Training Engagement and Performance Feedback as Predictors of Staff Nurses’ Compliance with Nursing Protocols: An Explanatory Sequential Mixed Methods Study

Patient safety and the quality of treatment are significantly influenced by staff nurses' adherence to established clinical guidelines. In a secondary-level Department of Health (DOH)-retained public hospital in Zamboanga del Sur, Philippines, this explanatory sequential mixed-methods study examined training engagement and performance feedback as determinants of staff nurses' adherence to nursing protocols. The study used a sample of 229 eligible staff nurses using a descriptive-correlational and predictive design; 149 of them took part in the quantitative phase (65% response rate). After eight interviews, qualitative data saturation was reached, and two further interviews verified this. Jamovi software was used to analyze quantitative data in order to calculate multiple linear regression with bootstrapping, Spearman's rank correlation, and descriptive statistics. Using semi-structured in-depth interviews and a qualitative inquiry informed by the Appreciative Inquiry (AI) 4D Framework (Discover, Dream, Design, and Destiny), the next qualitative phase investigated nurses' peak operational practices and success-oriented behaviors. All subcategories had strong baseline levels of protocol compliance, performance feedback, and training engagement, according to quantitative studies. According to multiple linear regression, typical supervisory feedback channels need a deliberate structural makeover, even though training engagement serves as a main positive predictor of protocol compliance. Five key compliance facilitators were identified using qualitative theme analysis: (a) experiential and simulation-based learning; (b) peer collaboration and mentorship; (c) constructive and reflective feedback; (d) the methodical application of procedural checklists; and (e) supportive leadership. According to integrated findings, protocol compliance is an intricate operational procedure. Healthcare organizations need to shift from high-volume, punitive performance audits to focused, reflective developmental coaching in order to optimize frontline autonomy and self-efficacy. The study comes to the conclusion that, in settings with limited resources, maintaining a culture of patient safety and promoting compliance habits require ongoing training involvement and developmental feedback.

training engagement, performance feedback, nursing protocols, staff nurses

1. Abdelrahman, E., Abdelrahim, A., Mohamed, T., Babikir, M., Ahmed, N., Gandour, H., Ahmed, N., Elsayed, A., Ahmed, O., Saeed, A., Alsayed, M., Mohammed, A., Fadhl, H. A. N., Abdalrahman, A., Ibrahim, N., & Mohamed, M. (2025). Enhancing Clinical Documentation: The Effect of Structured Templates on Follow-Up Notes in a Low-Resource Hospital Setting. Cureus, 17(7), e88510. https://doi.org/10.7759/cureus.88510 [Google Scholar] [Crossref]

2. Abu-Qutaish, R., Alosta, M. R., Abu-Shosha, G., Oweidat, I. A., & Nashwan, A. J. (2025). The relationship between transformational leadership, work motivation, and engagement among nurses in Jordanian governmental hospitals. BMC nursing, 24(1), 842. https://doi.org/10.1186/s12912-025-03518-7 [Google Scholar] [Crossref]

3. Ahmed, W. E., Fakhry, S. F., & Mohamed Badran, F. M. (2025). Bedside handover training and its effects on nurses' knowledge and compliance. BMC nursing, 24(1), 1472. https://doi.org/10.1186/s12912-025-04075-9 [Google Scholar] [Crossref]

4. Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://bit.ly/3Plsuac [Google Scholar] [Crossref]

5. Al Aamri, M., et al. (2024). P erformance appraisal systems and nursing accountability in healthcare organizations.https://tinyurl.com/3kw29v84 [Google Scholar] [Crossref]

6. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall. https://tinyurl.com/ym4v7psp [Google Scholar] [Crossref]

7. Black, A. T., Car, J., Pagliari, C., et al. (2022). The impact of eHealth on the quality and safety of healthcare: A systematic overview. PLOS Medicine, 19(3), e1000387. https://bit.ly/4euSEBw [Google Scholar] [Crossref]

8. Bradley, E. H., Curry, L. A., & Devers, K. J. (2009). Qualitative data analysis for health services research: Developing taxonomy, themes, and theory. Health Services Research, 44(4), 1358–1378. doi.org [Google Scholar] [Crossref]

9. Busebaia, T. J. A., & John, B. (2020). Can the flipped classroom enhance class engagement and academic performance among undergraduate nursing students? A mixed-methods study. Research and Practice in Technology Enhanced Learning, 15, 4. https://bit.ly/4tdsUgR [Google Scholar] [Crossref]

10. Cooperrider, D. L., & Srivastva, S. (1987). Appreciative inquiry in organizational life. In R. W. Woodman & W. A. Pasmore (Eds.), Research in organizational change and development (Vol. 1, pp. 129–169). Greenwich, CT: JAI Press. https://l1nq.com/m3x80ai [Google Scholar] [Crossref]

11. Cooperrider, D. L., & Srivastva, S. (1987). Appreciative inquiry in organizational life. Research in Organizational Change and Development, 1(1), 129–169. [Google Scholar] [Crossref]

12. Cooperrider, D. L., & Whitney, D. (2005). Appreciative inquiry: A positive revolution in change. Berrett-Koehler Publishers. https://bit.ly/4w6J0vb [Google Scholar] [Crossref]

13. Creswell, J. W., & Plano Clark, V. L. (2018). Designing and conducting mixed methods research (3rd ed.). SAGE Publications. https://l1nq.com/ekc6fqk [Google Scholar] [Crossref]

14. Creswell, J. W., & Plano Clark, V. L. (2018). Designing and conducting mixed methods research (3rd ed.). SAGE Publications. [Google Scholar] [Crossref]

15. Donati, D., Miccoli, G. A., Cianfrocca, C., Di Stasio, E., De Marinis, M. G., & Tartaglini, D. (2020). Effectiveness of implementing link nurses and audits and feedback to improve nurses' compliance with standard precautions: A cluster randomized controlled trial. American Journal of Infection Control, 48(10), 1204–1210. https://l1nq.com/hlwppzx [Google Scholar] [Crossref]

16. Donati, D., Miccoli, G. A., Cianfrocca, C., et al. (2020). Effectiveness of audits and feedback to improve nurses’ compliance. American Journal of Infection Control, 48(10), 1204–1210. https://l1nq.com/7lq9a9c [Google Scholar] [Crossref]

17. Faridi, S., Farsi, Z., Rajai, N., Kalyani, M. N., & Fournier, A. J. (2025). Effectiveness of Multimedia Electronic Training on the Nurses' Adherence to Patient Safety Principles: A Randomized Controlled Trial. Health science reports, 8(4), e70621. https://doi.org/10.1002/hsr2.70621 [Google Scholar] [Crossref]

18. Fetters, M. D., Curry, L. A., & Creswell, J. W. (2013). Achieving integration in mixed methods designs—principles and practices. Health Services Research, 48(6pt2), 2134–2156. doi.org [Google Scholar] [Crossref]

19. Fishbein, M., & Ajzen, I. (2010). Predicting and changing behavior: The reasoned action approach. Psychology Press. https://sl1nk.com/vvpw9x7 [Google Scholar] [Crossref]

20. Fishbein, M., & Ajzen, I. (2010). Predicting and changing behavior: The reasoned action approach. Psychology Press. https://sl1nk.com/vvpw9x7 [Google Scholar] [Crossref]

21. Fontaine, G., Vinette, B., Weight, C., Maheu-Cadotte, M. A., Lavallée, A., Deschênes, M. F., Lapierre, A., Castiglione, S. A., Chicoine, G., Rouleau, G., Argiropoulos, N., Konnyu, K., Mooney, M., Cassidy, C. E., Mailhot, T., Lavoie, P., Pépin, C., Cossette, S., Gagnon, M. P., Semenic, S., … Middleton, S. (2024). Effects of implementation strategies on nursing practice and patient outcomes: a comprehensive systematic review and meta-analysis. Implementation science : IS, 19(1), 68. https://doi.org/10.1186/s13012-024-01398-0 [Google Scholar] [Crossref]

22. Ghorbanmovahhed, S., Mohammadi, E., & Vanaki, Z. (2023). Feedback and nurses’ self-efficacy. Nurse Education Today, 123, 105678. https://l1nq.com/iiubcx3 [Google Scholar] [Crossref]

23. Giesbers, A. P. M., Schouteten, R. L. J., Poutsma, E., van der Heijden, B. I. J. M., & van Achterberg, T. (2021). Towards a better understanding of the relationship between feedback and nurses' work engagement and burnout: A convergent mixed-methods study. International Journal of Nursing Studies, 117, 103889. https://sl1nk.com/crm50yo [Google Scholar] [Crossref]

24. Go, E., Serad, J., Bacarisas, J., Amores, G. E., & Picardo, R. (2025). "Clinical Competence on Patient Care Quality with Workplace Support as Mediator among Nurses," International Journal of Research and Scientific Innovation, International Journal of Research and Scientific Innovation (IJRSI), vol. 12(6), pages 358-385, June. [Google Scholar] [Crossref]

25. Goh, P. Q. L., Ser, T. F., Cooper, S., Cheng, L. J., & Liaw, S. Y. (2020). Nursing teamwork in general ward settings: A mixed-methods exploratory study. Journal of Clinical Nursing, 29(19–20), 3802–3811. https://sl1nk.com/tb4k5j9 [Google Scholar] [Crossref]

26. Goh, P. Q. L., Ser, T. F., Cooper, S., Cheng, L. J., & Liaw, S. Y. (2020). Nursing teamwork in general ward settings: A mixed-methods exploratory study. Journal of Clinical Nursing, 29(19–20), 3802–3811. https://sl1nk.com/tb4k5j9 [Google Scholar] [Crossref]

27. Guest, G., Namey, E., & Mitchell, M. (2020). Collecting qualitative data: A field manual for applied research. SAGE Publications. https://sl1nk.com/lfan9x7 [Google Scholar] [Crossref]

28. Guest, G., Namey, E., & Mitchell, M. (2020). Collecting qualitative data: A field manual for applied research. SAGE Publications.https://sl1nk.com/lfan9x7 [Google Scholar] [Crossref]

29. Habib, N., Awan, S. H., Naveed, S., & Akhtar, C. S. (2020). Effectiveness of interpersonal leadership for engagement and task performance of nurses. SAGE Open, 10(2). https://l1nq.com/mza9q3f [Google Scholar] [Crossref]

30. Harb, A., Fakih, M. G., & Rachoin, J. S. (2025). Infection prevention and control practices among nurses: A global perspective. American Journal of Infection Control, 53(1), 45–52. https://sl1nk.com/d5bz596 [Google Scholar] [Crossref]

31. Hidalgo Tapia, E. C., León Yosa, J., Olalla García, M. H., Clavijo Morocho, N. J., & Sanmartín Calle, Y. A. (2025). Effectiveness of Nursing Documentation Frameworks (SBAR, SOAP, and PIE) in Enhancing Clinical Handoffs and Patient Safety. Cureus, 17(8), e89957. https://doi.org/10.7759/cureus.89957 [Google Scholar] [Crossref]

32. Ignacio, J., & Chen, H.-C. (2020). The use of web-based classroom gaming to facilitate cognitive integration in undergraduate nursing students: A mixed methods study. Nurse Education in Practice, 46, 102820. https://sl1nk.com/ch8h2xa [Google Scholar] [Crossref]

33. Ignacio, J., & Chen, H.-C. (2020). The use of web-based classroom gaming to facilitate cognitive integration in undergraduate nursing students: A mixed methods study. Nurse Education in Practice, 46, 102820. https://sl1nk.com/ch8h2xa [Google Scholar] [Crossref]

34. International Journal of Nursing Studies Advances, 3, 100039. https://l1nq.com/5idql89 [Google Scholar] [Crossref]

35. Ivankova, N. V., Creswell, J. W., & Stick, S. L. (2006). Using mixed-methods sequential explanatory design: From theory to practice. Field Methods, 18(1), 3–20. doi.org [Google Scholar] [Crossref]

36. Iversen, A.-M., Stangerup, M., From-Hansen, M., et al. (2021). Light-guided nudging and data-driven performance feedback improve hand hygiene compliance among nurses and doctors. American Journal of Infection Control, 49(6), 733–739. https://sl1nk.com/t4nwqff [Google Scholar] [Crossref]

37. Ju, H., & Jeong, S. (2025). Application of andragogy in nursing education: Enhancing learner engagement and outcomes. Journal of Nursing Education. https://l1nq.com/m1qzutp [Google Scholar] [Crossref]

38. Kassab, S. E., Al-Shafei, A. I., Salem, A. H., & Otoom, S. (2023). Health workforce development and Sustainable Development Goals: A systematic review. (1), 55. https://l1nq.com/5cxwai2 [Google Scholar] [Crossref]

39. Knowles, M. S. (1973). The adult learner: A neglected species. Gulf Publishing. https://sl1nk.com/ds41gqo [Google Scholar] [Crossref]

40. Knowles, M. S. (1973). The adult learner: A neglected species. Gulf Publishing. https://sl1nk.com/ds41gqo [Google Scholar] [Crossref]

41. Knowles, M. S., Holton, E. F., & Swanson, R. A. (2015). The adult learner: The definitive classic in adult education and human resource development (8th ed.). Routledge.https://tinyurl.com/6d2zrpj7 [Google Scholar] [Crossref]

42. Knowles, M. S., Holton, E. F., & Swanson, R. A. (2015). The adult learner: The definitive classic in adult education and human resource development (8th ed.). Routledge.https://tinyurl.com/6d2zrpj7 [Google Scholar] [Crossref]

43. McAlearney, A. S., et al. (2021). Organizational strategies and patient safety compliance in healthcare settings. BMC Health Services Research. https://tinyurl.com/5n98mh2k [Google Scholar] [Crossref]

44. McCauley, L., Kirwan, M., & Matthews, A. (2021).The factors contributing to missed care and non-compliance in infection prevention and control practices of nurses: A scoping review. [Google Scholar] [Crossref]

45. Polit, D. F., & Beck, C. T. (2021). Nursing research: Generating and assessing evidence for nursing practice (11th ed.). Wolters Kluwer. https://sl1nk.com/pf6544w [Google Scholar] [Crossref]

46. Polit, D. F., & Beck, C. T. (2021). Nursing research: Generating and assessing evidence for nursing practice (11th ed.). Wolters Kluwer. https://sl1nk.com/pf6544w [Google Scholar] [Crossref]

47. Pozo-Martin, F., Nove, A., Lopes, S. C., Campbell, J., Buchan, J., Dussault, G., & Cometto, G. (2024). Health workforce metrics pre- and post-COVID-19 pandemic: A global analysis. The Lancet Global Health, 12(2), e300–e310. https://doi.org/10.1016/S2214-109X(23)00510-8 [Google Scholar] [Crossref]

48. Pozo-Martin, F., Nove, A., Lopes, S. C., Campbell, J., Buchan, J., Dussault, G., & Cometto, G. (2024). Health workforce metrics pre- and post-COVID-19 pandemic: A global analysis. The Lancet Global Health, 12(2), e300–e310. https://doi.org/10.1016/S2214-109X(23)00510-8 [Google Scholar] [Crossref]

49. Radhakrishna, K., Waghmare, A., Ekstrand, M., Raj, T., Selvam, S., Sreerama, S. M., & Sampath, S. (2020). Real-time feedback for improving compliance with hand sanitization among healthcare workers in an open layout ICU using radiofrequency identification. Journal of Medical Systems, 39(6), 68. https://doi.org/10.1007/s10916-015-0251-1gh [Google Scholar] [Crossref]

50. Robbins, S. P., & Judge, T. A. (2019). Organizational behavior. Pearson.https://sl1nk.com/4zk4k63 [Google Scholar] [Crossref]

51. Seo, Y., & Lee, H. (2024). Nurses’ perceptions of clinical regulations and patient safety performance. International Journal of Nursing Studies. https://tinyurl.com/2uewx25x [Google Scholar] [Crossref]

52. Shah, S. G. S., Nogueras, D., van Woerden, H. C., & Kiparoglou, V. (2021). Healthcare practices and compliance challenges. Journal of Medical Internet Research, 23(11), e30795. https://sl1nk.com/1l3lejl [Google Scholar] [Crossref]

53. Shah, S. G. S., Nogueras, D., van Woerden, H. C., & Kiparoglou, V. (2021). Healthcare practices and compliance challenges. Journal of Medical Internet Research, 23(11), e30795. https://sl1nk.com/1l3lejl [Google Scholar] [Crossref]

54. Shahvaran, R, Rezaee, R & Bazrafkan, L. (2018). Effects of mutual structured feedback on nurses' performance. J Adv Pharm Edu Res, 8(S2):44-48. www.japer.in. E-ISSN: 2249-3379 [Google Scholar] [Crossref]

55. Sin, M. K., Park, Y. S., & Kim, H. J. (2022). Self-reported vs observed infection control practices. International Journal of Environmental Research and Public Health, 19(4) [Google Scholar] [Crossref]

56. Sin, M. K., Park, Y. S., & Kim, H. J. (2022). Self-reported vs observed infection control practices. International Journal of Environmental Research and Public Health, 19(4), 2156. https://l1nq.com/r2gkw2m [Google Scholar] [Crossref]

57. Skinner, B. F. (1953). Science and human behavior. Macmillan. https://l1nq.com/7eoh8l5 [Google Scholar] [Crossref]

58. Song, Y., et al. (2024). Timely feedback and formative assessment in clinical nursing education. Nurse Education Today.https://tinyurl.com/mr3as4kf [Google Scholar] [Crossref]

59. Taneva, D. I., Gyurova-Kancheva, V. T., Kirkova-Bogdanova, A. G., Paskaleva, D. A., & Zlatanova, Y. T. (2024). Electronic Nursing Records: Importance for Nursing and Benefits of Implementation in Health Information Systems-A Scoping Review. Nursing reports (Pavia, Italy), 14(4), 3585–3605. https://doi.org/10.3390/nursrep14040262 [Google Scholar] [Crossref]

60. van de Mortel, T. F., Armit, L., Shanahan, B., et al. (2020). Supporting Australian clinical learners in a collaborative clusters education model: A mixed methods study. BMC Nursing, 19, 57. https://sl1nk.com/l2wm8az [Google Scholar] [Crossref]

61. Walker, J. L., Sistrunk, W. W., Higginbotham, M. A., Burks, K., Halford, L., Goddard, L., Thombs, L. A., Austin, C., & Finley, P. J. (2020). Hospital hand hygiene compliance improves with increased monitoring and immediate feedback. American journal of infection control, 42(10), 1074–1078. https://doi.org/10.1016/j.ajic.2014.06.018 [Google Scholar] [Crossref]

62. Weller-Newton, J., et al. (2022). Barriers to continuing professional education among nurses. Journal of Continuing Education in Nursing. https://tinyurl.com/yamncn86 [Google Scholar] [Crossref]

63. Zhang, M., Wu, S., Ibrahim, M. I., Noor, S. S. M., & Mohammad, W. M. Z. W. (2024). Significance of Ongoing Training and Professional Development in Optimizing Healthcare-associated Infection Prevention and Control. Journal of medical signals and sensors, 14, 13. https://doi.org/10.4103/jmss.jmss_37_23 [Google Scholar] [Crossref]

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