2/d.f. of <3, AGFI >0Æ90, CFI >0Æ95, SRMR
was performed to recognize common factors. The eigenvalue <0Æ08 and RMSEA <0Æ08 were regarded as indicating good
>1 rule was used to decide the number of factors. A factor model fit.
loading >0Æ35 was regarded as statistically significant for our The data were analysed using SPSS 12Æ0 (SPSS Inc.), with
sample size (Hair et al. 2006, p. 128). descriptive statistics indicating the demographics of the
As shown in Table 1, two constructs (or subscales) were sample. To understand the relationships between the demo-
extracted as IM constructs. Additionally, two constructs were graphic characteristics of the nurses and their perceptions of
identified as OC constructs, and three constructs were IM, OC and SQ, a one-way ANOVA was conducted with
identified as SQ construct. The factor loadings for all equal variance assumed (Macnee & McCabe 2007).
constructs were >0Æ35. All Cronbach’s coefficients exceeded Furthermore, this study implemented a Scheffe post hoc
0Æ70; this is regarded as acceptable (DeVellis 2003, pp. comparison, focusing on results with statistically significant
95–96). differences.
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JAN: ORIGINAL RESEARCH Internal marketing, organizational commitment and service quality

Table 1 Factor naming (pattern matrix) and reliability analysis results

Factor Variance
No. Content of items, constructs and scales Mean SD loading explained Cronbach’s a

Internal marketing
Human resource management 64Æ96% 0Æ95
8 At our hospital, employees who provide excellent service are rewarded 4Æ66 0Æ98 0Æ96
for their efforts
13 Our hospital assesses and rewards employee performance that 4Æ80 1Æ01 0Æ91
contributes to achieving the organizational goal
11 Our hospital places significant emphasis on communication with 4Æ65 1Æ08 0Æ89
14 Our hospital communicates to employees the importance of their 4Æ62 1Æ08 0Æ87
service roles
7 Data gathered from employees are used to improve jobs and develop 4Æ48 1Æ02 0Æ83
hospital strategies
9 At our hospital, employees are properly trained to perform their 4Æ64 0Æ99 0Æ80
service roles
10 Our hospital has the flexibility to accommodate different employee 4Æ57 1Æ07 0Æ72
12 Our organization goes beyond simple training and educates employees 4Æ71 0Æ95 0Æ68
to work together
5 Our hospital teaches employees why they should do things’ and not 4Æ44 1Æ03 0Æ58
just ‘how they should do things
6 Our hospital makes preparations that enable employees to perform 4Æ48 1Æ07 0Æ53
Vision and development 7Æ55% 0Æ88
1 Our hospital offers employees a vision that they can believe in 4Æ62 1Æ03 0Æ96
2 The vision of our hospital is communicated to all employees 4Æ88 1Æ01 0Æ91
3 Our hospital views the development of knowledge and skills in 4Æ64 1Æ10 0Æ89
employees as an investment rather than a cost
4 Development of employee skills and knowledge is an ongoing process 4Æ99 0Æ97 0Æ87
in our hospital

Organizational commitment
Trust and honour 44Æ09% 0Æ90
6 I am proud to tell others that I am part of this hospital 4Æ52 1Æ00 0Æ84
5 I find that my values and the hospital’s values are very similar 4Æ52 1Æ00 0Æ79
13 I really care about the fate of this hospital 4Æ77 0Æ93 0Æ79
10 I am extremely glad I chose this hospital to work for over others I was 4Æ52 0Æ95 0Æ78
considering at the time I joined
14 This is the best hospital that I could work at 4Æ22 1Æ00 0Æ75
8 This hospital really inspires the best in me in terms of job performance 4Æ50 0Æ87 0Æ74
2 I tell my friends that this is a great hospital to work for 4Æ54 1Æ09 0Æ71
4 I would accept almost any type of job assignment to keep working for 4Æ43 0Æ90 0Æ68
this hospital
1 I am willing to put in a great deal of effort beyond that normally 4Æ74 0Æ94 0Æ66
expected to help the hospital be successful
Loyalty 14Æ00% 0Æ86
11 There is not much to be gained by sticking with this hospital 4Æ54 1Æ02 0Æ85
9 It would take only a very small change in my present circumstances to 4Æ30 1Æ01 0Æ81
cause me to leave this hospital
7 I could just as well be working for a different hospital as long as the 3Æ99 0Æ96 0Æ75
type of work was similar
12 Often, I find it difficult to agree with this hospital’s policies regarding 4Æ23 1Æ06 0Æ73
important matters related to its employees
15 Deciding to work for this hospital was a definite mistake on my part 4Æ84 1Æ07 0Æ73

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Table 1 (Continued)
Factor Variance
No. Content of items, constructs and scales Mean SD loading explained Cronbach’s a

3 I feel very little loyalty to this hospital 4Æ97 1Æ18 0Æ70

Service quality
Trust and response 61Æ89% 0Æ97
20 Nursing staff provide proper services to different patients 5Æ32 0Æ96 0Æ97
22 Nursing staff should know that different patients have different needs 5Æ40 0Æ98 0Æ92
18 Provide proper care to different patients 5Æ29 1Æ01 0Æ91
16 Nursing staff are polite to patients 5Æ43 0Æ96 0Æ91
19 Set up proper service time according to the needs of different patients 5Æ26 0Æ98 0Æ90
21 The benefit of the patient is the first priority 5Æ37 0Æ95 0Æ87
15 Provide a safe experience during medical services 5Æ41 1Æ00 0Æ86
17 Nursing staff are capable of answering patient questions 5Æ47 0Æ98 0Æ84
14 Nursing staff behaviours build patient confidence in medical services 5Æ35 0Æ96 0Æ69
10 Nursing staff should inform patients of the content of the services to 5Æ22 0Æ91 0Æ61
be provided
11 Nursing staffs should help patients immediately 5Æ19 0Æ98 0Æ50
12 Nursing staffs are highly willing to service patients 5Æ21 0Æ97 0Æ46
Guarantees and concern 9Æ28% 0Æ91
9 Nursing staff should keep records so as to avoid making mistakes 4Æ92 0Æ99 1Æ02
7 Do the right thing the first time 5Æ11 0Æ98 0Æ84
8 Provide services to patients on time 5Æ13 0Æ91 0Æ82
6 Do their best to help patients resolve problems 5Æ12 0Æ87 0Æ71
5 Nursing staff should execute commitment to patients on time 4Æ92 0Æ88 0Æ62
13 Nursing staffs were not so busy that they ignored patients 4Æ97 1Æ03 0Æ45
Tangibles 4Æ69% 0Æ89
2 The hospital has a modern building exterior 4Æ71 0Æ87 0Æ96
1 The hospital has modern equipment 4Æ87 0Æ94 0Æ94
4 Perfect services and service explanation are provided 4Æ84 0Æ86 0Æ73
3 The staff at the hospital keep the facilities clean 5Æ05 0Æ85 0Æ66

The KMO values of the three scales were 0Æ95, 0Æ91 and 0Æ95, respectively.

Trust & Honor Loyalty

Trust &
a b
Human resource
Management Service Guarantee &
Internal c’
Marketing Quality Concern
Vision &
Development a* b

Figure 1 The conceptual model: Model 1.

Results Inferential statistical analysis

Table 2 shows the demographic characteristics of the respon- Age was found to affect nurse perceptions of IM and SQ.
dents. Respondents between the ages of 30 and 39 scored signifi-
The means, standard deviations and bivariate correlations cantly higher on IM than employees below the age of 20. This
for all observational variables are given in Table 3. study also showed that employees aged 30–39 have markedly
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Table 2 Respondent demographics coefficient were larger than 0Æ45 (yielding an R2 larger than
0Æ20), which indicated acceptable convergent validity. In
Characteristic Categories N (%)
addition, the composite reliability of all constructs was
Gender (n = 288) Female 252 (87Æ5) >0Æ70, and the average for all constructs exceeded 0Æ50,
Male 36 (12Æ5)
indicating that the observational variables derive the latent
Marital status Married 156 (54Æ2)
(n = 288) Single, never married 132 (45Æ8)
variables well.
Years worked in the £1 years 45 (15Æ6)
profession (n = 288) 2–3 years 78 (27Æ0) Relationships between IM and OC as well as OC and SQ:
4–5 years 54 (18Æ8) direct effects in the structural model (Hypothesis 1 and 2)
6–7 years 54 (18Æ8) As shown in Table 6, the path coefficient ‘a’ from IM to OC
‡8 years 57 (19Æ8)
was statistically significant (B = 0Æ72, T = 13Æ79, P < 0Æ001).
Education level Vocational senior 7 (2Æ4)
(n = 288) high school This indicates that a favourable perception of IM was asso-
College 147 (51Æ1) ciated with increased OC. Thus, we confirmed the validity of
University 121 (42Æ0) Hypothesis 1. We also found that OC was positively associ-
Postgraduate 13 (4Æ5) ated with SQ (path coefficient ‘b’, B = 0Æ49, T = 3Æ51,
Age (years, n = 288) Age below 20 67 (23Æ3)
P < 0Æ01). Thus, Hypothesis 2 was also supported.
20–29 158 (54Æ9)
30–39 49 (17Æ0)
40–49 6 (2Æ0) The mediation effect of OC on the relationship from IM to
50–59 and >59 8 (2Æ8) SQ: the indirect effect in the structural model (Hypothesis 3)
The path ‘a*b’ shows the estimated total indirect effect of OC
as indicated via bootstrapped SE and BC 95% CI and Sobel
higher perceptions of SQ than do those aged 20–29 (Table 4). tests (Shrout & Bolger 2002). As shown in Table 7, this
Married individuals display stronger positive perceptions indirect pathway was statistically significant (Sobel Z = 3Æ41,
about SQ than do unmarried individuals. The number of BC 95% CI of B = 0Æ14–0Æ76), indicating the existence of a
years worked in the profession was also found to influence mediation effect of OC. Note that the indirect effect was
nurse perceptions of SQ. Those who had worked in the statistically significant, while the direct path ‘c¢’ was not
profession for 8 or more years showed stronger perceptions (B = 0Æ20, T = 1Æ74, ns). This may suggest that the relation-
of SQ than did those who had worked in the field for ship from IM to SQ was totally mediated by intervening
<5 years. The study did not find that any employee variables (that is, OC), consistent with Baron and Kenny
characteristics affected OC. (1986).
To confirm the mediation effect of OC, we created a
more parsimonious model from which the direct paths (c¢,
Analysis of the Measurement Model
or the relationship from IM to SQ) were removed. This
Convergent validity model was then compared with Model 1 [M2 vs. M1:
A parameter (k) was estimated for each latent variable and Dv2(1) = 2Æ33, ns]. According to Hair et al. (2006, pp. 866–
observational variable to determine statistical significance 870), a non-significant result indicates that the dropped
and thus evaluate convergent validity. As shown in pathway (that is, c¢) is not important to the model
Table 5, all t values exceeded 2, and all standardized (Table 7).

Table 3 Descriptive statistics and correlations for all variables (n = 288)

Mean SD 1 2 3 4 5 6 7

1 Human resource management 4Æ60 0Æ87 –

2 Vision development 4Æ78 0Æ88 0Æ76 –
3 Trust and honour 4Æ53 0Æ73 0Æ65 0Æ64 –
4 Loyalty 4Æ48 0Æ80 0Æ32 0Æ39 0Æ51 –
5 Trust and response 5Æ33 0Æ84 0Æ37 0Æ49 0Æ51 0Æ31 –
6 Guarantees and concern 5Æ03 0Æ79 0Æ37 0Æ48 0Æ52 0Æ28 0Æ76 –
7 Tangibles 4Æ87 0Æ77 0Æ45 0Æ51 0Æ59 0Æ35 0Æ63 0Æ74 –

All Pearson’s correlation coefficients were significant at the P < 0Æ001 level.

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Table 4 One-way ANOVA and Scheffe post hoc analysis

Variables Demographic characteristic F-value Significance Scheffe Post hoc test

Internal marketing (IM) Age 4Æ221 0Æ002** 3>1

Educational level 2Æ335 0Æ074
Marital status 0Æ868 0Æ421
Gender 0Æ013 0Æ908
Years worked in the profession 2Æ191 0Æ070
Organizational Age 1Æ517 0Æ198
commitment (OC) Education level 0Æ095 0Æ963
Marital status 0Æ039 0Æ962
Gender 0Æ042 0Æ839
Years worked in the profession 2Æ075 0Æ084
Service quality (SQ) Age 11Æ309 0Æ000** 3 > 1, 3 > 2
Education level 1Æ928 0Æ125
Marital status 3Æ929 0Æ021* 1>2
Gender 0Æ421 0Æ517
Years worked in the profession 7Æ670 0Æ000** 5 > 1, 5 > 2, 5 > 3

*Indicates significance at the P < 0Æ05 level; **indicates significance at the P < 0Æ01 level.

Table 5 Results of SEM analysis: Model 1 with path c¢

Non-standardized Standardized Composite
Construct/variable coefficient t value coefficient (k) reliability AVE

Internet marketing 0Æ87 0Æ77

Human resource management – – 0Æ86
Vision and development 1Æ04 16Æ16*** 0Æ89
Organizational commitment 0Æ73 0Æ59
Trust and honour – – 0Æ95
Loyalty 0Æ62 8Æ09*** 0Æ53
Service quality 0Æ88 0Æ72
Trust and response – – 0Æ82
Guarantees and concern 1Æ04 17Æ41*** 0Æ91
Tangibles 0Æ90 15Æ61*** 0Æ81

***P < 0Æ001.

AVE, average.

Table 6 Results of SEM analysis: Model

Non-standardized Standardized
1 with path c¢
Path Path way coefficient t value coefficient (b)

Direct effect
a Internet marketing 0Æ72 13Æ79*** 0Æ78
(n1) fi Organizational
commitment (g1)
b Organizational commitment 0Æ49 3Æ51** 0Æ48
(g1) fi Service quality (g2)
c¢ Internet marketing 0Æ20 1Æ74 0Æ22
(n1) fi Service quality (g2)
Indirect effect
a*b IM fi OC fi SQ 0Æ35 3Æ41** 0Æ38

**P < 0Æ01, ***P < 0Æ001.

Z value of Sobel’s (1982) formula for indirect effects.

Bootstrapping biased-corrected methods, 95% CI of non-standardized coefficient = 0Æ14–0Æ76,
P value = 0Æ006; 95% CI of b = 0Æ14–0Æ76, P value = 0Æ008.

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Table 7 SEM fit indices Discussion of results

Model v2 (d.f.) Dv2 AGFI SRMR CFI RMSEA Clinical practice managers aim to promote staff commitment
1 45Æ14 (11) – 0Æ89 0Æ04 0Æ97 0Æ10 and improve SQ. Previous studies focus on the influence of
2 47Æ47 (12) 2Æ33 0Æ90 0Æ04 0Æ97 0Æ10 the personal qualities of nurses on organization commitment.
These have included gender, pressure of characters and
Model 1 (with path c¢) is the model with direct pathways between
conflicts at work (Karrasch 2003, Lou et al. 2007). We try to
OC and SQ. Model 2 (without path c¢) is the model without direct
pathways between OC and SQ. present useful insights for managers to help them use IM to
AGFI, adjusted goodness of fit; SRMR, standardized root-mean- improve nurse OC and SQ.
squared residual; CFI, comparative fit index; RMSEA, root-mean- Lou et al. (2007) sampled nurses in southern Taiwan and
square error of approximation; OC, organizational commitment; SQ, found that the position in hospital and attribute of job played
service quality.
affect staff commitment to their organization. He suggested
The AMOS standardized estimates are illustrated in that nursing managers use salary compensation systems to
Figure 2. improve nurse commitment and reduce resignation inclina-
tion. In this study, we demonstrate that IM can strengthen
OC and thereby improve SQ, indicating that the greatest goal
of IM should be the proper use of salary compensation systems.
Thus, our results provide a response to Lou et al. (2007).
Study limitations
If nursing managers understand which personal character-
This study has focused on three regional teaching hospitals in istics affect SQ, this may help them choose their staff.
Taiwan, which might limit the inference of the study’s results, Previous studies have shown that staff characteristics influ-
although we used a cross-sectional methodology. The attitude ences SQ. Marjorie and Cattaneo (2001) find that employee
and behaviour of staff or the implementation of an encour- characteristics (including age, organizational tenure, job
agement system could influence the quality of the services position, gender, marital status and education level) can
that staff provide to patients, which also means that SQ could impact SQ. This study also indicates that the age affects SQ.
change over time. With sufficient time and a sufficient Characteristics of employees such as age, gender, education
research budget, future studies can use panel data to track and work experience also significantly influence nurse percep-
the effectiveness of the IM or quality improvement activities tions of IM (Jack & Cronin 2000). Older nurses are found to
of hospitals over time. have higher perceptions of IM and SQ than younger nurses.
The sample in this research is comprised of employees, This may be because older employees have a better under-
with perceptions about SQ being those of the respondents. standing of the organization’s vision and mission. The results
Thus, we do not take into account the perceptions of the of this study indicate that IM programmes can aid hospital
patients themselves. According to the concept of the SQ gap, managers in maintaining long-term cooperative relationships
there may be a difference between staff perceptions vs. with employees to reinforce the organizational mission.
patient perceptions. We suggest that future studies survey In addition to personal variables, staff perceptions based
patients directly for SQ. on national and regional culture may also affect nurse’s

Trust & Honor Loyalty

0·95 0·53
Trust &
0·78*** 0·48**
Human Resource 0·82
0·86 0·22
Management Internal (ns) Service Guarantee &
Marketing Quality 0·91 Concern
Vision &
Development 0·89 0·81

Figure 2 AMOS standardized estimates for Model 1. **P < 0Æ01, ***P < 0Æ001.
 2011 The Authors
Journal of Advanced Nursing  2011 Blackwell Publishing Ltd 2601
Y. Tsai and S-W Wu

What is already known about this topic
We are thankful for Dr. Shwn-Huey Shieh’s useful consulta-
• Previous studies show that the job satisfaction of the
tion about the clinical and practical operation of nursing. We
nursing staff can influence service quality and
appreciated her efforts in making the study more meaningful.
organizational commitment.
We also thank Dr. Ya-Hsin Li, who helped us with the editing
of the manuscript.
What this paper adds
• This research considers variations at the organization Funding
level by taking into account internal marketing (IM), to
This research received no specific grant from any funding
offer managers a useful management tool for improving
agency in the public, commercial or not-for-profit sectors.
staff OC and SQ.
• The results show that IM influences the OC and SQ of
the nursing staff. Conflict of interest
• Organizational commitment mediates between IM and
No conflict of interest has been declared by the authors.
SQ; IM is an effective way to enhance employee OC,
Using internal marketing to improve organizational commit-
and improving SQ.
ment and service quality.

Implications for practice and/or policy

Author contributions
• Managers should give employees explicit information
YT was responsible for the study conception and design. YT
on the organization, constantly offer educational and
and S-WW performed the data collection. YT and S-WW
training projects to promote their service abilities and
performed the data analysis. YT and S-WW were respon-
properly compensate them for better service
sible for the drafting of the manuscript. YT made critical
performance. This will enhance OC and employee SQ.
revisions to the paper for important intellectual content. YT
obtained funding. YT and S-WW provided administrative,
technical or material support. YT supervised the study.
attitudes towards their work (Sikorska-Simmons 2006,
Cummins 2009). Chang and Chang (2007) study nurses
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